Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Project Name PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Health Sector Support Project Region AFRICA Sector Health (100%) Project ID P065126 Borrower(s) GOVERNMENT OF GUINEA Implementing Agency Ministry of Public Health, B.P. 545, Conakry, Guinea (21-98-56) Environment Category [ ] A [] B [ ] C [ ] FI [x ] TBD (to be determined) Safeguard Classification Date PID Prepared February 17, 2004 Date of Appraisal February 26, 2004 Authorization Date of Board Approval May 4, 2004 1. Country and Sector Background [ ] S 1 [ ] S 2 [ ] S 3 [ ] S F [x ] TBD (to be determined) Report No.: AB399 Guinea is one of the poorest countries in Africa with a per capita GDP of US$ 560. According to latest estimates, 40 percent of the population lives below the poverty line with less than US$ 300 per year. Life expectancy at birth is 47 years, and 38 percent of the population is not expected to reach the age of forty. Only 52 percent have access to safe water, and 55 percent to health services. Health services in Guinea virtually collapsed during the many years of economic stagnation in the 1970-80s. Recovery started in 1986 when a new health policy was formulated which focused on improving primary health care coverage and quality of services. Adoption of the Bamako Initiative, with support from multiple donors, helped communities take greater responsibility in the management of health resources and ensured rapid expansion of services in rural areas. The results have been telling: immunization coverage and continuity, antenatal care, treatment of diarrhea, etc. have all improved during 1990s. The annual per capita visits to public facilities increased remarkably. Health outcomes like child mortality have shown dramatic reductions. Between 1992 and 1999, the urban under-five mortality rate decreased from 167 to 133. The decrease was more pronounced in rural areas where under-five mortality rate dropped from 247 to 187, a 24 percent decline as compared to 20 percent for urban areas. This has been attributed to the success of community-based health services introduced in rural Guinea from the 1980s. Despite the significant progress, health outcome indicators remain mediocre compared to other parts of the world, and the country s performance in this regard is lower than expected for its level of per capita GDP. This is due to two main reasons. Low cost interventions such as prevention and treatment of malaria, or early treatment of diarrhea and upper respiratory infections could bring about significant improvements only to a certain extent but require back-up from higher referral levels to decrease it further. Inequities in access and utilization of services still persist in spite of the best intentions of the community-based approach. Thus, children born to the poorest 20 percent of population were twice more likely to die before reaching their first birthday than those in the richest 20 percent of the population in both 1992 and 1999. Fertility has also remained high and contributes to maintaining the particularly high level of maternal mortality as one out of seven woman dies due to pregnancy. Fertility rate is extremely high in rural areas where it even appears to have slightly increased from 5.9 to 6.1 between 1992 and 1999. This increase is presumably a result of shorter breast-feeding periods now being practiced in rural areas of the country and no increase in the use of modern contraceptive methods.
For sustaining the momentum gained in the improvement of health in Guinea, more resources would be necessary. At the same time, just by increasing allocations alone will not do much good if technical and allocative efficiencies are not ensured. The momentum generated in health sector improvements during the 1990s need to be sustained, and strategies for poverty reduction through health sector need to build on existing strengths (such as community based health care via the Bamako Initiative) while gaps and weaknesses are addressed. Some of the main issues identified in the 2002 Country Status Report on Health are as follows: a) Relatively poor health outcomes: Although indicators are improving they are still below what they should be compared to other African countries. Contraceptive prevalence in Guinea is about 5%, maternal mortality is high, and neonatal mortality accounts for 50% of the deaths during the first year of life. b) Inequity: Over the last decade, public expenditures focused primarily on services in urban areas with emphasis on Conakry, and overall benefited the wealthier income groups. More than 60% of health personnel is in Conakry serving only 20% of the country s total population. Health indicators vary widely by Region. Public expenditures seem to benefit the rich more than the poor as hospitalization is the most subsidized of public health services and the 10% wealthiest use almost a quarter of the hospitalization expenditures. c) Insufficient Health expenditures: Health expenditures in relation to total government expenditure are extremely low in Guinea. Government spending on health even decreased from less than 1% of GDP in 1993 to approximately 0.75% in 1998. The sector s recurrent expenditure represents only 5.6% of the country s total recurrent budget, and the share of health sector investment budget is around 4.75 of the Government s total investment budget. Health sector budget allocations have been invariably low over the past decade, representing less than ¼ of the education sector budget allocation, when in most countries this ratio is closer to half. d) Poor Budget execution: The already low budgetary allocation is further hampered by poor execution; the executed budget is less than half the allocated budget. This is due to: (a) treasury constraints at the MOF level; (b) non-compliance with effectiveness or a priori disbursement conditions agreed to with donors; (c) administrative delays; and (d) contractor/supplier reliability. e) Human resources problems: There is a major problem of shortage and distribution of skilled health personnel in the country. This is worse in rural areas and explains the inequities and poor quality of maternal and child health services. For example, while 71% of pregnant women visit an antenatal clinic at least once, only 35% receive skilled attendance during delivery. Studies indicate problems of low level of salary and incentives of nurses in rural areas. The share of expenditures on salaries has remained unchanged in the last decade, and even deteriorated at the primary care level. This contributes probably to the low perceived quality of services, and, in addition to lack of personnel in rural areas, might explain the low rate of return visits. In addition, the problem of governance has reached unprecedented levels lately. A study undertaken in 2000 on parallel payment practices in the two main hospitals of Conakry showed that one patient out of three who benefits from services is not registered anywhere, that patients pay about 10 times the official fees for being treated as inpatients, and that only 14% of what patients pay go into the hospital s coffers. Those practices are in part linked to the human resources problems mentioned above. Even the Bamako Initiative, which has long been an example for the rest of Africa, seems to not be adhered to by some people. One of the reason is that the commercial bank where the health committees kept their money went bankrupt and the money became unavailable for a while. Another problem is that the Ministry of Finance asked a couple of times that some of the money from health committees be sent to Conakry, to the Treasury, thus touching upon one the principles of the Bamako Initiative which is that cost-recovery money belongs to health committees. All those factors explain an under-utilization of the health structures at the different levels of the system.
2. Objectives As this operation follows a program approach, its objectives cannot be dissociated from those of the Five-Year Plan. During that time period which appear in the table above. In addition, the following indicators will be monitored to ensure that institutional objectives are met: % of government allocation to health centers which reach the health center % of new financial management functions which the DAAF is able to carry out each year % of increased coverage achieved through contracting Municipalities, Rural Development Committees (CRDs) and private service providers % of indicators to graduate to budget support completed. The overall objective of the MOH Five Year Plan which this operation will support is to improve the health status of the population while reducing inequities. The proposed financing will finance a portion of this Five Year Plan. The indicators will be those for the MDGs (annex 1). 3. Rationale for Bank Involvement This project will complement other instruments which are either in existence in Guinea (the PRCI, PU III, and PACV projects). In addition, it should be seen as a transition project towards a full budgetary support through a PRSC when the sector is ready for it (see last part of Annex 3 on suggested criteria to determine when the sector will be ready for full budgetary support). The program, or sectoral, approach taken by the Ministry of Health necessitates that all donors be supporting it and the Bank is going to play the role of lender of last resort for that 5 year plan. 4. Description The five-years plan will help improve access, quality and equity of health care services. It was agreed that the Bank s comparative advantages would be channeled into activities around the following three components: Component I: Strengthening Health Care Services o o Sub-component 1: Quality of care: investments will be made in particular to improve the norms and adherence to the norms for basic as well as emergency birth delivery; to ensure a steady supply of drugs, vaccines and other medical supplies; to improve access to care by improving the referral system via radio and ambulances; to improve the referral system by improving maternal and infant care in hospitals and ensuring that hospitals seek out more at-risk cases. Sub-component 2: Community mobilization: investments will be made mainly to support the existing successful Muriga system, which is a health mutual system implemented during the previous World Bank financed project. Re-energizing of health committees around health centers will be done by ensuring that health centers who serve poor populations will receive their government allocation as they only receive 30% now according to the Health Expenditures Tracking Survey carried out in 2003. In order to
improve governance, the publication of the budget received by each health structure and how the money was spent will be done throughout the country so that the population is aware and government officials are accountable to them. Component II: Institutional Strengthening Investment will be made in monitoring and evaluation to see if the objectives are reached; the central DAAF and decentralized units will be strengthened in order to prepare them for budgetary support; for example a financial audit will be carried out on those decentralized structures every two years, and they will all receive assistance to meet certain basic requirements in terms of financial management and contract management. A yearly health expenditures tracking survey will be undertaken to see if there s any improvement. Finally, the purchasing function of the MOH will be improved in terms of public-public contracting, between the MOH and Municipalities or Rural Development Committees (CRD), and between the MOH and private service providers. Component III: Improving Human resources Implementation of the existing on-the-job master plan will be financed, along with assistance to the training of more midwives. Since the new mid-wives will not be available for three years, contracting of retired midwives will be implemented to fill the gap especially in rural areas. Although the Bank is positioning itself as a lender of last resort, it is believed that the above components are broad enough to accommodate any new financing needs which might emerge during the annual reviews. The components are also focused enough to help reach the program objectives. 5. Financing Source: ($m.) BORROWER/RECIPIENT 0 INTERNATIONAL DEVELOPMENT ASSOCIATION 20 Total 20 6. Implementation The Five Years Plan will be financed once its content is agreed upon through discussions between donors and Government. The main donors have agreed to do so. However, financing will be parallel, not pooled. A yearly review will take place, led by the MOH, and donors will be provided with a review of the previous year progress of the Five Years Plan, evaluation of progress relative to objectives, as well as planning for the next year There will be no separate implementation unit, and support will be provided to the DAAF of the MOH to manage the IDA credit. A Financial Management Agency will be hired to help the DAAF in certain functions. This FMA will be evaluated yearly according to how successful it has been in ensuring that the MOH s DAAF can now implement certain functions, in order to ensure a phasing out of the FMA 7. Sustainability
This operation is the second phase of a three-phases APL. The last phase will be budget support through an eventual PRSC. This operation will strengthen the MOH by consolidating its capacity to carry out a program and align donors behind such program 8. Lessons Learned from Past Operations in the Country/Sector This operation builds on the lessons learnt from three previous health operations financed by the World Bank since 1988 (see Annex 15, where the Guinean coordinators of those projects themselves listed the lessons to retain). For example, working at the community level, reinforcing the Bamako Initiative and introducing health mutuals is something that was seen as very positive, and will be financed again here. This operation will also build on existing successful operations, namely the Urban Project III which started writing contracts between the central government and Municipalities. The MOH will follow the same approach and strengthen this system by better defining the role of the DRS and DPS in relation to elected bodies such as Municipalities and CRDs. Finally, preparation of this project benefited form sector work such as the Health Expenditures Review, the Health Expenditures Tracking Survey, the Guinea Country Status Report, which all provided insight on problems to be tackled. 9. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.01) [ ] [ ] Natural Habitats (OP/BP 4.04) [ ] [ ] Pest Management (OP 4.09) [ ] [ ] Cultural Property (OPN 11.03, being revised as OP 4.11) [ ] [ ] Involuntary Resettlement (OP/BP 4.12) [ ] [ ] Indigenous Peoples (OD 4.20, being revised as OP 4.10) [ ] [ ] Forests (OP/BP 4.36) [ ] [ ] Safety of Dams (OP/BP 4.37) [ ] [ ] Projects in Disputed Areas (OP/BP/GP 7.60) * [ ] [ ] Projects on International Waterways (OP/BP/GP 7.50) [ ] [ ] 10. Contact point Contact: Tonia Marek Title: Sr Public Health Spec. Tel: (202) 458-0777 Fax: Email: Tmarek@worldbank.org 11. For more information contact: The InfoShop * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas
The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop