PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB1473 Country Mali Prpoject ID P093689 Project Name Sector-wide Health System and Social Development Support Project Region AFRICA Sector Health (80 %); Other social services (20 %) Borrower(s) GOVERNMENT OF MALI Implementing Agencies Ministry of Health Ministry of Social Development BP 235, Bamako BPE 3062 Bamako République du Mali République du Mali Fax/phone:(+223) 222 53 02 Tel : (+223) 222 03 87 Fax : (+223) 222 48 63 Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared March 15, 2005 Estimated Date of September 21, 2005 Appraisal Authorization Estimated Date of Board November, 2005 Approval 1. Country and Sector Background The poor health status of Mali s population remains a great challenge for the durable development of the country. The main causes of illness and diseases in Mali are communicable diseases (malaria, lack of immunization of preventable diseases, diarrhoea, acute respiratory illnesses) and malnutrition. Despite a slight improvement in the trends of health indicators since 1990, recent DHS (2001) indicates a high IMR of 113/1000 and a child mortality rate of 229/1000. Mali is still experiencing a very high fertility rate (6.8 children per woman), which has a negative impact on child nutrition, survival, maternal mortality, poverty and literacy. The use of modern contraceptives is still extremely low in Mali. Like many countries in the sub-region, Mali is off-track in achieving the millennium Development Goals (MDGs) for health. Today, Mali s health system is composed of (i) primary care services (CSCOM, Centres de Santé Communautaires) covering villages; they are mostly private, non- profit, and community based; and (ii) the second (district-level) and tertiary health levels (regional and national hospitals) which are mainly public, like the entire chain of delivery in most countries in the region. The Ministry of Social Development was established as a separated line ministry from the Ministry of Health in 2004. Key issues for the health and social development sectors are twofold: First, Mali suffers a very low spending in health, aggravated by the lack of allocative and technical efficiency of expenditures with the benefits from public spending skewed towards the richer quintiles of population. Second, the health service delivery system is plagued by very weak capacity, mainly due to the lack of human resources in certain areas and low demand for services. As a result, rural populations and the poor are underserved. Among key factors underlining the low demand for health services are the pricing of services paid mainly from out-of-pocket, but more importantly the poor quality of services, including non-availability of low-cost drugs, lack of motivation with the scornful and condescending attitude from staff, low expertise of health staff, weak geographical accessibility as well as nomadism in desert zones.
The diversity in donor aid forms and operating systems is overwhelming compared to the low administrative capacity of the health sector. Thus, the Government asked donors to consider budgetary support to help decrease the number of procedures and Special Accounts. In 2005, the Government of Mali developed and adopted a Ten-Year-Plan for Health and Social Development (PDDSS) in 1997, covering the 1998-2007. In consultation with development partners, private sector and civil society, a medium-term sector investment program, called Programme de Développement Sanitaire et Social (PRODESS), was developed in order to implement the first five-year phase of the PDDSS. The next five-year phase of PDDSS (PRODESS 2) will be implemented by 2005, and this operation is in line with PRODESS 2. 2. Project Objectives The goal of the sector-wide support is to contribute to achieving MDGs related to the health sector (decrease maternal and infant mortality, fight malaria, HIV/AIDS and other diseases) and to closely monitor these goals. The main objective is to strengthen health and social development systems at the decentralized level and to fine tune it to cover the underserved population. The project s specific objectives are (i) to increase the utilization of services for the lower quintiles of the population and to increase the quality of services as perceived by the users, particularly in rural areas, (ii) to improve efficiency and sustainability of financing, and (iii) to increase harmonization of financing procedures. This operation is expected to strengthen the health system s capacity so as to contribute to a decrease in maternal mortality, child malnutrition and child mortality. By improving the coverage and quality of the health care system, the project should help reduce malaria mortality and contribute to supporting the implementation of HIV/AIDS medical components.. 3. Project Description and Financing The Government of Mali requested that donors should harmonize their procedures regarding support to the health sector. A group of donors, including the Dutch, the Canadians and the Swedes, together with the World Bank, launched a health budget support working group to prepare an MoU. The group aims at providing health sector financing under a pooled financing mechanism and would complement any ongoing general budget support, such as the EU budget support. Specific attention will be paid to improving the deconcentration process and to implementing the decentralization of the health system as designed in the country s decentralization framework. Thus, the project has three components: (i) (ii) (iii) Support the Ministry of Health and Ministry of Social Development central directorates in (a) developing and enforcing policies, norms and standards of services, (b) promoting alternative financing mechanisms, (c) ensuring monitoring and evaluation, and (d) providing overall leadership to each sector - Amount of US $10.5 million (30 %); Support regional and district plans of operations (in regions and cercles) in (a) providing effective and quality health and social services in hospitals and Reference Health Centers (Centres de Santé de Référence), (b) supervising decentralized community health centers and (c) developing public-private partnership for health education, nutrition and relevant community-based programs Amount of US $12.25 million (35%); Support decentralized health programs in communes, including human resource and facilities management, in (a) developing local initiatives involving civil society in order to increase the demand of services, (b) in training community-based committees and (c) motivate service delivery staff in decentralized facilities- Amount of US $12.25 million (35%).
The steps towards project implementation will include: (i) reviewing the sector strategy to refocus on increasing quality and utilization as opposed to construction of new facilities, (ii) further designing and implementing the health sector Mid-Term Expenditure Framework (MTEF) in line with the government budgetary system process and schedule, (iii) designing a performance-based contracting system, including the development of the decentralized health system, building a better public-private partnerships (within line ministries and between those ministries and locally decentralized bodies) and expending publicpartnerships with the private health care sector, (iv) establishing baseline performance indicators and designing a coherent monitoring and evaluation system at both decentralized and deconcentrated levels of the health and social development systems, and (v) undertaking study trips to learn from other countries with relevant experiences in SWAP. Support to the Health and Social Development sectors would pursue the following principles: (i) (ii) (iii) Financing would be provided based on an agreed annual plan of action with central and decentralized levels; local authorities will be provided with resources to implement and monitor service provision at the peripheral level; Financing would be divided into unconditional (fixed) portion and variable portion. The variable portion would be adjusted yearly, depending on past performance at each level of the system. The details would be consigned into performance-based contracts with central and decentralized levels. The overall system should aim at encouraging best performers; and Performance will be measured according to how well the (deconcentrated and decentralized) system is contributing to improve access, quality and coverage of health care services linked to the MDGs and, possibly, how well management capacity is reinforced. The Mali health sector SWAP is a transition phase to a fully effective PRSC expected to be on the table by 2008. This SWAP will allow the health and Social Development sectors to strengthen their management capacity as well as their ability to integrate the decentralization process in Mali. The MTEF should become a routine tool for effective resource planning, allocation, and management that focuses on results. 4. Project Implementation, Coordination, Monitoring and Evaluation. The Ministry of Health and the Ministry of Social Development pooled-fund will be managed by their respective DAF, and the same mechanism will be used. Harmonization will be achieved through donors common reporting formats and timing of reporting, common performance indicators at different levels of the health system, joint reviews and use of national (common) procedures and norms. Data to monitor and evaluate the sector program will come from yearly Public Expenditures Tracking Surveys (to be financed through the project), National Health Accounts (one is currently financed by MoH and donors, including the Bank), specific surveys by local consultants as well as data from the health information system. The department of Public Health in the Medical School of Bamako is expected to play a major role in the monitoring and evaluation of the sector program. 5. Lessons Learned from Current Operations and ESW The ongoing PRODESS project proved to be too ambitious in its objectives while being not sufficiently oriented towards improving services at the first point of entry in the health system. Nevertheless, the project contributed to increase the availability and geographical accessibility of primary level care (from
340 public health centers in 1998 to more than 800 CSCOMs in 2003; however, health services utilization rate is still below 0.25 contact/inhabitant/year. The Bank and Moh conducted a study investigating the reasons for the low utilization of health services. It showed that the main reason was first and foremost, poor quality care, either perceived (from the unavailability of essential cheap drugs, unwelcoming environment, and condescending, dishonest, slipshod staff treatment) or objective (low professional skills of the health staff and failure to follow treatment protocols). From the healthcare providers vantage point, the factors inhibiting Mali s performance included: (i) disagreements between CSCOM staff and ASACO members who are in charge with the overall management of the CSCOM, (ii) ongoing conflicts among healthcare personnel since no authority oversees the CSCOM, and the lack of a solid supervisory structure which results in internal problems being unresolved, and (iii) the poor ASACO managerial capacity either due to a lack of skills and education or to a lukewarm interest in effective management. The absence of staff motivation linked with their temporary status, low salaries, and the lack of a career ladder also hamper the effective functioning of health facilities. The community-based management system lacks real capacity to influence the health professional s behaviour. They do not have the necessary moral authority, nor do they have the means to implement services according to their needs and desires. The involvement of decentralized bodies in the health sector will provide the missing overseeing function and the needed resources for effective human resource development and sustainability. The Bank will also draw lessons from other operations which are using performance-based contracts, such as the Burkina experience, the Brazil Family Health Project (under implementation), the Ghana Health Project (under implementation), and the Rwanda PRSC (not yet effective). 6. Safeguard Policies (including public consultation) Applicable? Safeguard Policy If Applicable, How Might It Apply? [X ] Environmental Assessment (OP/BP 4.01) [ ] Natural Habitats (OP/BP 4.04) [ ] Pest Management (OP 4.09) [ ] Involuntary Resettlement (OP/BP 4.12) [ ] Indigenous Peoples (OD 4.20) [ ] Forests (OP/BP 4.36) [ ] Safety of Dams (OP/BP 4.37) [ ] Cultural Property (draft OP 4.11 - OPN 11.03) [ ] Projects in Disputed Areas (OP/BP/GP 7.60) * [ ] Projects on International Waterways (OP/BP/GP 7.50) * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties claims on the disputed areas
7. List of Factual Technical Documents Bank s aide-memoire, March 2005 identification mission 8. Contact point Contact: Gaston Sorgho Title: Public Health Specialist Tel: (223) 222 22 83 Fax: (223) 222 88 67 Email: Gsorgho@worldbank.org Location: Bamako, MALI (IBRD) For more information, contact: Public Information Center The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458 5454 Fax (202) 422 1500