Document of The World Bank
FOR OFFICIAL USE ONLY
Public Disclosure Authorized Report No: 47537-AO
PROJECT APPRAISAL DOCUMENT
ON A
PROPOSED CREDIT
IN THE AMOUNT OF SDR 46.7 MILLION Public Disclosure Authorized (US$70.8 MILLION EQUIVALENT)
TO THE
REPUBLIC OF ANGOLA
FOR A
MUNICIPAL HEALTH SERVICE STRENGTHENING PROJECT (MHSS) (REVITALIZAÇÃO)
Public Disclosure Authorized May 12, 2010
Human Development 1 Southern Africa Country Cluster 2 Africa Region
Public Disclosure Authorized This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.
CURRENCY EQUIVALENTS
Exchange Rate Effective January 17, 2010
Currency Unit = Kwanza Kwanza 89.8 = US$1 US$1.56 = SDR 1
FISCAL YEAR January 1 – December 31
ABBREVIATIONS AND ACRONYMS
ACT Artemisin-based Combination Therapy AMDD Averting Maternal Death and Disability Program ANC Antenatal Care ARI Acute Respiratory Infection BCC Behavior Change Communication CCU Central Coordinating Unit CEmONC Comprehensive Emergency Obstetric and Neonatal Care CHW Community Health Worker CPAR Country Procurement Assessment Review CQS Consultants Qualification Selection DA Designated Account DDM Data for Decision Making DMS Departamento Municipal de Saúde, Municipal Health Department DNSP Direcção Nacional de Saúde Pública, National Department of Public Health DPT Diphtheria, Pertussis, and Tetanus EA Environmental Assessment EmONC Emergency Obstetric and Neonatal Care EMRP Emergency Multi-sectoral and Rehabilitation Program EMTA Economic Management Technical Assistance ESW Economic and Sector Work EU European Union FM Financial Management GAAP Governance and Accountability Action Plan GDP Gross Domestic Product GEPE Gabinete de Estudos, Planificação e Estadisticas, Planning Department of MOH HAMSET HIV/AIDS, Malaria, and Tuberculosis Control Project HMIS Health Management Information System HRDP Human Resources Development Plan HRH Human Resources for Health HWMD Hospital Waste Management Disposal IBRD International Bank for Reconstruction and Development IC Individual consultants ICB International Competitive Bidding ICR Implementation Completion Report
i IDA International Development Agency IEC Information, Education, and Communication IEG Independent Evaluation Group IFR Interim Financial Reports IMCI Integrated Management of Childhood Illnesses INE Instituto Nacional de Estadisticas, National Statistics Institute ISN Interim Strategy Note KAP Knowledge, Attitude, and Practice LCS Least-Cost Selection M&E Monitoring and Evaluation MAT Ministerio de Administração Territorial, Ministry of Territorial Administration MBB Marginal Budgeting for Bottlenecks MDG Millennium Development Goal MHSS Municipal Health Service Strengthening MICS Multiple Indicator Cluster Survey MTEF Medium-Term Expenditure Framework MOH Ministry of Health NCB National Competitive Bidding NGO Non-Government Organization ObGyn Obstetrics and Gynecology OPEC Organization of Petroleum Exporting Countries PCU Project Coordinating Unit PEMFAR Public Expenditure Management and Country Financial Accountability Review PER Public Expenditure Review PMI (US) President‘s Malaria Initiative QBS Quality-Based Selection QCBS Quality and Cost-Based Selection SBD Standard Bidding Document SIGFE Sistema Integrado de Gestão das Finanças do Estado, Integrated Financial Management Information System SIL Sector Investment Loan SOE Statement of Expenditures SSS Single-Source Selection TB Tuberculosis TBA Traditional Birth Attendant TH Traditional Healer TOR Terms of Reference TOT Training of Trainers UNFPA United Nations Fund for Population Activities UNICEF United Nations Children‘s Fund UNITA União Nacional da Independência Total de Angola, National Union for the Total Independence of Angola WHO World Health Organization
ii Vice President: Obiageli K. Ezekwesili Country Director: Olivier Godron (Acting) Sector Manager: Eva Jarawan Task Team Leader: Jean J. De St Antoine
iii ANGOLA Municipal Health Service Strengthening Project (MHSS)
CONTENTS
Page
I. STRATEGIC CONTEXT AND RATIONALE ...... 1 A. Country and sector issues...... 1 B. Rationale for Bank involvement...... 7 C. Higher-level objectives to which the Project contributes...... 7
II. PROJECT DESCRIPTION ...... 7 A. Lending instrument...... 7 B. Project development objectives...... 8 C. Project description...... 8 D. Lessons learned and reflected in the project design...... 12 E. Alternatives considered and reasons for rejection...... 14
III. IMPLEMENTATION ...... 14 A. Partnership arrangements...... 14 B. Institutional and implementation arrangements...... 15 D. Sustainability...... 17 F. Credit conditions and covenants ...... 19
IV. APPRAISAL SUMMARY ...... 20 A. Economic and financial analyses...... 20 B. Technical...... 21 C. Fiduciary...... 21 D. Social...... 22 G. Policy Exceptions and Readiness...... 25
Annex 1: Country and Sector Background ...... 26
Annex 2: Major Related Projects Financed by the Bank and other Agencies ...... 33
Annex 3: Results Framework and Monitoring ...... 35
Annex 4: Detailed Project Description ...... 46
Annex 5: Project Costs ...... 51
iv Annex 6: Implementation Arrangements ...... 54
Annex 7: Financial Management and Disbursement Arrangements ...... 67
Annex 8: Procurement Arrangements ...... 79
Annex 9: Economic and Financial Analysis ...... 88
Annex 10: Safeguard Policy Issues ...... 95
Annex 11: Project Preparation and Supervision ...... 98
Annex 13: Statement of Loans and Credits ...... 101
Annex 14: Country at a Glance ...... 102
Annex 15: Key High-Impact Health Interventions by Service Delivery Level ...... 104
Annex 16: Terms of Reference for the Development of a Human Resources Development Plan105
Annex 17: Terms of Reference for the Development of a Health Infrastructure Development Plan ...... 110
Annex 18: Voucher Scheme to Encourage Institutional Deliveries ...... 113
Annex 19: Governance and Accountability Action Plan ...... 119
Annex 20: Availability of Health Workers in the Five Targeted Provinces ...... 125
Annex 21: Availability of Obstetric Care in the Five Targeted Provinces ...... 128
Annex 22: Supervision Plan ...... 132
FIGURES
Figure 1:Trends in under-5 mortality rate ...... 1 Figure 2: MHSS Institutional Arrangements ...... 16 Figure 3: Trends in under-5 mortality rate ...... 26 Figure 4: MHSS Institutional Arrangements ...... 56 Figure 5: Funds Flow Arrangements ...... 76 Figure 6: IMR in Angola and Sub-Saharan Africa ...... 89 Figure 7: Under-five mortality rates in Angola and Sub-Saharan Africa ...... 90 Figure 8: Arrangements for Vouchers ...... 115 Figure 9: Angola‘s progress on governance, 2002 to 2006 ...... 121 Figure 10: Angola‘s governance in relation to the Sub-Saharan Africa average (2007) ...... 122
v
TABLES
Table 1: Key health indicators for the MHSS provinces ...... 5 Table 2: Risks ...... 18 Table 3: Impact on Under-Five and Maternal Mortality Reduction and Additional Cost Per Capita of Five Health Service Delivery Steps in Angola ...... 21 Table 4: Observations from Social Assessment ...... 22 Table 5: Key health outcome indicators ...... 27 Table 6: Key health indicators for the MHSS provinces ...... 31 Table 7: Major related projects financed by the Bank ...... 33 Table 8: Organizations Present in the Five Provinces ...... 33 Table 9: Project Development Objectives and Outcome Indicators ...... 35 Table 10: Monitoring Framework ...... 37 Table 11: Indicators and data source ...... 43 Table 12: Detailed Project costs ...... 51 Table 13: Project Costs By Component ...... 53 Table 14: Municipalities covered by the MHSS ...... 54 Table 15: Training Program ...... 58 Table 16 - Location of Delivery Rooms to be Built/Rehabilitated ...... 60 Table 17: MHSS Implementation Schedule ...... 62 Table 18: Summary Risk Table ...... 70 Table 19: Procurement Management Action Plan to Mitigate Procurement Risk ...... 82 Table 20: Procurement Thresholds ...... 84 Table 21: Key health outcome indicators ...... 89 Table 22: Selected health indicators in the five MHSS provinces compared to national average ..... 91 Table 23: Impact on Under-Five and Maternal Mortality Reduction and Additional Cost Per Capita of Four Health Service Delivery Steps in Angola ...... 93 Table 24 : Key High-Impact Health Interventions ...... 104 Table 25: HRH data in Angola and selected SADC countries per 10,000 persons ...... 105 Table 26: Health staff in facilities providing obstetric and neonatal care...... 106 Table 27: Cost of Vouchers ...... 113 Table 28: Governance and Accountability Action Plan ...... 123 Table 29: Minimum number of professionals per category per health facility ...... 125 Table 30: Availability of doctors and nurses in three selected municipalities ...... 127 Table 31: Percentage of health units with at least one person who can perform selected procedures ...... 130 Table 32: Percentage of health units with selected equipment ...... 130 Table 33: Percentage of health units with selected drugs ...... 131
vi
ANGOLA
MUNICIPAL HEALTH SERVICE STRENGTHENING PROJECT (MHSS)
PROJECT APPRAISAL DOCUMENT
AFRICA REGIONAL OFFICE
AFTH1
Date: May 12, 2010 Team Leader: Jean-Jacques de St. Antoine Country Director: Olivier Godron (Acting) Sectors: Health (JA) Sector Manager: Eva Jarawan Themes: Health system performance (67), Project ID: P111840 child health (63), other communicable diseases Lending Instrument: Sector Investment Credit (64), population and reproductive health (69) Environmental Screening Category: B
Project Financing Data [] Loan [X ] Credit [ ] Grant [ ] Guarantee [ ] Other: For Loans/Credits/Others: Total Project Cost (US$m.): 91.8 Government 16.5 Cofinancier 4.5 IDA (US$m.): 70.8 Proposed terms: Standard, with 20 years maturity including a grace period of 10 years
Financing Plan (US$m) Source Local Foreign Total Government 1.0 15.5 16.5 IDA 41.6 29.2 70.8 Total E&P Angola 3.8 0.7 4.5 Total Financing 46.4 45.4 91.8 Borrower: Republic of Angola
Responsible Agency: Ministry of Health Contact Person: Dr. José Vieira Dias Van-Dunem, Minister of Health
Project Implementation Period: 5 years Start: September 30, 2010 End: December 31, 2015 Estimated Disbursements (Bank FY/US$ million) FY 2011 2012 2013 2014 2015 2016 Annual 2.0 7.0 13.0 16.0 20.0 12.8 Cumulative 2.0 9.0 22.0 38.0 58.0 70.8 Project implementation period: 5 years Expected effectiveness date: September 30, 2010 Expected closing date: December 31, 2015
vii Does the project depart from the CAS in context or other significant [ ] Yes [X ] No respects Ref. PAD I.B. Does the project require any exception from Bank policies [ ] Yes [X] No Ref. PAD IV.G. Have these been approved by Bank management? [ ] Yes [ ] No Is approval for any policy exception sought for the Board? [ ] Yes [X] No Does the project include any critical risks rated ―substantial‖ or ―high‖ [X] Yes [ ] No Ref. PAD III. E. Does the project meet the Regional criteria for readiness for [X] Yes [ ] No implementation? Ref. PAD IV.D. Project development objective: Ref. PAD II.B; Annex 3. The development objective of the project is to improve the population‘s access to and quality of maternal and child health care services.
Project description: Ref. PAD II.C and Annex 4. The project will have three components: (i) Improvement of Health Service Delivery. (ii) Voucher Scheme Pilot (iii) Project Management and Monitoring and Evaluation Which safeguard policies are triggered, if any? Ref. PAD IV.F. Environmental Assessment (OP/BP 4.01)
Significant, non-standard conditions, if any, for: Credit effectiveness: (i) The Total E&P Co-financing Agreement has been executed and delivered and all conditions precedent to its effectiveness or to the right of the Borrower to make withdrawals under it (other than the effectiveness of the Financing Agreement) have been fulfilled; (ii) The MOH will have recruited qualified staff for the CCU, satisfactory to IDA, including international specialists for financial and procurement management, a public health specialist, and a training specialist with qualifications and experience, and pursuant to terms of reference, satisfactory to IDA; and (iii) The MOH has adopted an Operational Manual, including financial management and accounting procedures annexes, in form and substance satisfactory to IDA.
Disbursement condition. No disbursement will be made under component 2 (Piloting demand-side incentives to encourage institutional deliveries) until no later than two years following the effective date: (i) the Recipient will have adopted the Voucher Scheme Manual in a manner and substance satisfactory to IDA; and (ii) the Recipient has issued an internal decree, satisfactory to IDA, regulating the voucher system.
viii Other conditions: (i) The Recipient will implement the project in accordance with the Operational Manual and any substantial change in the Manual would require prior IDA approval; (ii) The Recipient will maintain the project management arrangements in form, substance, resources, and with functions satisfactory to IDA; (iii) The Recipient will conduct a mid-term review no later than December 31, 2012; (iv) The Recipient will build houses for medical staff on Government land designated for such purpose; the land acquisition and resettlement assessment will be documented; and no resettlement will occur. (v) The Recipient will cause the Project‘s external auditors to perform an audit of the procurement for all goods, works, consultants‘ services, payments for grants under the Voucher Scheme and Operating Costs required for the Project. Each audit will cover two calendar years, commencing with the calendar year in which the first withdrawal under the Project was made. The audit reports will be furnished to IDA not later than forty-five days after the end of each period and include action plans to improve performance and correct shortcomings. (vi) The Recipient shall ensure that under each yearly budget proposal to its legislature, adequate arrangements are made by the Recipient to assume such portion of the costs related to Recipient's in kind contribution, required to achieve the objectives of the Project. (vii) The Recipient shall, not later than three months following the Effective Date appoint the Project‘s internal auditors under terms of reference, qualifications and experience satisfactory to the Association. (viii) The Recipient shall, not later than six months following the Effective Date appoint the procurement auditors for the Project under terms of reference, qualifications and experience satisfactory to the Association.
ix
I. STRATEGIC CONTEXT AND RATIONALE
A. Country and sector issues.
1. At 260 deaths per 1,000 live births, the under-five child mortality rate is the second worst in the world after Sierra Leone (270). As shown on the chart, if the present trend continues, Angola has little chance of reaching that Millennium Development Goal (MDG). Maternal mortality, estimated at 1,750 per 100,000 live births, is also among the highest in the world. Key epidemiological indicators are presented in Annex 1.
Figure 1:Trends in under-5 mortality rate 2. The long-running war severely damaged the country‘s infrastructure, weakening its public administration network and social fabric. Angola has the highest concentration of landmines globally with 6-7 million mines spread over 35 percent of the country. The ruined infrastructure, diminished public and social network, and the presence of landmines make public service delivery difficult. The war resulted in 65 percent of health facilities being destroyed, while many health staff took refuge in Luanda where 70% of doctors and
30% of nurses were estimated to be living in 2004. However, during the last 2-3 years, the situation completely turned around. According to the results of a national survey of health facilities that provide obstetric and neonatal care, 70% of doctors now work at the provincial level1.
3. Even though the government is currently rehabilitating the health network, a high percentage of facilities are still not functional, especially the bottom tier of the health network (health centers and health posts), and yet this is the main vehicle to deliver primary health care to the population. Angola has only 8 doctors per 100,000 people, much lower than the average for African countries. The result is that 60 percent of the population does not have reasonable access to health care. Most people still have to walk more than one hour to reach a health facility.
4. Child mortality is mainly caused by malaria, acute diarrheal diseases, acute respiratory infections, measles and neonatal tetanus, which account for 60 percent of child deaths. These can be easily prevented or treated at the primary health care level, and through healthy practices and care at the household level. Child malnutrition, the main associated cause of child mortality, is alarmingly high. UNICEF estimates that 45 percent of children are underweight. This makes children vulnerable to diseases and health problems, and has enormous social and economic implications for the future. There are an estimated 6 million malaria cases per year, i.e. more than one-third of the population of 18 million2 is affected. Malaria represents the major cause of mortality (of which 40 percent is perinatal3 and 25 percent is maternal mortality), illness, and absence from work and school. It has the direct effect of increasing poverty.
1 Situation of Obstetric Care in Angola, UNICEF, 2007. 2 Based on a population estimate of 18,685,639, used by the DNSP of the MOH
3 Deaths occurring during late pregnancy, during childbirth and up to seven completed days of life.
1 5. Maternal mortality. The main causes of death for pregnant women are malaria, hemorrhage, eclampsia, abortion complications, and prolonged labor. Only 25 percent of births are assisted by skilled birth attendants. Complications occur in 15 percent of all pregnancies. Many of the causes of mortality are directly associated to poverty: lack of information at the household level about pregnancy complications and the risk of maternal death, delays in seeking care, lack of rapid access to transport, and insufficient reproductive health services. Yet, with emergency obstetric care in health facilities, skilled staff, proper surgical equipment, a safe blood supply and sufficient drugs, maternal mortality can be greatly reduced.
6. Obstetric Care. One of the most effective means of preventing maternal mortality is to encourage mothers to give birth in hospitals where they can have access to 24-hour emergency obstetric care. However, in Angola there are both supply and demand side constraints to increasing institutional deliveries.
7. In 2007, the government commissioned a national survey of obstetric and neo-natal care in Angola. The survey was carried out by the Averting Maternal Death and Disability Program (AMDD) of Columbia University, in partnership with the Angolan National Institute of Statistics (INE). Angola has a total of 83 units providing emergency obstetric care. Based on international norms and population ratios, the study found that Angola has a good supply of Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) facilities with 37 units. However, Angola is deficient in basic Emergency Obstetric and Neonatal Care (EmONC) with only 46 EmONC units, when a reasonable number would be 146. The demand for obstetric care is also low. Only 28 percent of women deliver in a health unit and only 15 percent in an EmONC facility. The quality of care is sub-optimal as there is a lack of qualified staff4, equipment and drugs, as shown in Annex 21. Less than 50 percent of hospitals and 33 percent of maternity units have ambulances.
8. The AMDD report, with which the Bank agrees, recommends that the MOH:
(i) Increase the proportion of women delivering institutionally and increase the number of EmONC facilities. (ii) Create links with the community to encourage women to give birth in health facilities. (iii) Provide support to reduce transport costs for pregnant women. (iv) Increase the number of maternity units in health centers so as to improve access. (v) Improve the quality of existing services. (vi) Scale up the training of doctors and nurses in obstetric care. (vii) Provide kits for normal deliveries and C-sections, as well as basic equipment. (viii) Provide ambulances. (ix) Ensure the availability of electricity and water. (x) Improve waste disposal. (xi) Provide safe blood for transfusion; and (xii) Conduct maternal death audits.
9. Essential drugs. Essential drugs are generally available in health care centers and posts. During the last 10 years, the MOH has received technical support for pharmaceutical work from Sweden, UNICEF and IDA. As a result, it has developed capacity in planning, procurement, and
4 There is a lack of neonatologists and anesthetists which the government is addressing through the contracting of Cuban doctors. Also a lack of nurse midwives that the project will address through training.
2 distribution. Over the last few years, drug purchases were made in a ―grouped manner‖, with hospitals receiving their own requirements as well as essential drugs to be deployed to associated lower-level facilities. In cases when this redistribution was not optimal, provinces have purchased drugs from their own budgets to complement the requirements for health centers and posts. The government will ensure that under each yearly budget proposal to its legislature, adequate arrangements are made by the government to assume such portion of the costs related to government‘s in kind contribution, required to achieve the objectives of the project. In addition, to smooth out distribution flows, the project will finance a buffer stock of US$5.2 million.
10. Health infrastructure. With peace in 2002, the government started an ambitious reconstruction program to rebuild the country‘s infrastructure and expand the health network. The program is financed by the government, with significant funding from China, the European Union (EU), as well as IDA through the Emergency Multisectoral and Rehabilitation Program (EMRP), which covers the provinces of Bié, Kwanza Norte, Malange and Moxico. It was initially essential to move fast with the reconstruction of facilities, so as to increase the supply of health services, but it is now important for the government to ensure that the existing and new infrastructure fit within a medium-term vision.
11. In 2008, supported by the EU, the MOH completed the first step of a mapping of the country‘s health infrastructure, covering five provinces: Benguela, Bié, Huambo, Huíla and Luanda. It provided detailed information about the physical status of every facility in each of the five provinces and allowed the planning of investments to rebuild the health facilities and other related infrastructure in accordance with government plans. The next step for the MOH is to complete this exercise in the rest of the country and develop a comprehensive and costed health infrastructure development plan for the period 2010-2020. This planning work will be supported under component 3 of the project. Terms of reference are presented in Annex 17.
12. Government spending has been increasing, but its impact is insufficient. The government recognizes the important role of the health sector in economic growth. The budget for the health sector significantly increased over the last five years, and even doubled between 2005 and 2006. In 2006, the health budget was US$71 per capita, representing 3.4 percent of GDP. This spending, although high by Sub-Saharan standards, is not having the expected impact on health outcomes, principally because of the low coverage, the poor targeting and quality of services5, and too much reliance on the provision of health services through fixed-based facilities, i.e. hospitals, health centers, and health posts.
13. Donors’ support. The main donors in the health sector are the EU, the Global Fund, the U.S. President‘s Malaria Initiative (PMI), and the Bank, which together provide about US$75-80 million annually. This represents about 14 percent of total public health expenditures. More recently, China has been financing the rehabilitation of health facilities.
14. The government has made positive achievements in the health sector. The government has made commendable efforts to control the HIV/AIDS epidemic and has been successful so far, with prevalence remaining at a low 2.5 percent. It is also scaling up its malaria control efforts, notably through the distribution of bed nets in all provinces and the replacement of chloroquine, to which
5 A detailed analysis of health sector issues and the financing of the sector is available in the report ―Angola – Public Expenditure in the Health Sector‖ by the EU and the World Bank (2007).
3 the malaria parasites have developed resistance, by an artemisin-based combination therapy (ACT). This will make an important contribution to child and maternal mortality reduction, which the government is now tackling directly through the Revitalização Program (Paras. 17-18).
15. Angola has a great opportunity to make a difference in health outcomes. First, since 2002, the country has been enjoying peace for the first time in more than 40 years. Second, Angola‘s economic outlook is promising. After a 0.6% contraction of GDP in 2009 as a result of the world economic crisis, OPEC production cuts and the drop in the price of oil, GDP is expected to grow at 6.5% per annum over the next three years. Economic growth is expected to resume in 2010. Third, the problems causing high child and maternal mortality are solvable. In fact, there is a large well- established body of knowledge about the efficacy and effectiveness of different health interventions, as well as the technologies to tackle these health problems. If the country can use this knowledge and spend money efficiently on the right interventions, the health status of the Angolan population will improve in a relatively short time.
16. Support for the government health strategy. The government health strategy is presented in a number of key documents: (i) The Government Program 2009-2012 (with a section on health); (ii) the Health Sector Development Plan; (iii) the Revival of Municipal Health Services Plan6; and (iv) the Plan for the Accelerated Reduction of Maternal and Child Mortality in Angola.
17. To improve the health status of the population, especially maternal and child health, the Ministry of Health (MOH) has started to introduce an integrated model of health service delivery consisting of: (i) health facilities providing a complete package of basic health care services; (ii) outreach teams that will start from health facilities and visit municipalities according to a regular schedule, bringing preventive and simple curative services to the population; and (iii) community health workers, supervised by outreach teams, who will mobilize communities, promote healthy behavior in the population, help recognize early signs of illness, and encourage the population to seek care from mobile outreach teams or health facilities when possible.
18. This approach is at the heart of the government‘s Revitalização Program. This program aims to cover 79 percent of the total population, i.e. about 14.8 million. It will cover 80 municipalities (out of a total 147) selected according to seven criteria: (i) population; (ii) health status: (iii) accessibility, including low risk of mines; (iv) availability of infrastructure; (v) inclusion in the decentralization program of the Ministry of Territorial Administration (to the extent possible); (vi) availability of staff, drugs, and supplies; and (vii) presence of UNICEF and WHO. The Revitalização program will improve the supply and quality of health services, increase access, and thus equity. It will improve the planning of health services at the municipal level through better meeting the needs of the population, providing adequate resources for staffing, equipment, and drugs; and strengthening the management of health services.
19. In 2006, the MOH started to implement the Revitalização program in five provinces: Huila, Bié, Cunene, Luanda, and Moxico. These five provinces and their 16 municipalities have prepared health maps, operational plans, budgets, and received training in the use of these instruments. The MOH has started to develop a Health Management Information System (HMIS), but results are limited. Much more work needs to be done to develop the instruments and train staff in recording the data and using it for decision-making. The MOH has also started to develop a community
6 Revitalização dos Serviços Municipais de Saúde
4 health workers (CHWs) program: 1,671 community health workers were trained in Huila and 948 in Luanda. This experience has led the government to determine that CHWs should be contracted by municipalities and not by the MOH -- because eventually their functions will be broadened to also cover other sectors such as agriculture, nutrition, and sanitation. The outreach program has been initiated: 130 outreach teams were created and provided with 117 motorcycles and 17 vehicles, and their visit routes planned.
20. To improve the program and expand the geographic coverage of Revitalização to the provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige, the government has asked for support from the World Bank and Total E&P Angola. The population of the selected municipalities in these five provinces is 1.9 million. Because of difficulties of access (e.g. landmines) that cannot be solved in the near term, the project will effectively cover a population of 1.5 million.
21. The five provinces were selected in close collaboration with the government, based on the seven Revitalização criteria mentioned earlier. Key health indicators for these provinces, presented in Table 1 below, show that they generally fare worse than the Angolan average. Also, in terms of total spending per province, these five provinces are in the lower 50 percent of all provinces7.
Table 1: Key health indicators for the MHSS provinces Bengo Malanje Lunda Moxico Uige Angola Norte % prevalence of fever 61.1 55.9 42.3 25.1 38.8 40.0 % prevalence of diarrhea 35.3 33.7 32.4 19.5 26.3 26.2 % prevalence of ARI8 18.3 4.8 1.7 4.8 3.9 7.0 % exclusive breastfeeding 16.2 17.0 14.9 10.4 37.0 63.9 % women receiving ANC9 80.1 67.7 67.7 71.4 67.7 79.8 % assisted deliveries 36.4 33.5 33.5 35.0 33.5 47.3
22. The framework for local governance in Angola has accelerated rapidly since 2007, especially with the Local Administration Law of January 2007 which: (i) clarifies the responsibilities for services delivered at provincial, municipal and communal levels; (ii) allows for municipalities to become independent budget units; and (iii) gives municipalities a direct connection with the center, through the Ministry of Finance and the Ministry of Territorial Administration (Ministerio de Administração Territorial, MAT). In August 2007, the Cabinet approved the ―Plano de Melhoria da Gestão Municipal‖ (Plan to Improve Municipal Management), later transformed into the Fund to Support Municipal Management (Fundo de Apoio a Gestão Municipal, FUGEM). Its aim is to address the financial, human resource and infrastructure challenges that municipal administrations are facing. It identified 68 pilot municipalities that were to receive US$5 million in fiscal transfers for investment during 2008 and 2009.
23. The MHSS will benefit from Angola‘s ongoing municipal decentralization program. In the case of the health sector, municipalities will become responsible for the management and planning of health services in addition to being responsible for other social sectors. They also have resources that allow them to complement provinces‘ spending in staffing and essential drugs and supplies.
7 EU and World Bank, Angola – Public Expenditure in the Health Sector (September 5, 2008) 8 ARI = Acute Respiratory Infection 9 ANC – Ante-Natal Care
5 24. Human resources strategy. The MOH employs about 62,500 health workers, of which 2,500 are doctors (1,200 Angolans and 1,300 from Cuba, Vietnam, and other countries), about 36,000 nurses, 20,000 support personnel, and 4,000 technicians. In the case of doctors, all the municipalities included in the project will be sufficiently staffed with specialists and generalists as they will receive, or have already received, a Cuban or other expatriate doctor team. The movement of Cuban doctors to the municipalities is expected to continue during 2009, and they will be renewed every three years. In the case of nurses, as a result of a significant training program during the conflict years, the MOH currently has a greater than sufficient number of nurses on its payroll.
25. However, the personnel are poorly distributed, some facilities having too many staff and others lacking them. A detailed analysis of personnel in the five targeted provinces is provided in Annex 20. To address this problem, the government is offering improved career prospects to encourage staff to work in rural areas and is considering a system of temporary rotation of staff from urban to rural areas. Finally, the MOH will provide houses as another incentive for qualified staff to go to rural areas.
26. The MOH‘s policy is also to upgrade the quality and productivity of its personnel. The MOH provides specialized courses allowing health personnel to improve their skills, progress to a higher category (e.g. from basic nurse to nurse midwife), and increase their salary and motivation. In-service training allows health workers to refresh their knowledge and improve their performance. These initial steps and ongoing discussions with the government show promise for addressing the challenge in a systematic and comprehensive manner. The project will support government efforts by supporting a significant amount of training (see II.C).
27. The MOH has taken the first steps towards developing a Medium-Term Human Resources Development Plan. The main strategic directions have been outlined, but the plan must be further developed and its cost estimated, under different scenarios. The project includes support to the MOH for the development of this plan, under component 3. Terms of reference to that effect are presented in Annex 16.
28. HAMSET project experience. The MHSS will build upon the strong track record of the HAMSET project. The HAMSET Project Coordinating Unit (PCU) team has gained substantial experience in implementing Bank projects including a significant grasp of Bank procedures. The HAMSET PCU is located within the MOH, and the staff already have a good relationship with health personnel working on the HIV, TB and malaria programs, as well as with partners and donors. The PCU has played a strong role in developing strategic action plans for various public sector ministries as well as private companies, and could likewise work with the National Department of Public Health (DNSP) of the MOH to assist municipalities in developing their annual action plans. The PCU staff is a strong and cohesive team that has successfully overcome staff rotation issues and remained dedicated to its work, including taking over the financial and procurement management functions when a private company, contracted to that effect, canceled its contract. The HAMSET PCU‘s growing experience in procurement will be useful for the MOH in implementing the MHSS and disbursing funds.
6 B. Rationale for Bank involvement.
29. The Bank and Total E&P Angola will support an integrated model of health service delivery to be implemented under the Revitalização Program, which the government ultimately plans to scale up throughout the country using its own resources. The large infusion of global resources towards HIV/AIDS, tuberculosis, and malaria in recent years has left a large unmet financing gap for maternal and child health services, which the project will help fill. By using its technical expertise and experience from other countries, the Bank will help the government develop outreach and community health services and introduce demand-side incentives in the health sector, an innovative concept in Angola, which the government could scale up, and consider adapting to other sectors. The Bank‘s proposed contribution has helped to leverage funds from other donors. It will help strengthen Angola‘s health system, both in the short and medium term.
30. The Bank has been involved in the health sector through the HAMSET project (US$21 million) and the health component (US$8 million) of the Emergency Multi-Sector Rehabilitation Project (EMRP), HAMSET with a moderately satisfactory rating for implementation and EMRP with a satisfactory rating. The Bank also conducted two pieces of analytical work: (i) ―Capacity Assessment of the Ministry of Health (2006)‖; and (ii) jointly with the EU, ―Public Expenditure in the Health Sector (2007)‖, both used in designing the proposed project.
31. Angola‘s governance indicators are below the African average on most indices. But, the trend is improving over time, albeit from a very low base. The project includes a Governance and Accountability Action Plan (GAAP) whose objective is to strengthen governance around the project and as a result eliminate corruptive practices so that the full potential impact of the project is attained. The GAAP is presented in Annex 19.
C. Higher-level objectives to which the Project contributes.
32. The project is directly in line with the Bank‘s Interim Strategy Note (ISN) for 2007-2009, whose second pillar is ―supporting the rebuilding of critical infrastructure and the improvement of service delivery for poverty reduction‖. It is also aligned with one of the key focus areas of the World Bank‘s Africa Action Plan: ―Strengthen national health systems and combat malaria and HIV/AIDS‖. The operation supports the Millennium Development Goals (MDGs) as follows: Goal 4: Reduce child mortality; Goal 5: Reduce maternal mortality; and Goal 6: Combat HIV, malaria and other diseases. Finally it is directly in line with the following objectives of the Bank‘s HNP Strategy: (i) improve the level and distribution of key HNP outcomes (e.g. MDGs), outputs, and system performance to improve living conditions, particularly for the poor and the vulnerable; (ii) improve financial sustainability in the HNP sector; and (iii) improve governance, accountability, and transparency in the health sector.
II. PROJECT DESCRIPTION
A. Lending instrument.
33. The project will be financed through a Sector Investment Loan (SIL). The total project cost is US$91.8 million and will be financed as follows: (i) IDA: US$70.8 million; (ii) Total E&P Angola: US$4.5 million; and (iii) government: US16.5 million. Total E&P Angola will finance part of the training program, solar kits and the rehabilitation/construction of four delivery rooms in
7 Malange and will channel its funds through a cofinancing arrangement with the Bank through a Trust Fund. Total E&P Angola relies on the Bank‘s appraisal and the next step is the signature by Total E&P Angola of a Trust Fund Agreement with IDA. A detailed project cost table is presented in Annex 5.
B. Project development objectives.
The development objective of the project is to improve the population‘s access to and quality of maternal and child health care services.
C. Project description.
34. The project has three components: (i) improvement of service delivery (US$56.3 million); (ii) voucher scheme pilot10 (US$0.8 million); and (iii) project management and monitoring and evaluation11 (US$18.2 million). The project will be implemented in the five provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige in 18 municipalities12. It will have a life of five years.
35. The MHSS project supports an integrated model of health service delivery with a minimum package of interventions (see Annex 15) aimed at reducing child and maternal mortality. By bringing health services to the population through outreach and community health workers, the project will help municipalities deliver a higher volume of cost-effective preventive and curative services to a population that may not have sought these services in the first place. This is because people face trade-offs on the use of their time between walking long distances to reach health centers and employing it for productive or other family activities. Better planning and management will help increase the volume of services in both urban and rural areas. Details on the functioning of outreach teams and community health workers and their relationship with the rest of the system are provided in Annex 4. The provision of demand-side incentives and the improvement of the supply and quality of obstetric care should increase the number of institutional deliveries and help reduce maternal mortality. To increase access to obstetric care, the project will have a dual strategy: (i) it will provide equipment to existing municipal health centers, to help improve the quality of care; and (ii) it will expand the supply of obstetric care by building 36 new delivery rooms in health centers and posts, bringing the services closer to the population.
36. Finally, the project supports the training of midwives and nurses to provide better obstetric care in these facilities. Nurses trained in EmONC and pre-natal care will be part of the integrated primary care outreach teams that will visit the most distant communities. The training will focus on the improvement of practical skills rather than on theoretical concepts.
37. Why are the proposed project interventions appropriate? They are the right ones for four reasons. First, they are technically sound and consistent with a series of Lancet articles which recommended interventions to reduce child and maternal mortality, prioritized on the available evidence (see IV. B). Second, the project supports the development of a delivery system that can be put in place relatively quickly as it involves the training and redeployment of existing staff, thus improving the quality and efficiency of service delivery. The pre-service training of CHWs takes
10 Piloting of demand-side incentives to encourage institutional deliveries 11 Includes significant activities to strengthen the capacity of the MOH and municipalities 12 The list of municipalities covered is in Annex 6.
8 45 days. In-service training for outreach team nurses lasts only 1-2 weeks. Taking into consideration the time it takes to organize the courses, the project will take 12-18 months to train the required staff. By contrast, it would take a decade and perhaps more to train new doctors and nurses, as well as build the fixed-base infrastructure. Long-term investment in training and infrastructure is also necessary and is being undertaken by the government. What the Revitalização program does is to put in place a short-term strategy to reach the MDGs more quickly. Third, project interventions make economic sense. The per capita costs of outreach and community services are estimated to be 33 and 80 percent respectively of those of fixed-base facilities. Finally, significant experience from Brazil, South Asia, and African countries such as Ethiopia, Eritrea, and Mauritania indicate that outreach and community health services have been major contributors to the reduction of maternal and child mortality. Details are provided in Annex 6.
38. Component 1 - Improvement of health service delivery (US$56.3 million). Component 1 will help strengthen the Angola health system in the five targeted provinces through training of health personnel, scaling up of outreach and community health services, strengthening of obstetric care, and improvement of hospital waste management, The training subcomponents (1a and 1b) are substantial. Their organization and feasibility are described in Para. 74 and Annex 6. There will be six subcomponents as described below.
39. Subcomponent 1a - Strengthening of municipal health services at the primary level13, entirely financed by Total E&P Angola, would finance the following training activities:
(i) Training of 20 trainers in Emergency Obstetric and Neonatal Care (EmONC); (ii) Training of 180 general nurses in EmONC; (iii) Pre-service training of about 80 nurse midwives; (iv) Training of 22 trainers in the Integrated Management of Childhood Illnesses (IMCI); and (v) Initial in-service training of about 345 general nurses in IMCI.
40. Subcomponent 1b - Strengthening of municipal health services at the primary level will finance goods, consultants, and training for the following activities:
(i) Pre-service training of about 75 general nurses; (ii) Training of about 92 staff in health service management and planning; (iii) A specialization course (public health, management of common diseases, and selected surgical procedures) for about 20 general physicians; (iv) Printing and distribution of manuals and information, education, and communication (IEC) posters; (v) Teaching and learning materials, and library books; (vi) Introduction of telemedicine in five provincial hospitals; (vii) A study of drugs planning, budgeting, acquisition and logistics; (viii) Provision of drugs and supplies in kind by the MOH and provinces; and (ix) An 18-month buffer stock of essential drugs and supplies.
41. Subcomponent 2 – Scaling up of outreach services will finance training and goods for the following activities:
13 This subcomponent is split into 1a and 1b to allow Total to finance a discrete number of activities totaling US$3.3 million equivalent under 1a.
9 (i) A refresher course for about 300 nurses in common disease management; (ii) Integrated outreach activities by mobile teams (per diem and fuel); (iii) Vehicles (4x4s, ambulances) and maintenance; (iv) Quad vehicles and maintenance kits; (v) Motorcycles and maintenance kits; (vi) Solar kits and camping kits for outreach teams.
42. To simplify accounting and reporting, operating costs for outreach activities by mobile teams (per diem and fuel) are included with all other operating costs under component 3.
43. Subcomponent 3 – Improving community interventions will finance training and goods for the following activities:
(i) Training of about 28 trainers for community health; (ii) Training of about 1,080 community health workers (CHWs); (iii) Yearly refresher courses for CHWs; (iv) Mobilization and education training meetings with traditional birth attendants (TBAs); (v) Kits (T-shirts, caps etc.) for CHWs, TBAs, and traditional healers (THs); (vi) Clean delivery kits for TBAs; and (vii) Kits for THs.
44. Subcomponent 4 (a) – Improving obstetric care will finance works, goods, and consultants for the following activities:
(i) Rehabilitation and construction of about 32 delivery rooms (for pre and post delivery, and child care) in health centers and posts14; (ii) Construction of about 24 houses for health professionals at provincial and municipal levels15; (iii) Management and supervision of civil works; (iv) Goods and equipment for pre-natal care, family planning, delivery and IMCI rooms, and maternities; (v) Radios for ambulances; (vi) Review of norms for delivery kits (normal and C-sections); and (vii) Delivery kits.
45. Subcomponent 4 (b) – Improving obstetric care, entirely financed by Total E&P Angola, would finance works and goods for rehabilitation and construction of 4 delivery rooms (for pre and post delivery, and child care) in health centers and posts in Malange.
46. Subcomponent 4 (c) – Improving obstetric care, entirely financed by Total E&P Angola, would finance goods for solar kits for maternal and child health care16.
47. Subcomponent 5 – Improving hospital waste management disposal (HWMD) will finance goods, consultants, and training for the following activities:
14 The location of delivery rooms to be built or rehabilitated is provided in Annex 6. 15 Houses will be provided with access to water, electricity, and telecommunications. 16 Not to be procured from Total E&P Angola because of conflict of interest.
10 (i) Materials and equipment for HWMD by municipal hospitals, health centers, and health posts; (ii) Training in HWMD for provincial supervisors and municipal-level personnel; (iii) Training in biosafety and universal protection; and (iv) Supervision and quality control of HWMD.
48. Component 2 – Voucher Scheme Pilot (US$0.8 million). This component will finance provision by the government of : (i) cash transfers to beneficiaries residing in the municipalities of Negage and Caculama to facilitate access to child delivery services and pre-natal care, all in accordance with the provisions of the Voucher Scheme Manual; and (ii) technical assistance to manage these activities.
49. The project will pilot vouchers to encourage pregnant women to deliver in a health facility. These consist of: (i) transport voucher subsidies; and (ii) direct subsidies for pregnant women. The pilot will start in the second year. Vouchers will be available to pregnant women living within the selected municipalities. The municipalities chosen, Negage in Uige province, and Caculama in Malange province, already have a reasonable supply of obstetric care which will be further strengthened during year 1 of the project (see Annex 20).
50. Communities and hospitals will be sensitized about the scheme to ensure the support of the male and local community leaders within the target areas. The ability of women to redeem their vouchers may be in the hands of other household members, therefore the target segments for the marketing campaign includes: (i) women between the age of 15-45 years; (ii) transport providers; (iii) health workers; and (iv) other critical community members such as fathers and community leaders. The social assessment suggests that men, especially husbands of pregnant women, must be targeted with advocacy and health education activities to make them more involved in the early stages of preparing for the birth.
51. Health facilities will be prepared about the mechanics of the scheme (e.g. the need to provide copies of a delivery certificate to each woman who delivers), but will also be encouraged to increase their productivity and at least maintain the quality of their services so as to meet the increased demand. These hospitals will also receive support (goods and equipment, training, etc.) through component 1 of the project.
52. At community level, CHWs and TBAs will be informed about the scheme and encouraged to accompany pregnant women to the hospital. Partnerships with local NGOs, Faith-based organizations, village committees, or women‘s groups where they exist, will help ensure the availability of transport.
53. The Recipient will issue an internal decree (Decreto Executivo) at Ministry level, regulating the voucher scheme through a pilot approach. A Voucher Scheme Manual will establish the system and procedures for the pilot. Both will be conditions of disbursement for component 2 whose implementation will start in year 2.
54. The overall management of the scheme will be contracted to an NGO. M&E will also be contracted out. Details on the voucher scheme are provided in Annex 18. A manual of procedures governing the administration and monitoring of the vouchers is under preparation. The adoption of
11 the manual establishing the system for the vouchers, satisfactory to IDA, is a condition of disbursement for this component.
55. This component will finance consultants.
56. Component 3 – Project Management and Monitoring and Evaluation (US$18.2 million). This component will have three subcomponents: (i) strengthening program management; (ii) strengthening the capacity of the Department of Planning of the MOH; and (iii) strengthening of monitoring and evaluation.
57. Subcomponent 1- Strengthening Program Management. This subcomponent will finance consultants and operating costs for the following activities:
(i) Strengthening the staffing of the Central Coordinating Unit; (ii) Strengthening the capacity of Provincial Departments of Health through the contracting of two specialists (health service management and M&E) for each of the five provinces; (iii) Supervision of provinces (per diem and transport); (iv) Outreach activities by mobile teams (per diem and fuel) (v) Participation in international conferences and training; (vi) Coordinating meetings for implementation planning and monitoring; (vii) Financial and procurement audits; and (viii) Preparation of detailed provincial and municipal health plans.
58. Subcomponent 2 - Strengthening the Capacity of the Department of Planning of the MOH. This subcomponent will finance consultants to support the preparation of: (i) a Medium-Term Human Resources Development Plan; (ii) a Health Infrastructure Investment Plan and (iii) a Medium-Term Expenditure Framework (MTEF).
59. Subcomponent 3 - Strengthening of Monitoring and Evaluation (M&E). This subcomponent will finance goods, consultants, and training for the following activities:
(i) Strengthening the M&E capacity of the MOH in the use of the current HMIS; (ii) Capacity building in data for decision-making at central, provincial, and municipal level; (iii) Preparation and conducting of access and quality surveys; (iv) Mid-term and final evaluations of the project; and (v) Computers, training manuals, and stationery for M&E.
D. Lessons learned and reflected in the project design.
60. This review of experience draws lessons from Bank projects in Angola in health and other sectors, and similar health projects in other African countries and elsewhere. It also draws from the World Bank publication: ―Improving Effectiveness and Outcomes for the Poor: An IEG Evaluation of World Bank Group Support for HNP Since 1997.‖ The main lessons are presented below.
61. Project design should adopt successful local interventions in the sector. With support from HAMSET as well as from the Global Fund and the President‘s Malaria Initiative, the government started reducing mortality and morbidity rates for malaria, through an IEC-based prevention strategy using community workers and outreach by local and international NGOs. This project will
12 utilize the lessons learned from this approach to implement IEC programs targeting institutional deliveries through the CHWs and outreach teams.
62. Experience in demand-side incentive programs. A number of demand-side subsidy programs around the world have been successful in increasing demand for underutilized health services. India‘s Universal Institutional Program introduced in 2006 provides monetary incentives to women to deliver in a government hospital as well as a transport subsidy for her or the accompanying community health worker. The program has not been evaluated yet, but early indications are that it has resulted in a tremendous increase in institutional deliveries, although it has faced some difficulties as it put pressure on the supply of services and their quality. Using these lessons, the project will upgrade the facilities and train the personnel in year 1 before the voucher system is initiated in year 2.
63. Linkages with the water sector are important. Adequate water and sanitation services are an essential ingredient to supporting good health. For example, the Morocco Rural Water Supply and Sanitation Project (1998-2003) showed a 24 percent reduction in diarrheal diseases in young children between 1995 and 2000. The MHSS will benefit from and develop linkages with the Bank-financed Angola Water Sector Institutional Development Project approved in July 2008.
64. Project design should be built on solid economic and sector work (ESW). Before designing the MHSS, the Bank undertook two pieces of analytical work: (i) Capacity Assessment of The Ministry of Health (2006); and (ii) Public Expenditure Review (PER) of the Health Sector (2007)17. Both reports were extensively discussed with the government and donors, and their analysis and conclusions, particularly those of the second one, have been instrumental in the design of the MHSS.
65. The Bank and governments need to focus more on monitoring and evaluation. During recent years, the Bank has started to make significant efforts to ensure that clients frame objectives in measurable terms, obtain baseline data, adhere to plans for routine monitoring, conduct periodic surveys, and disseminate the results. It is important to avoid ambitious development objectives and inappropriate performance indicators, and be realistic about what a project can achieve. Lessons from ICRs show that it is important to: (i) follow a good result framework in project design and M&E; and (ii) avoid using higher-level objectives, such as mortality reduction, as project development objectives.
66. The government’s commitment and ownership are prerequisites for success. As stated earlier, extensive analytical work and project preparation have been carried out with full MOH involvement. The strong government support for strengthening the health system through the implementation of the existing Revitalização municipal health systems strengthening approach should also ensure the success of the project. Previous projects in Angola, including HAMSET, have shown that when government leadership is strong, institutional changes and the sustainability of investments are more guaranteed.
67. Flexible and simple design. The project adopts a simplified design with a limited geographic scope rather than full national coverage, by prioritizing five provinces for activities. This will allow
17 A joint European Union – World Bank report
13 the MOH to build up institutional capacity before expanding at the national level. Also, the project design makes the objectives of each component independent, measurable, and monitorable.
68. Intensive supervision will be required for this project given the country’s limited institutional capacity. The project‘s supervision plan is presented in Annex 22.
E. Alternatives considered and reasons for rejection.
69. Why not HAMSET II? Through HAMSET, the Bank has been the first external financier to help the government control HIV/AIDS, TB, and malaria. This has led the way to further funding from the Global Fund and the U.S. President‘s Malaria Initiative, and increased financing for HIV/AIDS control from the government itself. On the other hand, maternal and child health indicators are appalling, justifying the strategic decision to give priority to investing in the improvement of these health outcomes.
70. Angola is a large country with still low implementation capacity. Both the government and the Bank considered that attempting a project on the national scale would be overly risky and perhaps not feasible. By targeting only five provinces, the project design matches the country capacity and reduces complexity, an important lesson from IEG‘s Evaluation of World Bank Group Support for Health, Nutrition, and Population Since 1997
71. No project alternative. The ―no project‖ alternative is not desirable because child and maternal mortality are very high in Angola, and malaria devastating. Without an operation that supports an integrated service delivery model, Angola‘s chances of reaching the MDGs in 2015 would be slim.
III. IMPLEMENTATION
A. Partnership arrangements.
72. The partnership arrangements for project implementation will be with Total E&P Angola for financing. The project will collaborate with UNICEF, WHO, and UNFPA on technical and implementation issues. Total E&P Angola‘s financing of US$4.5 million will support training under subcomponent 1a the rehabilitation and construction of 4 delivery rooms in health centers and posts in Malange; and solar kits for maternal and child health care in component 4 (b)18. All other MHSS project components will be funded by the Bank (US$70.8 million).
73. Joint Project Implementation Reviews. A Steering Committee will monitor the progress of the MHSS project. The Committee will be chaired by the Minister of Health or his designate. Its members will be, inter alia, the Vice-Minister for Hospital Management, the Vice-Minister for Public Health, the Director for Human Resources, the Director of Planning, the National Director for Medical Equipment and Medicines, the Director for Public Health, and one representative of Total E&P Angola.
74. Bi-annual Joint Project Implementation Reviews will be led by the MOH with the participation of stakeholders and development partners. The Reviews will have three components: (i) joint review of the past year‘s activities and of critical questions in a number of thematic areas;
18 To be procured from entities other than Total E&P Angola
14 (ii) a joint visit to a province to better understand the problems in the field and discuss with stakeholders; and (iii) a plenary session to consolidate the field work and approve the plan of activities for the following year.
B. Institutional and implementation arrangements.
75. Institutional arrangements are presented in Figure 2. The Ministry of Health will have the overall responsibility for the implementation of the project. The National Department of Public Health (DNSP) will be in charge of the day-to-day implementation of the project. In 2006, the DNSP created the MHSS Central Coordinating Unit (CCU). The CCU is headed by a Coordinator who reports to the National Director of Public Health, and will be strengthened by the addition of a Deputy Coordinator, an M&E Specialist, an Infrastructure Specialist, a Training Specialist, a Health Specialist, a Financial Management (FM) Specialist, and a Procurement Specialist, as well as supporting staff.
76. The Financial Management and Procurement Specialists will be physically located within the Central Project Coordinating Unit (located within the National Department of Public Health), however that other specialists such as the Training Specialist, the Infrastructure Specialist, the Monitoring and Evaluation Specialist could be physically located in other departments of the MOH as this would allow other MOH staff to benefit from their experience, thus building capacity and ensuring a better sustainability of the Project. Although all the above mentioned staff would work in different offices, they will work as a team to coordinate Project implementation activities.
77. A Project Implementation Unit (the CCU) is justified because the Bank‘s Interim Strategy Note for The Republic of Angola dated April 26, 2007 explicitly states that ―to reduce the risk of poor governance to Bank projects, the Bank will take a ring-fenced approach until capacity in government for sound fiduciary management can be built‖. In addition, the CCU will contribute to building capacity of staff who will be fully integrated in the MOH after the end of the project.
78. At the provincial level, Provincial Health Directors are responsible for the implementation of the MHSS. Their role is to coordinate program implementation in the municipalities that are part of the province. To strengthen implementation capacity in each of the five provinces, the project will contract a technical support team of two persons: (i) a public health systems specialist; and (ii) an M&E Specialist.
79. The MOH will enter into subsidiary agreements with the five provinces whereby the provinces will show their commitment to provide their share of human resources, drugs, supplies etc. to ensure the good implementation of the project.
80. At the municipal level, the Municipal Health Officer‘s tasks are to: (i) prepare the MHSS municipal operational plan; (ii) manage the municipal health teams; (iii) prepare a monthly plan of visits to health units to monitor progress and provide implementation support to health staff and mobile teams; and (iv) produce a monthly report documenting the maternal and child health services provided in the municipality.
81. Training. While there is a large number of persons to be trained, this is feasible because: (i) there are training institutes in each of the provinces and the overall training workload will be divided into five; (ii) trainers from Luanda and Lubango will train the trainers in each of the
15 institutes; (iii) training materials and curriculums are available; (iv) there are enough supervisors for the practical part of the training (e.g. for the midwives); and (v) there are clear responsibilities in the CCU with a Training Specialist who will manage and coordinate the training program. Details are provided in Annex 6.
82. The Infrastructure Specialist of the CCU will be responsible for managing the implementation of civil works and equipment. TORs for the contracting of consultants will be the responsibility of the Deputy Coordinator. The Health Care Waste Management Specialist, part of the DNSP, will be in charge of implementing subcomponent 5. The pilot testing of demand-side vouchers will be contracted to an NGO. Monitoring and Evaluation will be the responsibility of the M&E Specialist who will work with the provincial and municipal staff, but the access and quality surveys will be contracted out. Details are provided in Annex 6.
Figure 2: MHSS Institutional Arrangements
Ministry of Health National Department of Public Health
HCWM MHSS Central Coordinating Unit Specialist (CCU) Coordinator
Deputy Coordinator
M&E Training Infrastructure Health FM Procurement Specialist Specialist Specialist Specialist Specialist Specialist
FM Officer Procurement Officer
Provincial Departments of Health Provincial Bengo, Malange, Lunda Norte, Moxico, and Uige Training Institutes (Including Public Health Specialist and M&E Specialist supported by MHSS in each province)
Municipal Health Officers
C. Monitoring and evaluation of outcomes and results.
83. Output indicators will be collected through the routine HMIS and during supervision visits. However, since the HMIS has shortcomings in the quality, completeness and timeliness of data, the project will also use annual rapid surveys to collect confirmatory data for outcome indicators. At the same time, the project will strengthen provinces and municipalities in data collection and in the use of data for decision-making (DDM).
16 84. Health Delivery Channel Household Survey (WHO Rapid KAP Survey). WHO and the MOH have agreed on TORs for the first round of the survey. This survey will sample households from target municipalities and provide information on knowledge, practices, coverage of key health interventions, and reasons why mothers do not access services. After each annual survey, WHO will conduct workshops to strengthen provinces‘ capacity to use data for planning.
85. Rapid Health Facility Assessment. The MHSS will support an annual rapid health facility assessment focusing on obstetrical and emergency neonatal care services, and sick-child services (IMCI). The survey will be contracted out to WHO. The latter will finalize the survey instruments, carry out the surveys, and provide data analysis and reporting. This survey will be performed in close collaboration with the Health Delivery Channel Household Survey, as the information they provide is complementary.
86. Strengthening the HMIS. In theory, the HMIS is able to provide data on all of the key indicators. However, at present, the information is either not easily available or is incomplete. The project will help strengthen the M&E capacity of municipalities and provinces by: (i) developing a training manual on DDM; (ii) training provincial M&E officers as DDM trainers; and (iii) helping them to replicate the training for provincial directors and M&E officers. This will be the first step in strengthening M&E capacity.
87. The second step includes support for quarterly reviews and planning sessions. At these sessions, provincial M&E officers will host meetings for municipal directors and M&E officers where the quarterly HMIS data are presented, together with other survey information that becomes available during the period. The data will be presented, analyzed, and used to update municipal and provincial work plans.
D. Sustainability.
88. Prospects for the project‘s sustainability are strong. First, sustainability efforts will focus on demonstrating the feasibility of implementing the project cost-effectively in the five provinces. Given the high level of poverty, the project focuses less on the financial sustainability of project inputs through direct household contributions or other alternative local financing. Rather, the project focuses on three critical ingredients of sustainability. First, on the supply side, the project will promote institutional sustainability by showing that the basic package of services can be delivered cost-effectively in the five provinces. To achieve this, health services will be reconfigured so that they cater increasingly to community and outreach services.
89. Second, sustainability efforts will also be directed to achieving policy support at the national level for the demonstrated improvements in health coverage and outcomes. This project is non- threatening as it is based on an agreed-upon agenda, the government‘s Revitalização Program, and is supported by evidence both through the modeling exercise conducted as part of the PER.
90. Third, the project will support demand-side household behavior change interventions. It will promote positive change in household and community behavior in order to increase their demand for health services. To this end, the acquisition of health knowledge will be promoted through IEC activities and community involvement.
17 91. Fourth, the government will have the means to sustain and increase spending in the health sector. Although GDP decreased slightly in 2009, economic growth will resume afterwards and Angola‘s medium-term economic prospects are good. The Bank projects GDP to grow by around 6.5% per annum from 2010 to 2012. An analysis was made to assess the sustainability of operational expenses after the project. These include the cost of outreach teams (per diem and fuel), the increase in salaries of nurses and doctors who will have moved to a higher grade as a result of training, maintenance of delivery rooms, staff houses, and vehicles, the cost of the CCU including two additional staff in each province, and supervision and surveys. These would amount to about US$5.5 million per year, which represents only 0.43 percent of the MOH budget, and is easily sustainable.
92. By helping the MOH prepare a Health Infrastructure Investment Plan, a Medium-Term Human Resources Development Plan, and a Medium-Term Expenditure Framework, the Bank will help the government in the planning and scaling up of service delivery over the medium term, thus making the proposed investment integrated into the MOH planning, which will facilitate sustainability.
E. Critical risks and possible controversial aspects
Table 2: Risks Risk Risk Mitigation Measure Risk Rating19 Country Risk The Bank is taking a number of measures: (i) the EMTA H Systemic corruption, governance project is helping to build the capacity of the public sector issues, and lack of transparency. In in governance, contract enforcement, and property rights; the Transparency International‘s and (ii) the GAAP will enhance public disclosure and Corruption Perception Index for compliance mechanisms, will help mitigate collusion and 2009, Angola‘s score ranks 162th fraud risks, and will improve institutional capacity to out of 180 countries, compared to manage the sector. 147th in previous year. From Outputs to Objective The MHSS does not introduce threatening policy changes Decline in political commitment. that could create resistance. It will, however, bring some L alterations in health service delivery at the local level, which will require support from managers at the provincial and central levels. Major stakeholders in the MOH at the central and local levels will be regularly involved during project implementation. Incentives to outreach health workers will benefit the sector and will not induce controversy.
From Components to Outputs Staff with strong project management experience, will be Insufficient management capacity at contracted by the MHSS Central Coordinating Unit. Given M the MOH central level leading to that HAMSET will not have closed when the MHSS delays in procurement and becomes effective, the CCU procurement and financial disbursement of funds. officers will be able to receive support from HAMSET‘s international procurement and financial management specialists. The CCU will also recruit a public health specialist.
19 After mitigation
18 Lack of project implementation Training and supervision of provinces and municipalities by capacity at the provincial and the CCU (10 percent of project budget will be used for this S municipal levels. training).
Delays in training of additional While there are a large number of persons to be trained, this S human resources required for scaling is feasible because: (i) there are existing training institutes up of health service delivery in each province, therefore the overall training workload will be divided into five; (ii) trainers from Luanda and Lubango will train the trainers in each of the institutes; (iii) training materials and curriculums are available; and (iv) a Training Specialist in the CCU will manage and coordinate the training program.
Implementation risks of demand-side Fund deviation risk will be mitigated by close cash flow S subsidies: (i) deviation of funds for monitoring and control procedures, and audits focused on private gains; (ii) a program that potentially vulnerable areas. Credibility risk will be does not function well at the mitigated by setting up clear institutional responsibilities, a beginning and loses credibility; and well-designed project cycle, clear rules for the selection of (iii) program stimulates demand, but beneficiaries, and a reliable management information supply cannot respond system. Excess demand risk will be addressed by increasing the existing capacity for institutional delivery. The overall risk will be mitigated by implementing the pilot in only two municipalities.
Fiduciary problems, including Mechanisms built into the project design include: (i) prior S misuse of funds review of large contracts; (ii) random reviews of statements of expenditures during implementation; (iii) financial management reporting linking performance to financial costs; (iv) random audits of small executing entities; and (v) financial audits of all large executing agencies.
Overall Risk Rating S H: High S: Substantial M: Moderate L: Low
F. Credit conditions and covenants
93. Conditions of effectiveness will be as follows:
(i) The Total E&P Co-financing Agreement has been executed and delivered and all conditions precedent to its effectiveness or to the right of the Borrower to make withdrawals under it (other than the effectiveness of the Financing Agreement) have been fulfilled; (ii) The MOH will have recruited qualified staff for the CCU, satisfactory to IDA, including international specialists for financial and procurement management, a public health specialist, and a training specialist with qualifications and experience, and pursuant to terms of reference, satisfactory to IDA; and (iii) The MOH has adopted an Operational Manual, including financial management and accounting procedures annexes, in form and substance satisfactory to IDA.
19
94. Disbursement condition. The disbursement condition is as follows:
No disbursement will be made under component 2 (Piloting demand-side incentives to encourage institutional deliveries) until no later than two years following the effective date: (i) the Recipient will have adopted the Voucher Scheme Manual in a manner and substance satisfactory to IDA; and (ii) the Recipient has issued an internal decree, satisfactory to IDA, regulating the voucher system.
95. Other conditions will be as follows:
(i) The Recipient will implement the project in accordance with the Operational Manual and any substantial change in the Manual would require prior IDA approval; (ii) The Recipient will maintain the project management arrangements in form, substance, resources, and with functions satisfactory to IDA; (iii) The Recipient will conduct a mid-term review no later than December 31, 2012; (iv) The Recipient will build houses for medical staff on Government land designated for such purpose; the land acquisition and resettlement assessment will be documented; and no resettlement will occur. (v) The Recipient will cause the Project‘s external auditors to perform an audit of the procurement for all goods, works, consultants‘ services, payments for grants under the Voucher Scheme and Operating Costs required for the Project. Each audit will cover two calendar years, commencing with the calendar year in which the first withdrawal under the Project was made. The audit reports will be furnished to IDA not later than forty-five days after the end of each period and include action plans to improve performance and/correct shortcomings. (vi) The Recipient shall ensure that under each yearly budget proposal to its legislature, adequate arrangements are made by the Recipient to assume such portion of the costs related to Recipient's in kind contribution, required to achieve the objectives of the Project. (vii) The Recipient shall, not later than three months following the effective date appoint the Project‘s internal auditors under terms of reference, qualifications and experience satisfactory to the Association. (viii) The Recipient shall, not later than six months following the effective date appoint the procurement auditors for the Project under terms of reference, qualifications and experience satisfactory to the Association.
IV. APPRAISAL SUMMARY A. Economic and financial analyses. 96. The justification for government involvement, cost-effectiveness of project interventions, and the sustainability of the project are summarized below. A detailed analysis is presented in Annex 19.
97. Justification for government involvement. Although Angola has an average per capita income of US$740, relatively high for sub-Saharan Africa, 68 percent of the population lives below the poverty line of $1.70 per day. Urban poverty is rising, mainly due to the influx of
20 displaced people into cities and the lack of job opportunities. Women‘s illiteracy is high (46%). Government involvement is justifiable, given the project's focus on poor and remote provinces, the overwhelming incidence of communicable diseases in these provinces, the absence of private providers, and the need for the government to drive the health reform process and steward the sector at the national and provincial levels. Thus, preventive and promotional health interventions supported by the project will have significant externalities.
98. Cost-effectiveness of project interventions. The project design relies heavily on the analytic work, conducted as part of the PER, which identified and costed out the packages of supply interventions that could best reduce the burden of disease in the country. The results of this modeling exercise are presented in Table 3.
Table 3: Impact on Under-Five and Maternal Mortality Reduction and Additional Cost Per Capita of Five Health Service Delivery Steps in Angola Reduction Reduction Reduction Cost (US$ per in IMR in U5MR in MMR capita per year) Step 1: Undertake community-based social 29% 39% 1% 2.51 mobilization and behavioral interventions Step 2: Scale up population-based outreach 9% 8% 9% 1.05 services Step 3: Expand primary health care 17% 23% 1% 3.05 Step 4: Strengthen the first level referral care 2% 2% 3% 0.97 Step 5: Improve the second level referral care 1% 1% 3% 0.89 All five steps 51% 62% 17% 8.48
B. Technical.
99. The MHSS supports a package of interventions aimed principally at reducing child and maternal mortality in the five selected provinces. Child care and maternal care key interventions are supported by a body of evidence, notably in a series of Lancet20 articles published in 2003, 2006, and 2008 as well as Cochrane collaboration reviews21 on interventions to reduce maternal mortality. C. Fiduciary.
100. Financial management. The Ministry of Health will have the overall responsibility for the management of the project. The National Department of Public Health (DNSP will be responsible for the day-to-day management of the project through its Central Coordinating Unit (CCU). The CCU staff, including financial management, contract management, procurement, monitoring and evaluation, will work closely with the HAMSET Project Coordinating Unit, and will benefit from their experience, including from HAMSET‘s internationally contracted Procurement and Financial Management (FM) Specialists.
20 The Lancet, founded in 1823, is one of the oldest peer-reviewed medical journals in the world, published weekly in England. The Lancet is considered to be one of the core general medical journals. 21 The Cochrane Collaboration, founded in 1993, was developed in response to Archie Cochrane's call for up-to-date, systematic reviews of all relevant randomized controlled trials of health care. A group of over 6,000 specialists in health care review biomedical trials and results of other research.
21 101. The project‘s financial management arrangements were reviewed in accordance with the FM Practices Manual issued by the FM Board on November 3, 2005. The review concluded that the overall risk rating for the project is substantial. Several mitigating measures are proposed, and are summarized in an FM action plan that sets up the necessary arrangements for a smooth implementation of the project. After the proposed measures, the residual risk is reduced to moderate. Details are provided in Annex 7.
102. Procurement. The last Country Procurement Assessment Review (CPAR) for Angola was conducted in April 2002. In March 2004 the government produced its own procurement reform document, which is based on the CPAR, and is now supported by the Economic Management Technical Assistance project (EMTA). The reform is still in the early stage of implementation, with the drafting of the new procurement code continuing.
103. As mentioned above, the MOH has already established a Central Coordinating Unit (CCU) reporting to the Director of Public Health. The CCU will be staffed with an international procurement specialist and local procurement staff who have developed procurement experience with the HAMSET project. The overall risk for procurement is rated moderate.
104. Procurement for the project will be carried out in accordance with the World Bank's Procurement Guidelines and the provisions stipulated in the Legal Agreement. After the new procurement code is ready, government procedures may be acceptable under National Competitive Bidding if found satisfactory by IDA. Details are provided in Annex 8.
D. Social. 105. Local socio-cultural behavioral aspects that influence health and illness are important factors in the effective implementation and outcomes of health interventions. A social assessment was conducted to better understand these factors so as to improve the project design, implementation and sustainability. The main social development issues reviewed were: (i) community mobilization and participation; (ii) social diversity and gender; and (iii) socio-cultural barriers to services. The assessment was conducted through meetings with focus groups in one urban and one rural area each in the provinces of Malange and Bengo. The main results of the assessment and how the analysis will be used are presented below.
Table 4: Observations from Social Assessment Observations from Social Assessment Project measures to address them In rural areas, people tend not to take many initiatives In the initial selection process of CHWs, and expect support from the government traditional leaders will be encouraged to select candidates recognized for taking some initiative. Men do not see themselves as responsible for disease The training curriculum of CHWs will pay prevention, such as using bed nets, using boiled water particular attention to this aspect. Training of or removing trash. CHWs will not be limited to health matters, but will include inter-personal communications and leadership.
22 The population complained about how poorly they are The training program of health workers and received when they go to a health facility. This facility administrators will emphasize the discourages them from seeking care, resulting in importance of relationships with patients. A some women preferring to deliver at home. module will stress the importance of respect for the community and the need to consider the rural population as clients even if their health knowledge is limited. Many persons complained about user fees charged by As part of the GAAP, the MOH will start a health workers. program to place posters in health facilities informing the public that health services are free and that no payment should be made to health workers. Women complained about their excessive number of The project will put emphasis on family pregnancies. planning. Many women do not go to a hospital if they have to CHWs will work with communities to identify deliver at night. persons who can accompany women to the hospital.
E. Environment.
106. The project has been classified as ―B‖ for environmental screening purposes. An assessment of current health care waste management and disposal systems was undertaken. The detailed findings are presented in Annex 10 and are summarized below.
107. When the HAMSET project was appraised in 2004, practices in health care waste handling, storage and disposal raised environmental and social concerns. There were no national environmental and social policies and regulations for the safe handling, storage and disposal of health care waste. A thorough assessment was conducted, and under HAMSET, the government developed a national Health Care Waste Management Plan. HAMSET helped the government start implementing the plan, including capacity building, mitigation measures and their timely monitoring. Financing for priority actions of the Plan, up to US$200,000 were included in the HAMSET project.
108. The MHSS project adheres to the key objectives and activities of the National Health Care Waste Management Strategy. The project will apply the lessons learned from the implementation of the HCWM Plan during the HAMSET project to foster a sound management of health care waste at the national level. The project will emphasize the implementation of this action plan in the five targeted provinces.
109. This project will build on the progress already achieved under HAMSET to help the government improve healthcare waste disposal in the project area and throughout the country. The HCWM Plan was updated in March 2009, and revised to reflect the current realities faced in the targeted provinces. The Medical Waste Management Plan (MWMP) and The Environmental and Social Management Framework (ESMF) were published by the Bank in Infoshop on November 25, 2009, and on the MOH website on April 21, 2010.
110. The HCWM Plan will be applied through the life of the MHSS project. It involves intensive training and capacity building activities, review of legal and institutional framework, the provision of protective clothing and biosafety kits, basic equipment, technical support, and monitoring.
23 Financing of US$995,000 for activities of the HCWM Plan is included under Subcomponent 3. This is over four times the budget allocated under HAMSET.
111. More progress is required in health care waste management in Angola. Despite the inadequate picture of current health care waste management practices and context, there is reasonably fertile ground for success for the health care waste management plan. The commitment of the central, provincial and local government to the National Health Care Waste Management strategy is encouraging. A new centralized incineration center for infectious health care waste has been established. The government is also contracting three new private waste management service providers to complement the activities of the existing provider, URBANA 2000, and broaden the coverage of the waste management and disposal activities in a safe and timely fashion. Finally, a number of NGOs have been playing a crucial role in public awareness and in behavior change activities targeted at medical staff, cleaning personnel and the general public.
112. The project will build houses for medical staff in 18 municipalities. They will be built on Government land designated for such purpose. The land acquisition and resettlement assessment will be documented, and the project team will verify that no resettlement will occur.
113. In discussions with Government officials, the team has been assured that all houses would be either built within hospital grounds or in Government land reserves designated for such purpose. The team provided the government with translated copies of the Land Acquisition Assessment Forms and asked to have them completed and signed to document the legal description of the land, location, occupation, use. The ESMF includes copies of signed forms for each site, verifying that no resettlement will occur.
114. To prevent environmental impacts due to the construction or rehabilitation of houses for medical staff in health centers and posts, the ESMF addresses the General Environmental Management issues associated with civil works and include an annex with Detailed Environmental Management Conditions for Construction Contracts.
F. Safeguard policies.
Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP 4.01) [x] [ ] Natural Habitats (OP/BP 4.04) [ ] [x] Pest Management (OP 4.09) [ ] [x] Physical Cultural Resources (OP/BP 4.11) [ ] [x] Involuntary Resettlement (OP/BP 4.12) [ ] [x] Indigenous Peoples (OP/BP 4.10) [ ] [x] Forests (OP/BP 4.36) [ ] [x] Safety of Dams (OP/BP 4.37) [ ] [x] Projects in Disputed Areas (OP/BP 7.60)* [ ] [x] Projects on International Waterways (OP/BP 7.50) [ ] [x]
* By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas
24 G. Policy Exceptions and Readiness.
115. The project does not require exceptions from Bank policies. It meets the Regional criteria for readiness for implementation. The government is progressing well in meeting the three conditions of effectiveness. Two of them are well advanced; (i) the draft Operational Manual is ready; and (ii) the co-financing agreement with Total E&P Angola is currently being prepared by IDA. As regards the third condition which is the recruitment of staff for the Central Coordinating Unit, the government has prepared the TORs for these positions and started to prepare short lists of candidates.
25
Annex 1: Country and Sector Background ANGOLA: Municipal Health Service Strengthening Project (MHSS)
116. After a lengthy struggle between Portugal and the Angolan nationalist movement, Angola gained independence in 1975. A civil war, lasting 27 years, broke out after independence over power sharing options between the nationalist groups. The war severely damaged the country‘s infrastructure, leaving its public administration network and social fabric in tatters. Angola has the highest concentration of landmines globally with 6-7 million mines over 35 percent of the country. The ruined infrastructure, broken public and social network, and the presence of landmines make public service delivery difficult. Inequalities persist and are widening. Angola has an average per capita income of US$740, relatively high for sub-Saharan Africa, but 68 percent of the population lives below the poverty line of $1.70/day. Urban poverty is rising, mainly due to the influx of displaced people and the lack of job opportunities. Women‘s illiteracy (46% nationally but 66% for rural women) is far higher than that of men (16%). Most women only have access to unskilled jobs, mainly in the informal sector (where two-thirds of the jobs are done by women). 117. Angola is a potentially rich country, blessed with rich deposits of oil and diamonds. It is the second largest oil producer in sub-Saharan Africa, with rising oil production, which accounts for almost half of the GDP and about 75 percent of government revenue. Angola is also the world‘s fourth largest producer of rough diamonds, which represent 95 percent of non-oil exports. Angola‘s economic outlook is promising, although it has been affected in 2009 by the global economic crisis, GDP is expected to grow by 6.5 percent in real terms over the period 2010-2012. Figure 3: Trends in under-5 mortality rate 118. Given these positive trends, Angola has a great opportunity to make a difference in health outcomes. The government recognizes the important role of the health sector in economic growth. The budget for the health sector has significantly increased over the last five years, and even doubled between 2005 and 2006. However, Angola faces considerable challenges in addressing its current health outcomes.
119. At 260 deaths per 1,000 live births, the child mortality rate is the second worst in the world after Sierra Leone (270). As shown on the chart, Angola has little chance of reaching its Millennium Development Goal (MDG) target with its existing health services. Maternal mortality, estimated at 1,750 per 100,000 live births, is also among the highest in the world. The prolonged war resulted in 65 % of health facilities being destroyed, while many health staff took refuge in Luanda where 70% of doctors, 30% of nurses, and 45% of other health staff have remained. The distribution problem has worsened the overall shortage of health staff in remote provinces, whereas by contrast there is overstaffing in Luanda. As a result, the coverage for basic health services is low, and the majority of the population is not protected by basic and effective health services.
26 120. Even though the government is currently rehabilitating the health network, many facilities particularly in the bottom tier (health centers and health posts) are still not functional, mainly due to a damaged infrastructure that needs to be rebuilt or repaired, and the lack of staff and key inputs. In 2002, 11 percent of hospitals, 10 percent of health centers, and 46 percent of health posts were not operational, and yet these are required to deliver primary health care to the population. Angola has 0.9 doctor per 10,000 inhabitants (or 8 doctors per 100,000 people) compared to 2.4 in Botswana (2002), 1.3 in Zimbabwe (2003), and 0.2 in Mozambique (2000). People still have to walk more than an hour to reach a health facility. The government relies on service delivery in fixed facilities (hospitals and health centers), whereas experience from other countries shows that service delivery should be complemented by outreach and community services that are highly cost- effective. 121. Epidemiological profile. Angola has not gone through the epidemiological transition yet and has a young growing population estimated at 18 million. There is a high prevalence of communicable diseases and child and maternal mortality. Malaria, tuberculosis, diarrhea, and HIV/AIDS are among the most serious diseases, which have affected the economic recovery and quality of life. With an estimated 6 million cases per year, malaria is the principal cause of mortality (of which 40 percent of perinatal22 and 25 percent of maternal mortality) and morbidity. Diarrhea prevalence is 25 percent among the under-5 year olds (MICS II), but only 7 percent of these cases were treated with rehydration fluids and continued feeding. 122. TB is one of the common reasons for visits to health facilities. Recent estimates indicate that tuberculosis prevalence is increasing with around 7,000 new cases diagnosed every year. The overall HIV prevalence rate is estimated at 2.5% (MOH), which is not very high when compared with its neighbors. There is much variation between provinces, with a minimum of 0.8 percent in the central province of Bié and a maximum of 11 percent in southern province of Cunene that borders Namibia. Surveys of sex workers demonstrated a rapid increase in prevalence from 19 percent in 1999 to 32.8 percent in 2001. During the last five years there have been outbreaks of Marburg disease, meningitis and cholera in specific areas that put an added burden on the already weakened health system.
123. Angola compares unfavorably with other Sub-Saharan African countries, which themselves have significantly higher rates compared to the rest of the world, in key health outcomes. Table 5: Key health outcome indicators Sub-Saharan Indicator Angola Africa Average Life expectancy at birth (years - 2003) 40 49 Fertility rate (2002) 7.0 5.0 Infant mortality rate (per 1000 live births - 2000) 154 92 Under-five mortality rate (per 100,000 live births - 2000) 260 171 Maternal mortality ratio (estimates) 1,700 914 Contraceptive prevalence/100,000 (2003) 6.0 22.9 GDP/Capita US$ 975 1,073 Source: UNICEF MICS 2001 and World Development Indicator 2006
22 Deaths occurring during late pregnancy (at 22 completed weeks gestation and over), during childbirth and up to seven completed days of life
27
124. Child (under-5) mortality is mainly caused by malaria (23%), acute diarrheal diseases (18%), acute respiratory infections (15%), and premature birth (7%), which account for about 60 percent of child deaths23. These can be easily prevented or treated at the primary health care level, and through healthy practices and care at the household level. Regional differences in child mortality are salient in Angola, with the west, central and capital regions showing the highest under-5 mortality rates. These regions also possess the highest population concentration, which indicates that a large share of child deaths occurs in these regions. Child malnutrition is alarmingly high and comparable to Afghanistan and Southern Sudan. According to the 2001 MICS, 45 percent of children are malnourished and underweight. Angola has a high level of stunting and wasting which will make children vulnerable to diseases and health problems, and can have enormous social and economic implications in the future.
125. The main causes of maternal mortality are malaria, hemorrhage, eclampsia, abortion complications, and prolonged labor, and one in seven pregnant women die from avoidable reasons. Only 25% of births are assisted by skilled staff; complications occur in 15% of all pregnancies. Many of these causes are directly associated to poverty: delays in seeking care, lack of rapid access to transport, and insufficient reproductive health services. Yet, with emergency obstetric care in health facilities, skilled staff, proper surgical equipment, a safe blood supply and sufficient drugs, maternal mortality can be greatly reduced.
126. Angola also has poor health service coverage, except for vaccination coverage for polio (63%24 compared to 46% for Africa25), deliveries in health facilities (45% compared to 39%), and ante-natal consultations (66% of pregnant women attend one or more ante-natal consultations). A 2002 Management Sciences for Health (MSH) survey, covering only 3 municipalities in Luanda province, found that only 17% of women of reproductive age use any method of contraception. Combined with the data on attendance at ante-natal consultations and deliveries attended by trained health personnel, services related to pregnant women still lag far behind the rest of the continent.
127. If Angola can use this knowledge and spend money efficiently on the right interventions, the health status of the population can be improved in a relatively short time. Relative health expenditures have been stable at 4-5 percent of GDP since 2001, but increased in absolute terms, from US$213 million in 2002 to US$447 million in 200526. In 2006, the health budget was US$1 billion27 representing 3.4 percent of GDP and US$71 per capita, substantially above the majority of African countries and above the US$37 basic health package calculated by the Commission on Macroeconomics and Health.
128. This spending is not having the expected impact on health outcomes, principally because of low coverage, and the poor targeting and quality of services28. Angola continues to have poor health outcomes compared to other Southern Africa Development Community (SADC) countries that spend less per capita. Zimbabwe spends less than Angola on health (US$14 per capita), but has
23 Ministry of Health -Angola. Studies, Planning and Statistics Office. Deaths in Luanda cemeteries.2002-2003 24 MICS 2001 survey only covered areas accessible during the war. 25 State of the World‘s Children, UNICEF 2002. 26 Estrategia de Combate a Pobreza (ECP, Angola‘s PRSP) and SIGFE; numbers for 2006 are budgeted numbers. 27 The exchange rate used for the proposed 2006 budget was of 94.2 kwanzas per US dollar. 28 Detailed analysis of issues and financing is available in ―Angola – Public Expenditure in the Health Sector‖ by the European Union (EU) and the World Bank (2007).
28 a lower under-5 mortality rate with 129 deaths per 1,000 live births. South Africa spends US$114 per capita and has a maternal mortality ratio of 67 per every 100,000 live births, compared with 1,700 deaths per 100,000 live births in Angola29.
129. The main donors are the European Union (EU), the Global Fund, the U.S. President‘s Malaria Initiative (PMI), and the Bank, which together provide about US$75-80 million annually. China has also been financing the rehabilitation of health facilities. With donor support, the government has made commendable efforts to control the HIV/AIDS epidemic and has been successful so far, with prevalence remaining at 2.5 percent. It is also scaling up its malaria control efforts, notably through the distribution of bed nets in all provinces and the replacement of chloroquine for malaria treatment by artemisin-based combination therapy (ACT). This will contribute to child and maternal mortality reduction. Currently, efforts to rebuild health facilities, from municipal hospitals to health centers, are being made in all provinces. It is expected that the health infrastructure being built will improve the population‘s access to essential health services.
130. Support of the government health strategy. The government health strategy is presented in a number of key documents: (i) the Government Program 2009-2012 (with a section on health); (ii) the Health Sector Development Plan (currently being updated); (iii) the Municipal Health Service Strengthening (MHSS) Plan30; and, (iv) the Investment Plan for the Accelerated Reduction of Maternal and Child Mortality (2007-2013) in Angola. These documents provide a general direction in which the health sector should be heading. However, they usually do not link expected outcomes with effective and efficient spending and do not include detailed implementation arrangements. As a result, resources are not being used optimally and better health status has not been achieved.
131. The government developed an Investment Plan for Accelerated Child Survival and Development to revitalize the country‘s primary health services and help achieve the health-related MDGs. This investment plan will cover five of the country‘s 18 provinces and reach 33% of the Angolan child population in the first phase (2007-2009) and aims to cover the whole country by its completion. It is designed to save an estimated 58,000 children and 3,000 mothers‘ lives every year. The proposed project will support this effort, in close collaboration with UNICEF.
132. The Strategic Plan for the Accelerated Reduction of Maternal and Child Mortality (2004- 2008) prioritized an essential package of interventions as its means to reduce child and maternal mortality. The package is organized by service delivery mode: (i) primary health services; (ii) mobile and advance health teams; and (iii) community health agents. The interventions included in the package are proven cost-effective services with high impact on child and maternal mortality. They are very much in line with the international best-buy list of interventions.
133. The donor community provides help in three different ways:
(i) Funds for vertical programs for the control of specific diseases such as malaria and HIV/AIDS (including the Bank HAMSET project for US$21 million). There has been growing support for more integrated approaches. (ii) Institutional development and strengthening of implementation capacity. This is provided to the MOH and provincial governments through technical assistance and
29 Health indicators in Angola are not reliable and, apart from the 2001 UNICEF MICS, there has been no adequate health survey conducted after the war. 30 Revitalização dos Serviços Municipais de Saúde
29 training to help design policies and implementation strategies. The Bank supported analytical work: (i) ―Capacity Assessment of the Ministry of Health (2006)‖; and (ii) jointly with the EU, ―Public Expenditure in the Health Sector (2007).‖ (iii) Direct provision of services, mostly in remote areas, with donor funds channelled mainly through NGOs. Service provision tends to be coordinated with municipal and provincial authorities, but less so with the MOH.
134. The MOH is also in the process of increasing the supply and quality of basic health services through the MHSS Program. This program aims to cover 79 percent of the total population, i.e. about 14.8 million31. It will cover 80 municipalities selected in function of: (i) population; (ii) health status: (iii) accessibility, including low risk of mines; (iv) availability of infrastructure; (v) inclusion in the decentralization program of the Ministry of Territorial Administration (to the extent possible); (vi) availability of staff, drugs, and supplies; and (vii) presence of UNICEF and WHO. The objectives of the MHSS are to improve the supply and quality of health services, increase access, and thus equity.
135. The key elements of the MHSS Program are: (i) planning the supply of health services at the municipal level in function of the needs of the population in the catchment area of the municipality; (ii) developing an integrated network of health services consisting of fixed-based facilities, outreach, and community health services; (iii) providing adequate resources for staffing, equipment, and drugs; and (iv) strengthening the management of health services.
136. In 2006, the MOH started to gradually implement the MHSS with support from the EU, UNICEF, WHO, and UNFPA in 19 municipalities located in four provinces: Huila, Bié, Cunene, and Luanda. This allowed the MOH to test its new management and planning instruments and learn key lessons that will be useful to expand the Program throughout the country. The MOH is attempting to reverse the inequitable distribution of health personnel and outcomes through the MHSS, notably by creating incentives for the settlement of specific cadres in the peripheral and disadvantaged areas.
137. To expand the geographic coverage of the MHSS, the government has asked for support from the World Bank and Total E&P Angola in the provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige. The total population of the selected municipalities in these five provinces is 1.9 million. Because of difficulties of access that cannot be solved in the near term, the project would effectively cover a population of 1.5 million.
31 Based on a population estimate of 18,685,639, used by the DNSP of the MOH
30 138. Selected health indicators for the provinces are presented in Table 6 below.
Table 6: Key health indicators for the MHSS provinces Bengo Malanje Lunda Moxico Uige Angola Norte % prevalence of fever 61.1 55.9 42.3 25.1 38.8 40.0 % prevalence of diarrhea 35.3 33.7 32.4 19.5 26.3 26.2 % prevalence of ARI32 18.3 4.8 1.7 4.8 3.9 7.0 % exclusive breastfeeding 16.2 17.0 14.9 10.4 37.0 63.9 % women receiving ANC33 80.1 67.7 67.7 71.4 67.7 79.8 % assisted deliveries 36.4 33.5 33.5 35.0 33.5 47.3
139. The health system relies heavily on vertical arrangements for the delivery of some key services. The MOH national departments are organized by diseases and supported vertically by donors, which has created parallel management, logistics and information systems that are generally not integrated. It is important to recognize that successes have been achieved through the vertical arrangements. For example, the immunization program reached a relatively high coverage level in a short time. The HIV/AIDS, TB, and malaria programs have been able to expand the coverage of prevention and treatment services.
140. The experience of the Revitalização program. In 2006, the MOH started to implement the Revitalização program in 19 municipalities located in five provinces: Huila, Bié, Cunene, Luanda, and Moxico. The objectives of the Revitalização program are to improve the supply and quality of health services, increase access, and thus equity. The key elements of the Program are: (i) planning the supply of health services at the municipal level in function of the needs of the population in the catchment area of the municipality; (ii) developing an integrated network of health services consisting of fixed-based facilities, outreach, and community health services; (iii) providing adequate resources for staffing, equipment, and drugs; and (iv) strengthening the management of health services.
141. The key results of this program are as follows:
(i) The 5 provinces and 16 municipalities have prepared health maps, operational plans, budgets, and received training in the use of these instruments. The training experience went well and similar training will be provided in the provinces supported by the project;
(ii) The MOH has started to develop an HMIS, but results are limited. Much more work needs to be done to develop the instruments and train staff in recording the data and using it for decision-making;
(iii) The MOH has started to develop a community health workers (CHWs) program: 1671 community health workers were trained in Huila and 948 in Luanda. This experience has allowed determining that CHWs should be contracted by municipalities, and not by the MOH (because eventually their functions will be broadened to also cover other sectors such as agriculture, nutrition, and sanitation). Their package of services, originally
32 ARI = Acute Respiratory Infection 33 ANC = Ante-Natal Care
31 limited to immunization has been broadened to include basic maternal and child prevention activities, and the control of malaria, TB, and HIV/AIDS. They are expected to visit 300 families per month and are paid on the basis of a report showing the tasks they have performed. They mobilize communities and prepare them for outreach visits.
(iv) The outreach program has been initiated: 130 outreach teams were created and provided with 117 motorcycles and 17 vehicles, and their routes of visits were planned. The objective is to bring health services to populations who are too far to access health facilities. They also provide an integrated package of health services and supervise the CHWs.
32 Annex 2: Major Related Projects Financed by the Bank and other Agencies ANGOLA: Municipal Health Service Strengthening Project (MHSS)
Table 7: Major related projects financed by the Bank Latest Supervision Ratings Sector Project Implementation Development Progress Objectives HIV/AIDS, HIV/AIDS, Malaria, and MS S Malaria, and Tuberculosis Control project TB (HAMSET) (US$21 million) Rehabilitation Health component of Emergency S S of health Multisector Rehabilitation Program sector (EMRP) (US$8 million)
Table 8: Organizations Present in the Five Provinces Province/Municipality Name of Organization Area of Interest Bengo Centro de Investigação em Training of laboratory Saúde (CISA)-IPAD and technicians and support of F.C. Gulbenkian internships for medical students. The partnership of Gulbenkian with the Provincial Institute is likely to improve the quality of teaching. Catholic Church - Training of Polish MDs. Could St.Lucas Hospital support the training of Angolan General Physicians
Lunda Norte Chemonics-USAID Provide in-service training and TA to the Provincial Health department in MCH. Complements MHSS project.
Malange UNICEF Maternal and child health OMS Malaria ADRA (Associação para o HIV/AIDS prevention Desenvolvimento Rural de Angola) CONSAUDE In 2009, started training in IMCI and malaria case management. The training program of MHSS takes this
33 into consideration to avoid overlap. Moxico UNICEF Revitalização
Uige Uige (capital) CUAMM (Italy) Support to DPS in TB and leprosy control. Potential partnership with MHSS given their experience in MCH and management of health services. ADB (African Provided training to about 3 Development Bank) doctors and a limited number of nurses. Infrastructure construction and rehabilitation included in the ADB project (but financing taken over by the MOH). It complements the MHSS. Negage Catholic Church (Caritas) Provides health services in a limited number of its own facilities, complementing the provincial health network provincial health network
Rede HIV HIV prevention
34 Annex 3: Results Framework and Monitoring ANGOLA: Municipal Health Service Strengthening Project (MHSS)
Table 9: Project Development Objectives and Outcome Indicators Project Development Project Outcome Indicators Use of Project Outcome Objectives Information Improve the population‘s - Institutional deliveries (%) Lack of progress will result in access to and quality of recommended modifications to maternal and child - Children 0-1 year immunized with sector strategy and/or analysis to rd healthcare services34. pentavalent vaccine 3 dose (%) understand relationship between - Children immunized (number) CORE35 the implementation of the strategy - Children receiving a dose of Vitamin A and the outcomes. (number) CORE - Pregnant women receiving antenatal care during a visit to a health provider (number) CORE - Direct Project Beneficiaries (number) of which female (%) CORE - People with access to a basic package of health, nutrition and population services (number) CORE Intermediate Results Intermediary Results Indicator Use of Results Monitoring
Component 1 Improved availability of - Health facilities constructed, renovated infrastructure, trained and/or equipped (number) CORE Progress will be assessed by personnel and equipment in - Delivery rooms built (number) government and partners at the targeted delivery rooms - Delivery rooms in designated health Annual Reviews (based on most centers with necessary trained personnel, recently available data). equipment, supplies and medicines to provide 24-hour emergency obstetrical Lack of anticipated progress will and neonatal care (%) result in analysis of obstacles to Improved monitoring of - Health facilities receiving at least 2 implementation and health facilities supervision visits per year using reconsideration of assumed standardized checklists (%) linkages between inputs/processes Improved planning capacity - MHSS municipalities that have an annual and outcomes. at the municipal and municipal plan (number) provincial level - Provinces that have an investment plan (number) Improved conditions for - Staff houses built (number) and knowledge of health - Health personnel receiving training personnel (number) CORE - CHWs trained (number) - General nurses trained in EmONC (number)
34 Many of these indicators will cover the five provinces of Bengo, Lunda Norte, Malange, Moxico and Uíge where the project will be implemented. 35 CORE = IDA 15 Indicators
35 - Nurse midwives who received pre- service training (number) - Nurses trained in IMCI (number)
Intermediate Results Intermediary Results Indicators Use of Results Monitoring
Increased outreach to - Ambulances and 4x4 station wagons targeted areas purchased (number) - Programmed communities receiving at least 3 outreach visits per year (%) - Motorcycles purchased for outreach teams (number) - Municipalities that have implemented 80% of municipal outreach plans (number) Component 2 Increased demand for basic - Women receiving vouchers (number) Progress will be assessed as part and emergency obstetrical - Women that deliver in a health facility of the pilot and will inform the and comprehensive that redeem vouchers (number) decision to adjust and scale up the neonatal care at municipal - Mothers satisfied with transportation and program. level direct vouchers (%) - Municipalities with voucher pilot completed (number) Component 3 Strengthen the managerial, - Municipal Annual Health Reports Progress will be assessed by planning and M&E capacity Received on time (%) government and partners at the of the MOH and - Health professionals trained in health Annual Reviews (based on most Municipalities system management (number) recently available data). - MHSS municipalities with operational plans (number) Lack of anticipated progress will result in analysis of obstacles to implementation and reconsideration of assumed linkages between inputs/processes and outcomes.
36 Table 10: Monitoring Framework Target Values Data collection and reporting Outcome Indicators Baseline Year 1 Year 2 Year 3 Year 4 Year 5 Frequency Data Responsibility (2009) of collection for data reporting instruments collection 1. Percentage of institutional 4136 50% 52% 55% 57% 60% Annual Annual MOH deliveries Report 2. Percentage of children 0-1 year immunized with Penta rd KAP Survey vaccine 3 dose. 27 29 31 33 35 38 Annual MOH
37 3. Children immunized Annual (number) CORE 34,000 42,000 49,000 56,000 61,000 64,000 Annual MOH Report
4. Pregnant women receiving antenatal care during a visit Annual to a health provider 81,000 86,000 93,000 98,000 103,000 109,000 Annual MOH (number) CORE Report
5. Direct Project Beneficiaries 38 (number) of which female 0 128,300 270,300 424,300 588,300 762,672 Annual Annual MOH (%) CORE (70%) (67%) (66%) (64%) (63%) (63%) Report
36IBEP. Preliminary results, 37 Estimate based on the coverage of fully immunized children (according to information provided by the mother and health card) of 29%, found in the IBEP report (preliminary results). It is assumed that this percentage should reach at least 50% by the end of the project. 38 The total number of beneficiaries is equal to the number of children immunized and women receiving Ante-natal care. The number of institutional deliveries was not taken into account because of the risk of double counting and the fact that the M&E system cannot track the overlap. Also the % of female beneficiaries goes down because the number of children fully immunized increases at a faster rate than that of the deliveries according to our projections. Also no addition of children immunized to estimate the indirect benefit on women was done. 6. People with access to a39 basic package of health, 1 nutrition and population N/A visit/person Annual MOH services (number) CORE /year
Component 1 – Improvement in Service Delivery 7. Health facilities 0 0 12 24 36 36 Annual Supervision MOH constructed, visits (DNSP) renovated and/or equipped (number) CORE - delivery rooms built40 8. Delivery rooms in 0 0 50% 60% 70% 90% Annual Supervision MOH designated health visits (DNSP) centers with all necessary trained personnel, equipment, supplies and medicines to provide 24-hour emergency obstetrical and neonatal care (%) 9. Health facilities 0 20% 30% 40% 55% 70% Annual Supervision MOH receiving at least 2 visits (DNSP) supervision visits per year using
39 It is proposed to use number of outpatient visits per inhabitant as a proxy of access to basic HNP services 40 In Angola the health infrastructure has been severely damaged during the war. The number and types of health facilities is not fully known. A mapping exercise will soon take place and will help establish a baseline in 1-2 years.
38 standardized checklists (%) 10. MHSS 0 3 7 11 15 18 Annual Supervision MOH municipalities that visits (DNSP) have an annual municipal plan (number) 11. Provinces that have 0 0 1 2 3 5 Annual Supervision MOH an investment plan visits (DNSP) (number) 12. Staff houses built 0 0 6 12 18 24 Annual Supervision MOH (number) visits (DNSP)
13. Health personnel 0 0 705 1495 1575 1680 Annual Supervision MOH receiving training visits (DNSP) (number) CORE - CHWs trained 0 0 500 1080 1080 1080 Annual Supervision MOH (number) visits (DNSP)
- General nurses 0 0 90 180 180 180 Annual Supervision MOH trained in EmONC visits (DNSP) (number) - Nurse midwives 0 0 35 75 75 75 Annual Supervision MOH who received pre- visits (DNSP) service training (number) - Nurses trained in 0 0 80 160 240 345 Annual Supervision MOH IMCI (number) visits (DNSP)
14. Ambulances and 0 0 20 40 54 54 Annual Supervision MOH 4x4 station wagons visits (DNSP) purchased (number)
39 15. Programmed 0 15 30 45 60 70 Annual Supervision MOH communities visits (DNSP) receiving at least 3 outreach visits per year (%) 16. Motorcycles 0 0 30 60 146 146 Annual Supervision MOH purchased for visits (DNSP) outreach teams (number) 17. Municipalities that 0 3 6 9 12 18 Annual Supervision MOH have implemented visits (DNSP) 80% of municipal outreach plans (number) Component 2 – Voucher Scheme Pilot 18. Women receiving 0 vouchers (number)
19. Women that 0 1 deliver in a health facility that redeem vouchers (number) 20. Mothers satisfied 0 40% 50% 65% 70% 75% with transportation and direct vouchers (%) 21. Municipalities 0 0 0 1 2 2 Annual Supervision MOH with voucher pilot visits (DNSP) completed (number)
40 Component 3 – Project Management and M&E 22. Municipal Annual 0% 30% 50% 75% 85% 95% Annual MOH reports MOH Health Reports Received on time (%) 23. Health 0 0 20 40 60 92 Annual Supervision MOH professionals visits (Human trained in health Resources system Department) management (%) 24. Municipalities 0 0 4 8 12 18 Annual Supervision MOH with operational visits (DNSP) plans (number)
The following IDA 15 CORE Indicators were not included in this project because they are tracked under the IDA-financed Angola HAMSET Project, currently under implementation, that directly targets malaria and HIV: (i) Long-lasting insecticide-treated malaria nets purchased and/or distributed (number) (ii) Adults and children with HIV receiving antiretroviral combination therapy (number) (iii) Pregnant women living with HIV who received antiretroviral to reduce the risk of Mother-To-Child Transmission (number)
41 142. All the output indicators for the project will be collected through the routine HMIS and supervision visits. However, as regards outcome indicators, the HMIS has shortcomings in the quality, completeness and timeliness of data. Thus, for outcome indicators, the MHSS will also use rapid surveys to collect confirmatory data for all of the indicators at least annually. At the same time, the MHSS will strengthen municipal and provincial HMIS data collection as well as the use of data for decision-making.
143. Rapid Health Facility Assessment. The MHSS will support an annual rapid health facility assessment focusing on obstetrical and emergency neonatal care services, and sick-child services (IMCI). This survey will be performed in a sample of four health facilities in each target municipality, including the provincial reference facilities and each facility where a new delivery room is constructed and equipped. The survey instrument will be based on a draft survey instrument developed by WHO, which focuses on obstetrical and emergency neonatal care services. An additional module will be developed to provide information on the quality of IMCI services, including the direct observation of five sick child consults in each facility.
144. The survey will be implemented through the contracting of WHO. The agency will be responsible for finalizing the survey instruments, carrying out the surveys and analysis and reporting. The MHSS CCU M&E officer will provide oversight and technical assistance for the survey, in collaboration with WHO. This survey will be performed in close collaboration with the Health Delivery Channel Household Survey, as the information they provide is highly complementary.
145. Health Delivery Channel Household Survey (WHO Rapid KAP Survey). WHO and the MOH have agreed on terms of reference for the first round of the Health Delivery Channel Household Survey. This survey will sample households from target municipalities providing information on knowledge, practices and coverage of key maternal and child health interventions, as well as information about why mothers do not access services. The survey will include all MHSS target provinces by groups, with each survey area requiring a sample of about 300-500 households. The survey instrument will be based on a model developed by WHO which is now being translated and adapted to the Angolan context. The MHSS will provide some financial support for the MHSS target provinces. Technical assistance will be provided by WHO and the MHSS CCU M&E officer. Implementation of the survey will be done through a procurement contract with WHO, with considerable participation from the MOH. This survey will be closely coordinated with the Health Facility Assessment, which will provide information that is highly complementary. After each survey round, WHO will support provincial workshops to strengthen data use for planning.
146. Strengthening the HMIS. The MOH HMIS design in theory is able to provide all of the indicators listed as sourced from the HMIS. However, at baseline the information is either not easily available or is incomplete. The MHSS will support the strengthening of the M&E capacity of municipalities and provinces. This will include the development of a training manual on data for decision-making, training of provincial M&E officers as DDM trainers, and support for them to replicate the training for provincial directors and M&E officers. This will be the first step in strengthening M&E capacity.
147. The second step includes support for quarterly review and planning sessions. At these sessions, provincial M&E officers and provincial MHSS officers will host meetings for municipal directors and M&E officers where the quarterly HMIS data are presented, together with any other
42 relevant survey information or other information that becomes available during the period. The data will be presented, analyzed, and used to update municipal and provincial work plans. Training materials and instruments for conducting the quarterly review and planning meetings will form part of the DDM training materials described above.
Evaluation of the Demand-Side Incentives Pilot
148. The demand-side incentives pilot will require special arrangements for monitoring and evaluation, as both ongoing monitoring and impact evaluation are important to guarantee both coverage and transparence, as well as to evaluate the impact on demand for services and to identify bottlenecks and correct them. The following table lists the indicators that will be tracked together with the source of information:
Table 11: Indicators and data source Indicator Data source Comments
Number of women HMIS—requires additional MHSS CCU will design receiving vouchers form to record this forms for recording the information at pilot health HMIS—requires additional facilities. Number of women that form or place on registry to deliver in a health facility note it down and report it. that redeem vouchers This is not routinely collected.
HMIS—calculated from Percentage of all women previous indicator divided delivering that redeem by total institutional vouchers deliveries
HMIS—requires new Number and % of transport system (recorded at vouchers redeemed redemption site)
HMIS—requires new Number and % of other system. Recorded at (direct) vouchers redeemed redemption site.
As above: HMIS confirmed Number of and % of by MICS and WHO rapid institutional deliveries KAP annually.
% of facilities that report no difficulty attending to the Rapid Health Facility demand for institutional Assessment deliveries
43 % of mothers receiving transportation and direct WHO rapid KAP survey,
vouchers41 during the annual previous pregnancy.
% of mothers that received transportation and direct WHO rapid KAP survey, vouchers during the annual previous pregnancy that redeemed them.
% of mothers satisfied with WHO rapid KAP survey, transportation and direct annual vouchers
Questionnaire of sample of Drivers‘ satisfaction with drivers at the time of MHSS CCU M&E officer vouchers (waiting time for redemption of vouchers in will design and tabulate. redemption, amount) sentinel sites. Semi- quantitative questionnaire
Total value of voucher Financial reports MHSS CCU program
149. The data sources that will be required are described below.
150. Routine Health Information System. The MHSS CCU M&E officer will work with the MOH M&E unit to design and implement instruments for collecting the routine indicators listed above as deriving from the HMIS. This will require the following special instruments:
Design of a registry form for use during antenatal care to capture the number of transportation and clothing vouchers issued by health facilities to pregnant women. Design of a registry for use at the time the post-partum mother requests a copy of the birth registration to give to the driver so he can redeem the voucher. The person issuing the birth registration form will record that the woman used a transportation voucher and requested a birth registration copy for the purpose of redeeming the form. It may be advisable to design an additional redundant registry for use by nurses interviewing women that arrive for delivery about whether she used a transportation voucher to come pay for transportation to the facility. This would help identify obstacles between using the voucher for transportation and acquiring the birth registration so the driver can redeem the voucher.
151. Rapid health facility assessment. A series of questions will be added to the health worker interview that ask about increased demand for institutional deliveries and whether the facility is able
41 There are two types of vouchers: (i) transport voucher subsidies; and (ii) direct subsidies for pregnant women to encourage them to give birth in a health facility.
44 to cope with the demand. This information will be collected annually in the municipalities where the pilot is implemented. It will be the responsibility of the MHSS M&E officer to make certain that these questions are included in the HFA.
152. Delivery Channel Household Survey (WHO Rapid KAP Survey). A series of questions assessing mothers‘ satisfaction and ease of use of the voucher system will be added to the Delivery Channel Survey only in the municipalities where the pilot is being implemented. The questions will assess the coverage of the distribution of the vouchers, whether the voucher was a factor in her decision to deliver at the facility, why or why not, and ease of redemption (for both transportation and clothing). This information will be collected annually in the areas where the pilot is being implemented. It will be the responsibility of the MHSS M&E officer to make certain that these questions are included in the Delivery Channel Household Survey.
153. Questionnaires at Sentinel Sites. At least one sentinel voucher redemption sites will be designated in each province where the program is being implemented. At the time that vouchers are redeemed by providers of transport and pregnant women, a questionnaire will be administered to a sample of transportation providers and of women. The questionnaires will ascertain their satisfaction with the vouchers, their value, prior knowledge about the voucher system, ease of redemption, time it took to redeem them, and whether a secondary market for vouchers has arisen, Responsibility for the design of the sentinel site sampling and questionnaires will be the responsibility of the MHSS CCU M&E officer. Implementation, supervision and reporting will be shared between the CCU and the provincial MHSS officers.
45
Annex 4: Detailed Project Description ANGOLA: Municipal Health Service Strengthening Project (MHSS)
154. The project would have three components: (i) improving service delivery in five provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige in 18 municipalities 42(US$56.3 million); (ii) piloting of demand-side incentives to increase institutional deliveries (US$0.8 million); and (iii) strengthening the capacity of the MOH and municipalities (US$18.2 million). It would have a life of five years.
155. The project would support an integrated model of health service delivery with a package of interventions (detailed in Annex 16) aimed principally at reducing child and maternal mortality. By bringing health services to the population through outreach and community health workers, the project would help municipalities deliver a higher volume of cost-effective preventive and curative services to a population that would not have sought these services in the first place. This is because people face tradeoffs on the use of their time between walking long distances to reach health centers and employing it for productive or other family activities. Also, better planning and management would help increase the volume of services in both urban and rural areas. The provision of demand-side incentives as well as the improvement of the supply and quality of obstetric care would increase the number of institutional deliveries and help reduce maternal mortality.
156. Considering the enormous size of the provinces and the fact that it will take many years to build and staff a network of health facilities in the most distant villages, the MOH has developed a strategy of outreach teams, for areas beyond a range of 20 km. Outreach teams are scheduled to visit each community at least four times a year.
157. Teams of community health workers (CHWs) would be developed in each village. They would be trained to undertake health promotion and prevention. Outreach teams would provide technical support to CHWs when visiting their area.
158. To increase access to obstetric care, the project will have a dual strategy: (i) it will provide equipment to existing municipal health centers, thus helping to improve the quality of care; and (ii) it will expand the supply of obstetric care by building 36 new delivery rooms in health centers and posts, bringing the services closer to the population.
159. Finally, the strategy calls for the training of midwives and nurses who will provide obstetric care in these facilities. Nurses trained in EmONC and pre-natal care will be part of the integrated primary care mobile teams that will visit the most distant communities at least four times a year. The training process will focus mostly on the improvement of practical skills rather than on theoretical concepts.
160. Component 1 - Improvement of health service delivery (US$56.3 million). Component 1 will help strengthen the Angola health system in the five targeted provinces through training of health personnel, scaling up of outreach and community health services, strengthening of obstetric
42 The list of municipalities covered is provided in Annex 22.
46 care, and improvement of hospital waste management, The training subcomponents (1a and 1b) are substantial. Their organization and feasibility are described in Para. 74 and Annex 6. There will be six subcomponents as described below.
161. Subcomponent 1a - Strengthening of municipal health services at the primary level43, entirely financed by Total E&P Angola, would finance the following training activities:
(i) Training of 20 trainers in Emergency Obstetric and Neonatal Care (EmONC); (ii) Training of 180 general nurses in EmONC; (iii) Pre-service training of about 80 nurse midwives; (iv) Training of 22 trainers in the Integrated Management of Childhood Illnesses (IMCI); and (v) Initial in-service training of about 345 general nurses in IMCI.
162. Subcomponent 1b - Strengthening of municipal health services at the primary level will finance goods, consultants, and training for the following activities:
(i) Pre-service training of about 75 general nurses; (ii) Training of about 92 staff in health service management and planning; (iii) A specialization course (public health, management of common diseases, and selected surgical procedures) for about 20 general physicians; (iv) Printing and distribution of manuals and information, education, and communication (IEC) posters; (v) Teaching and learning materials, and library books; (vi) Introduction of telemedicine in five provincial hospitals; (vii) A study of drugs planning, budgeting, acquisition and logistics; (viii) Provision of drugs and supplies in kind by the MOH and provinces; and (ix) An 18-month buffer stock of essential drugs and supplies.
163. Subcomponent 2 – Scaling up of outreach services will finance training and goods for the following activities:
(i) A refresher course for about 300 nurses in common disease management; (ii) Integrated outreach activities by mobile teams (per diem and fuel); (iii) Vehicles (4x4s, ambulances) and maintenance; (iv) Quad vehicles and maintenance kits; (v) Motorcycles and maintenance kits; (vi) Solar kits and camping kits for outreach teams.
164. To simplify accounting and reporting, operating costs for outreach activities by mobile teams (per diem and fuel) are included with all other operating costs under component 3.
165. Subcomponent 3 – Improving community interventions will finance training and goods for the following activities:
(i) Training of about 28 trainers for community health; (ii) Training of about 1,080 community health workers (CHWs);
43 This subcomponent is split into 1a and 1b to allow Total to finance a discrete number of activities totaling US$3.3 million equivalent under 1a.
47 (iii) Yearly refresher courses for CHWs; (iv) Mobilization and education training meetings with traditional birth attendants (TBAs); (v) Kits (T-shirts, caps etc.) for CHWs, TBAs, and traditional healers (THs); (vi) Clean delivery kits for TBAs; and (vii) Kits for THs.
166. Subcomponent 4 (a) – Improving obstetric care will finance works, goods, and consultants for the following activities:
(i) Rehabilitation and construction of about 32 delivery rooms (for pre and post delivery, and child care) in health centers and posts44; (ii) Construction of about 24 houses for health professionals at provincial and municipal levels45; (iii) Management and supervision of civil works; (iv) Goods and equipment for pre-natal care, family planning, delivery and IMCI rooms, and maternities; (v) Radios for ambulances; (vi) Review of norms for delivery kits (normal and C-sections); and (vii) Delivery kits.
167. Subcomponent 4 (b) – Improving obstetric care, entirely financed by Total E&P Angola, would finance works and goods for rehabilitation and construction of 4 delivery rooms (for pre and post delivery, and child care) in health centers and posts in Malange.
168. Subcomponent 4 (c) – Improving obstetric care, entirely financed by Total E&P Angola, would finance goods for solar kits for maternal and child health care46.
169. Subcomponent 5 – Improving hospital waste management disposal (HWMD) will finance goods, consultants, and training for the following activities:
(i) Materials and equipment for HWMD by municipal hospitals, health centers, and health posts; (ii) Training in HWMD for provincial supervisors and municipal-level personnel; (iii) Training in biosafety and universal protection; and (iv) Supervision and quality control of HWMD.
170. Component 2 – Voucher Scheme Pilot (US$0.8 million). This component will finance provision by the government of : (i) cash transfers to beneficiaries residing in the municipalities of Negage and Caculama to facilitate access to child delivery services and pre-natal care, all in accordance with the provisions of the Voucher Scheme Manual; and (ii) technical assistance to manage these activities.
171. The project will pilot vouchers to encourage pregnant women to deliver in a health facility. These consist of: (i) transport voucher subsidies; and (ii) direct subsidies for pregnant women. The pilot will start in the second year. Vouchers will be available to pregnant women living within the selected municipalities. The municipalities chosen, Negage in Uige province, and Caculama in
44 The location of delivery rooms to be built or rehabilitated is provided in Annex 6. 45 Houses will be provided with access to water, electricity, and telecommunications. 46 Not to be procured from Total E&P Angola because of conflict of interest.
48 Malange province, already have a reasonable supply of obstetric care which will be further strengthened during year 1 of the project (see Annex 20).
172. Communities and hospitals will be sensitized about the scheme to ensure the support of the male and local community leaders within the target areas. The ability of women to redeem their vouchers may be in the hands of other household members, therefore the target segments for the marketing campaign includes: (i) women between the age of 15-45 years; (ii) transport providers; (iii) health workers; and (iv) other critical community members such as fathers and community leaders. The social assessment suggests that men, especially husbands of pregnant women, must be targeted with advocacy and health education activities to make them more involved in the early stages of preparing for the birth.
173. Health facilities will be prepared about the mechanics of the scheme (e.g. the need to provide copies of a delivery certificate to each woman who delivers), but will also be encouraged to increase their productivity and at least maintain the quality of their services so as to meet the increased demand. These hospitals will also receive support (goods and equipment, training, etc.) through component 1 of the project.
174. At community level, CHWs and TBAs will be informed about the scheme and encouraged to accompany pregnant women to the hospital. Partnerships with local NGOs, Faith-based organizations, village committees, or women‘s groups where they exist, will help ensure the availability of transport.
175. The Recipient will issue an internal decree (Decreto Executivo) at Ministry level, regulating the voucher scheme through a pilot approach. A Voucher Scheme Manual will establish the system and procedures for the pilot. Both will be conditions of disbursement for component 2 whose implementation will start in year 2.
176. The overall management of the scheme will be contracted to an NGO. M&E will also be contracted out. Details on the voucher scheme are provided in Annex 18. A manual of procedures governing the administration and monitoring of the vouchers is under preparation. The adoption of the manual establishing the system for the vouchers, satisfactory to IDA, is a condition of disbursement for this component.
177. This component will finance consultants.
178. Component 3 – Project Management and Monitoring and Evaluation (US$18.2 million). This component will have three subcomponents: (i) strengthening program management; (ii) strengthening the capacity of the Department of Planning of the MOH; and (iii) strengthening of monitoring and evaluation.
179. Subcomponent 1- Strengthening Program Management. This subcomponent will finance consultants and operating costs for the following activities:
(i) Strengthening the staffing of the Central Coordinating Unit; (ii) Strengthening the capacity of Provincial Departments of Health through the contracting of two specialists (health service management and M&E) for each of the five provinces; (iii) Supervision of provinces (per diem and transport); (iv) Outreach activities by mobile teams (per diem and fuel)
49 (v) Participation in international conferences and training; (vi) Coordinating meetings for implementation planning and monitoring; (vii) Financial and procurement audits; and (viii) Preparation of detailed provincial and municipal health plans.
180. Subcomponent 2 - Strengthening the Capacity of the Department of Planning of the MOH. This subcomponent will finance consultants to support the preparation of: (i) a Medium-Term Human Resources Development Plan; (ii) a Health Infrastructure Investment Plan and (iii) a Medium-Term Expenditure Framework (MTEF).
181. Subcomponent 3 - Strengthening of Monitoring and Evaluation (M&E). This subcomponent will finance goods, consultants, and training for the following activities:
(i) Strengthening the M&E capacity of the MOH in the use of the current HMIS; (ii) Capacity building in data for decision-making at central, provincial, and municipal level; (iii) Preparation and conducting of access and quality surveys; (iv) Mid-term and final evaluations of the project; and (v) Computers, training manuals, and stationery for M&E.
50 Annex 5: Project Costs ANGOLA: Municipal Health Service Strengthening Project (MHSS)
Table 12: Detailed Project costs Component 1 - Improvement in service delivery 1.1 (a) Strengthening of municipal health services at primary level Training of 20 trainers (TOT) for emergency obstetric care (EmONC) and Safe motherhood 99,350 Training of 180 general nurses (medium-level nurses) in EmONC 378,000 Pre-service training of 80 nurse midwifes 1,890,000 Training of 20 trainers in IMCI 68,050 Initial training of 345 nurses in IMCI 815,000 Subtotal 3,250,400
1.1 (b) Strengthening of municipal health services at primary level (continued) Pre-service training of 75 general nurses 3,780,000 Training of 92 staff in health management and planning at provincial and municipal level 283,500 Specialization course for 20 general physicians 756,000 Printing and distribution of FP, PNC, Delivery, Pediatric Care, EDP manuals and IEC posters 486,000 Teaching and learning materials, library books, and internet connection 32,200 Introduction of telemedicine in 5 provincial Hospitals 72,000 Study of drugs acquisition, planning, distribution budgeting and logistics 76,400 Buffer stock of drugs and commodities 5,174,982
1.2 Scaling-up of population-based outreach services Refresher course for 300 nurses in common diseases management 195,000 Outreach activities as integrate health interventions by mobile teams (per diem and fuel) 5,937,800 Mobile solar kits for outreach activities 18,400 Camping kit ( to include tents, blankets, sleeping bags) per mobile team 40,000 Vehicles ( 4x4, ambulances and maintenance) for municipal, provincial and UCC levels 3,672,000 Quad vehicles and maintenance kit, Municipal, Provincial, UCC levels 360,000 Motorcycles and maintenance kit, Municipal, Provincial, UCC levels 554,800
1.3 Improving community interventions Training of 28 trainers for community health 96,450 Training of 1080 community health workers (CHWs) 5,900,000 Refresher course CHWs 63,000 Bicycles for CHW 60,000 Mobilization and education meetings with TBAs 53,500 Non-monetary incentives, i.e. kits for CHWs/TBA/TH 205,920 Clean delivery kits for TBAs 882,020
51
1.4 (a) Improving obstetric care Rehabilitation/construction of 32 delivery rooms (for pre and post delivery, and child care) 4,732,000 Housing for health professionals at municipal and provincial levels 7,980,000 Management and supervision of civil works 840,000 Equipment for PNC/FP, delivery and IMCI rooms and provincial maternities 635,500 Radios for ambulances, municipalities and provincial DPS 834,000
Review of norms for delivery and C-Section kits 19,350 Provide Kits for normal deliveries 4,884,239 Kits for C-Section 1,953,696 Kits for THs 162,000 Subtotal 6,857,285
1.4 (b) Improving obstetric care (continued) Solar kits for MCH care 720,000 Rehabilitation/construction of 32 delivery rooms (for pre and post delivery, and child care) in Malange 560,000 Subtotal 1,280,000
1.5 Improving Hospital waste management disposal (HWMD) Provision of basic materials and equipment for HWMD by municipal hospitals, health centers and health posts 324,000 Basic training in HWMD for municipal level personnel 171,000 Training in HWMD for provincial supervisors 80,850 Training in biosecurity and universal protection 230,000 Supervision and quality control of HWMD 188,754 Total component 1 56,265,760
Component 2 – Voucher Scheme Pilot Qualitative study in two municipalities of cultural, economic, and social determinants of demand for reproductive health and delivery services 52,200 Management of voucher system by NGO, including awareness and BCC campaigns 295,000 Cost of vouchers 332,663 Monitoring and Evaluation of the pilot 100,000
Total component 2 779,863
Component 3 – Project Management and M&E 3 (a) Strengthening program management Strengthening the staffing of Central coordination unit 4,718,000 Strengthening the capacity of Provincial Health Departments (contracting of health management and M&E specialists in 5 provinces) 4,200,000
52 Local travel 120,000 Per diem for support visits to the provinces- Technical assistants 300,000 Per diem for support visits to the provinces- coordinators 150,000 Per diem for support visits to Luanda 75,000 Transportation between Provinces and to Luanda 80,000 Support to supervision to provinces from regional coordination and technical support teams 2,869,500 Participation in international conferences and training 69,600 Coordinating meetings for implementation planning and monitoring 1,200,000 Financial and procurement audits 750,000 Preparation of detailed provincial and municipal health plans 950,700
3 (b) Strengthening the capacity of the Department of Planning of the MOH Preparation of Human Resources Development Plan, Infrastructure Development Plan, and MTEF 321,600
3 (c) Strengthening Monitoring and Evaluation Strengthening M&E capacity of MOH in the use of the current HMIS 379,500 Capacity building in data for decision-making at central, provincial and municipal level 119,000 Training at central level of 2 M&E staff of each of the 5 provinces in the use of HMIS 100,000 Preparation and conducting of Access and Quality surveys 1,246,464 Mid Term Evaluation and Final Evaluation 300,000 Computers, training manuals, and stationery for M&E 303,680
Total Component III 18,253,044 Government contribution for drugs 16,500,000 TOTAL PROJECT COST 91,888,667
Table 13: Project Costs By Component Local Foreign Total Project Cost By Component (US$ million) (US$ million) (US$ million) Improvement in service delivery 17.0 34.0 51.0 Piloting of demand-side incentives to 0.7 0.1 0.8 encourage institutional deliveries Strengthening the Capacity of the 14.8 2.0 16.8 Ministry of Health at the Central, Provincial, and Municipal Levels Government contribution for drugs 1.0 15.5 16.5 Physical Contingencies 1.8 1.6 3.4 Price Contingencies 1.7 1.6 3.3 Total Project Costs 37.0 54.8 91.8 Total Financing Required 37.0 54.8 91.8
53 Annex 6: Implementation Arrangements ANGOLA: Municipal Health Service Strengthening Project (MHSS)
Table 14: Municipalities covered by the MHSS Province Municipality Health Unit Bengo Dande/Caxito PS Ùcua PS Kikabo Icolo e Bengo CS/Maternidade Sede PS Maria Teresa Ambriz PS Tabi CS Sede
Uige Negage CS Dimuca CS Useke/Quisseke Uige Sanza Pombo Alfandega CS Materno Infantil (HQ) Maquela do Zombo
Malange Malange PS Kambaxi PS Ngola Luixi Cacuso PS Kizenga PS Pungo Andongo Caculama PS Caxinga PS Muquixe Calandula CS Sede PS Cota Moxico Luena PS Mandunbwe PS Sangondo Camanongue PS Muxivingugi CS da Sede Luau H. Municipal PS Marco 25
Lunda Norte Chitato Hospital Municipal Lucapa Repair of Maternity Nzaji Maternity Cuango Centro de Saúde (HQ) CS Calonda
182. Institutional arrangements are presented in Figure 4. The Ministry of Health will have the overall responsibility for the management of the project. The National Department of Public Health (DNSP) will be in charge of the day-to-day management of the project. In 2006, the DNSP created the MHSS Central Coordinating Unit (CCU). The CCU is headed by a Coordinator who reports to the National Director of Public Health, and will be strengthened by the addition of a Deputy
54 Coordinator, an M&E Specialist, an Infrastructure Specialist, a Training Specialist, a Health Specialist, a Financial Management (FM) Specialist, and a Procurement Specialist, as well as supporting staff.
183. The Financial Management and Procurement Specialists will be physically located within the Central Project Coordinating Unit (located within the National Department of Public Health), however that other specialists such as the Training Specialist, the Infrastructure Specialist, the Monitoring and Evaluation Specialist could be physically located in other departments of the MOH as this would allow other MOH staff to benefit from their experience, thus building capacity and ensuring a better sustainability of the Project. Although all the above mentioned staff would work in different offices, they will work as a team to coordinate Project implementation activities.
184. The CCU‘s responsibilities are to: (i) manage the expansion of the program throughout the country; (ii) make resources available for the MHSS and ensure their rational use; (iii) ensure that Regional Coordinating Teams respect their implementation timetables; (iv) guarantee the quality of the training program; (v) monitor and supervise the MHSS program, prepare quarterly reports, and organize national meetings to review progress; (vi) transfer experience between regions; (vii) promote the MHSS program at the national level. The CCU is supported by four working groups: (i) monitoring and evaluation; (ii) supervision and training; (iii) logistics; and (iv) health promotion and education.
185. Depending directly from the CCU, there are six Regional Coordinators, each supported by a technical team. The responsibilities of the Regional Coordinator are to: (i) analyze the epidemiological profile as well as the supply and demand of health services in each province included in the region, municipality by municipality; (ii) help prepare municipal operational plans; (iii) train provincial and municipal teams; (iv) help municipalities prepare the annual MHSS budgets and ensure their inclusion in the overall municipal budget; (v) help municipalities mobilize resources; (vi) ensure that provincial and municipal teams respect their implementation timetables; (vii) organize the training of provincial health teams; (viii) monitor and supervise the implementation of municipal operational plans, and prepare quarterly reports; (ix) help exchange experience between regions through monthly or bi-monthly meetings; and (x) promote the MHSS program at the regional level.
186. Joint Project Implementation Reviews. A Steering Committee will monitor the progress of the MHSS project. The Committee will be chaired by the Minister of Health or his designate. Its members will be, inter alia, the Vice-Minister for Hospital Management, the Vice-Minister for Public Health, the Director for Human Resources, the Director of Planning, the National Director for Medical Equipment and Medicines, the Director for Public Health, and one representative of Total E&P Angola.
187. Bi-annual Joint Project Implementation Reviews will be led by the MOH with the participation of stakeholders and development partners. The Reviews will have three components: (i) joint review of the past year‘s activities and of critical questions in a number of thematic areas; (ii) a joint visit to a province to better understand the problems in the field and discuss with stakeholders; and (iii) a plenary session to consolidate the field work and approve the plan of activities for the following year.
55 Figure 4: MHSS Institutional Arrangements
Ministry of Health National Department of Public Health
HCWM MHSS Central Coordinating Unit Specialist (CCU) Coordinator
Deputy Coordinator
M&E Training Infrastructure Health FM Procurement Specialist Specialist Specialist Specialist Specialist Specialist
FM Officer Procurement Officer
Provincial Departments of Health Provincial Bengo, Malange, Lunda Norte, Moxico, and Uige Training Institutes (Including Public Health Specialist and M&E Specialist supported by MHSS in each province)
Municipal Health Officers
188. At the provincial level, the governor is responsible for the implementation of the MHSS through the Vice-Governor for the Social Sector, supported by the Provincial Health Director. The attributions of the Provincial Health Director as regards the MHSS are similar to those of the Regional Coordinators, but with a focus on the coordination of program implementation in the municipalities that are part of the province.
189. At the municipal level, the Municipal Health Officer is responsible to: (i) prepare the MHSS municipal operational plan and ensure their integration in the overall municipal budget; (ii) manage the municipal health teams and ensure that they deliver an integrated package of maternal and health services through fixed-based and mobile teams, and provide them with the logistical means; (iii) prepare a monthly plan of visits to health units to monitor progress and provide implementation support to health staff and mobile teams; and (iv) prepare a monthly report documenting the maternal and child health services provided in the municipality, inventory of drugs and supplies, vaccines and the status of the cold chain, as well as the epidemiological situation of the municipality.
190. Outreach teams. Considering the enormous size of the provinces and the fact that it will take many years to build and staff a network of health facilities in the most distant villages, the MOH has developed a strategy of outreach teams, for areas beyond a range of 20 km. Outreach teams have been used in Angola, but until now they only provided vaccination services. The Revitalização program has now determined that mobile teams are expected to provide integrated
56 primary health care services. They are responsible for health promotion and health prevention activities, dissemination of health messages related to specific diseases prevalent in the area, safe motherhood practices, birth preparedness, and encouraging women to give birth in a health facility.
191. Outreach teams are scheduled to visit each community at least four times a year. The outreach teams will be composed of three nurses. One of them will be a midwife or a nurse trained in EmONC and pre-natal care. A second one will have been trained in IMCI and the management of most common infectious and chronic diseases. Finally, the third nurse will be in charge of promotion and prevention services.
192. The mobile teams will ensure the link with community health workers, TBAs and even traditional healers. During their visits, the nurses will supervise the CHWs, collecting information and data on the promotion activities CHWs have done. They will provide immediate feedback and training in technical problems raised by CHWs. They will also hold meetings with traditional authorities such as ―Sobas‖ to listen to their queries and suggestions related to health problems in the community.
193. Teams of community health workers (CHWs) will be developed in each village. They will be trained to undertake growth monitoring, provide oral rehydration therapy, immunization, female education including the use of bed nets, family planning and contraceptive use, promotion of exclusive breast feeding, nutrition, good hygiene such as washing hands, avoidance of risky sexual behavior, and increasing the capacity of families to recognize the early danger signs of common diseases so to seek care sooner. Outreach teams will provide technical support to CHWs when visiting their area.
194. Obstetric care. To increase access to obstetric care, the project will have a dual strategy: (i) it will provide equipment to existing municipal health centers, thus helping to improve the quality of care; and (ii) it will expand the supply of obstetric care by building 36 new delivery rooms in health centers and posts, bringing the services closer to the population.
195. Three criteria were used to select the facilities: (i) the population to be covered (the higher the better); (ii) the distance of these facilities from current maternities located in municipal health centers or hospitals (faraway facilities were chosen to bring services nearer the population); and (iii) accessibility of roads to ensure the referral of patients. In total, the project will rehabilitate or create delivery rooms in 12 municipal hospitals used as referral centers, and in 24 peripheral health posts in the project municipalities.
196. Finally, the strategy calls for the training of midwives and nurses who will provide obstetric care in these facilities. Nurses trained in EmONC and pre-natal care will be part of the integrated primary care mobile teams that will visit the most distant communities at least four times a year. The training process will focus mostly on the improvement of practical skills rather than on theoretical concepts.
197. Increased access to institutional deliveries is expected to create more demand for not only normal deliveries, but will allow increasing the detection and referral of complicated cases that will need surgery or specialized treatment. As a result the current low prevalence of C-sections would also increase.
57 198. Training program. The training of nurses and midwifes in EmONC and IMCI will be undertaken by a team of 20 trainers (four from each province) who will be trained in Luanda Maternity (Lucrecia Paín) for 15 days in the case of EmONC and 10 days for IMCI. The courses will be provided by the Provincial Technical Institutes of Bengo, Malange, Uige, and Moxico. The trainers and supervisors will consist of Cuban and Angolan doctors already present in the provinces. Training curriculums and materials are also available.
199. The same principle will apply to the training of CHWs. A group of 28 trainers from the provinces and municipalities will be trained by the DNSP, with UNICEF support, for a period of 10 days. In each province, the course will be given by a team of two trainers from the Provincial health Department and one from the municipality. The course will benefit 60 CHWs from each of the 18 municipalities. It will last 45 days.
200. Training in health services management will be provided by the Lubango Institute who will send trainers to each province. The course will benefit 60 nurses in each of the 5 provinces.
201. In the CCU a full-time Training Specialist will be in charge of programming the courses, making the appropriate arrangements with the trainers from Luanda and Lubango, liaising with the provinces, and supervising the implementation of the training program. Details on this program are provided below.
Table 15: Training Program Activity Description Cost (US$) Training of 20 trainers in Four trainers from each province to be 459,350 EmONC trained in Luanda Maternity (Lucrecia Pain) by a team of 2 doctors and one nurse. One of the trainers form the province will be the Pedagogical Director of the Provincial Training Institute. A 2-week course. In-service training of 180 The course will benefit 10 nurses from 360,000 general nurses in EmONC each of the 18 municipalities. The course will take place in provincial and selected municipal hospitals. A 2-week course. Pre-service training of 80 Nurses who are currently working as 1,800,000 nurse midwives. general nurses will be trained as nurse midwives. The course will last 18 months. Of these 36 will be the coordinators for each of the new delivery rooms in the 18 municipalities of the project (2 per municipality). Courses in Bengo, Malange, Uige, Lunda Norte and Moxico.
58 Pre-service training of 75 Nurses come from the existing pool of 3,600,000 general nurses. nurses in each province will be upgraded from basic to mid-level nurses, allowing for a higher salary. The course will take place in Bengo, Malange, and Uige. The course will contribute to upgrading of skills and allow provinces to rebalance the distribution of nurses. The course will last 2 years. Training of 20 trainers in Similar to the training of trainers for 68,050 IMCI EmONC, but for a duration of 10 days. Initial in-service training of This course will train 15 nurses from 776,250 345 general nurses in IMCI. each of the 18 municipalities, plus 15 from each provincial hospital. The course will last 6 days. It will allow nurses to improve their skills in case management of child diseases, for their work in facilities and outreach teams. The course will take place in each province within the provincial and selected municipal hospitals. Training of 92 staff in Training of 4 staff from each of the 5 270,000 health service management DPSs and 4 from each of the 18 and planning municipalities. The course will be provided by the Lubango Training Institute which will go to each province to provide the course at the Provincial Training Institute. Training of 20 general Training of doctors in public health, 720,000 physicians management of common diseases, and selected surgical procedures. The course will take place at Luanda University Hospital for a period of 3 years. Refresher course for 300 This 5-day refresher course will benefit 195,000 nurses in common disease 60 nurses per province. The trainers will management come from the provincial level and provide the course in each of the 18 municipalities. Training of 28 trainers to Training by the DNSP (with UNICEF 96,450 train CHWs support) of one trainer from each of 18 municipality and 2 from each DPS. The course will last 10 days.
59 Training of 1080 This 45-day course will benefit 60 5,900,000 community health workers CHWs from each of the 18 municipalities. The course will be given by a provincial group of 2 trainers and one municipal trainer. Refresher training for One-day course each year. 63,000 CHWs
202. Civil works and equipment will be under the overall responsibility of the Infrastructure Specialist in the CCU. For delivery rooms, technical norms will be provided by the MOH Department of Planning (GEPE). Contracting will be undertaken at the provincial level through national competitive bidding (check). GEPE will also provide the norms for staff houses. These will be packaged and contracted through international competitive bidding. The Infrastructure Specialist will also be in charge of the equipment (ambulances, vehicles, radios, solar panels) and commodities (delivery kits and essential drugs), working in close collaboration with the Health Specialist for the latter.
Table 16 - Location of Delivery Rooms to be Built/Rehabilitated Province Municipality Health Facility Bengo Dande/Caxito PS Ùcua PS Kikabo Icolo e Bengo CS/Maternity (HQ) PS Maria Teresa Ambriz PS Tabi CS HQ
Uíge Negage CS Dimuca CS Useke/Quisseke Uige 2 PS Sanza Pombo PS Alfandega CS Materno Infantil (HQ) Maquela do Zombo 2 PS
Malange Malange PS Kambaxi PS Ngola Luixi Cacuso PS Kizenga PS Pungo Andongo Caculama PS Caxinga PS Muquixe Calandula CS HQ PS Cota
60 Moxico Luena PS Mandunbwe PS Sangondo Camanongue PS Muxivingugi CS (HQ) Luau H. Municipal PS Marco 25 Lunda Norte Chitato Municipal Hospital – Maternity PS Lovua Lucapa Repair of Maternity CS Camunongo Cuango Maternity of Health Center PS Loremo Cambulo/N‘Zagi CS Calondo CS Cassanguidi
203. Contracting of consultants. TORs will be the responsibility of the Deputy Coordinator with support from DNSP and GEPE, as well as UNICEF and WHO when needed.
204. Pilot testing of vouchers to encourage institutional deliveries. This will be contracted to an NGO who would work closely with communities, health centers, hospitals, drivers, and the municipal administration financial departments. The M&E of the pilot would be contracted to a local Angolan consulting firm or an NGO.
205. Monitoring and Evaluation will be the responsibility of the M&E Specialist of the CCU who will be in charge notably of: (i) ensuring the availability of routine indicators from the HMIS; (ii) training of staff; and (iii) coordination with other partners. Access and quality surveys will be contracted to WHO.
61
Table 17: MHSS Implementation Schedule PP F 1º YEAR 2º YEAR 3ºY 4ºY 5ºY 1 2 Activities T T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T Responsible Participant General Preparatory and launching activities Prepare TORs and contract M&E specialist for CCU DNSP-CCU HAMSET Prepare TORs and contract specialist for qualitative survey DNSP-CCU with mothers on incentives Consultant HAMSET conduct survey DNSP-CCU DPS Conduct a survey and prepare document on the existence, role and projects by NGOs in the 5 provinces DNSP-CCU DPS Base line survey on needs for maternal health - obstetric care in the five provinces DNSP-CCU DPS Prepare TORs and contract training, infrastructure, procurement, financing specialists DNSP-CCU HAMSET Prepare the protocols to be signed by the governors and municipalities by each province DNSP-CCU DPS Organize meeting with Provincial Governors to sign implementation protocols Preparing the Operational Manual I - Improving Health Services delivery in five provinces (a) Strengthening of municipal health services at primary level Meeting with DNRH to ensure prioritization of allocation of nurses and MCH nurses to the 5 provinces DNRH DNSP Agreement protocol on HR training and allocation prepared and signed between DNRH, DNSP- DNRH and DPS CCU DPS Training of nurse midwifes Mobilize candidates from provinces DPS DNRH Implement course ETPS ETPS Graduation ETPS ETPS Arrive to Municipalities DPS DMS Training of general nurses (Medium level nurses) Mobilize candidates from provinces DPS DNRH Implement course ETPS ETPS Graduation ETPS ETPS
62 Table 17: MHSS Implementation Schedule PP F 1º YEAR 2º YEAR 3ºY 4ºY 5ºY 1 2 Activities T T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T Arrive at Municipalities DPS DMS Training on IMCI Training of trainers for 5 provinces DNSP-CH CCU, DPS Do training for municipal nurses in each province DPS, DMS DNSP, CCU Refresher training on IMCI DPS DMS Training in Safe motherhood Provinces chose trainees DPS DMS Preparing training materials and organize course logistics DNSP-SRH CCU, DPS Do training for each province DNSP-SRH CCU, DPS Refresher training on Safe motherhood DPS DMS Training in Health Management and Planning at provincial and municipal level Adapt existing PASS training materials CCU, DNSP GEPE Organize course logistics and mobilize candidates CCU, DPS DMS Do training for each province DNSP GEPE, DPS Refresher training DPS CCU, GEPE (a-2) Scaling-up of population-based outreach services a)Implement Outreach activities as integrate health interventions by mobile teams Define outreach service provision protocols with organizational structure, responsibilities, case management and health CCU, DNSP, promotion activities DNRH DPS Refresher courses on common diseases case management and health promotion for existing nurses in outreach teams DNSP, DPS DNRH Prepare specifications, procure , buy and distribute Solar kits CCU, for outreach teams HAMSET, DPS DNSP, DPS Procure, buy and install solar CCU, kits for each team HAMSET, DPS DNSP, DPS Prepare specifications, tender documents, launch bid and buy Vehicles ( 4x4, ambulances and maintenance) for municipal, provincial and CCU CCU, levels HAMSET, DPS DNSP, DPS Prepare specifications, tender documents, buy and distribute CCU, motorcycles, quad HAMSET, DPS DNSP, DPS
63 Table 17: MHSS Implementation Schedule PP F 1º YEAR 2º YEAR 3ºY 4ºY 5ºY 1 2 Activities T T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T motorcycles, and maintenance
Prepare specifications, tender, buy and install, radios for mobile teams, municipalities CCU, and provincial DPS HAMSET, DPS DNSP, DPS Implement at least 4 outreach visits a year in hard to reach DAMS, Mobile communities team DPS (b) Improving obstetric care Rehabilitation/construction of Delivery rooms( pre, post and delivery ) including improvement of water and sewage facilities and reproductive and sexual health CCU, HAMSET, equipment DPS DNSP, DMS Identify Health Centers where obstetric rooms will be rehabilitated/constructed CCU, DPS DMS Prepare tender and launch bids HAMSET, for construction and equipment CCU DMS construct and hand out rooms to the DMS Prepare technical specifications, tender buy and install Solar kits for delivery CCU, HAMSET, rooms DPS DPS, DMS Prepare Technical Specification, tender, buy and distribute Kits for normal deliveries CCU, DNSP DPS, DNME Prepare Technical Specification, tender, buy and distribute Kits for caesarean CCU, DNSP DPS, DNME (c) Train Community workers Define schedule, identify, prepare teaching materials and do Training new CHWs CCU, DNSP DPS Refresher course existing CHWs CCU, DNSP DPS Define schedule, identify, prepare teaching materials and do Training to TBAs CCU, DNSP DPS Define list and buy Non- monetary incentives, i.e. kits for CHWs CCU, DNSP DPS Prepare Technical Specification, tender, buy and distribute Clean delivery kits for TBAs and mothers CCU, DNSP DPS Prepare Technical Specification, tender, buy and distribute Clean cut kits for THs CCU, DNSP DPS d) Improving Hospital waste
64 Table 17: MHSS Implementation Schedule PP F 1º YEAR 2º YEAR 3ºY 4ºY 5ºY 1 2 Activities T T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T management disposal (HWMD) Provision of basic materials and equipment for HWMD at municipal hospital, health centers and health posts CCU, DNSP DPS, DNME Basic training for HWMD for municipal level personnel CCU, DNSP DPS, DNME Training on HWMD for provincial supervisors CCU, DNSP DPS, DNME Training on biosafety and CCU, DNSP, universal protection INLS DPS Supervision and quality control on HWMD CCU, DNSP DPS ii) Voucher Scheme Pilot Develop qualitative studies in each one of the five provinces to identify cultural, economic and social and health service determinants on demand side RH and delivery services CCU, TA DPS, DMS Based on study define precise strategy and implementation activities CCU, DNSP, DPS Design and implement community based awareness and BCC intervention to women to deliver in the health CCU, DNSP, facility DPS DMS Provide incentives on transportation III. Project Management and M&E (a) Strengthen the program management Strengthening the staffing of Central coordination unit Prepare integrated supervision manual, train health professionals and Implement at least 3 yearly supervision visits to provinces from regional coordination and technical support teams CCU, DNSP Prepare TORs, Procure and contract DPS-operational technical consultant and administrative assistant for 5 DPS., Provinces CCU, DNSP HAMSET Strengthening with TA the capacity of GEPE of MOH CCU, DNSP DPS Prepare TORs, Procure consultants, and contract TA to DPS., develop HRDP, PIP, MTEF CCU, DNSP HAMSET Strengthening M&E capacity in MOH
65 Table 17: MHSS Implementation Schedule PP F 1º YEAR 2º YEAR 3ºY 4ºY 5ºY 1 2 Activities T T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T 5 day training at central level of 2 M&E people for each of the 5 provinces for the use of HMIS TA, GEPE CCU; DNSP Prepare specifications, tender documents, Bid and buy and distribute computers and Stationery materials for M&E HAMSET, including the 5 provinces CCU DPS Implement Provincial and Municipal HMIS CCU, HAMSET DNSP, DPS Prepare TORs , launch Bid and contract firm and do Annual financial audits Prepare TORs, Bid, contract external evaluator and do Mid Term Evaluation Prepare TORs, Bid, contract external evaluator and do Final Evaluation CCU, DNSP DPS, GEPE Prepare regulation and implement Revitalization coordination committee- regional/National meetings for project monitoring and for planning CCU, DNSP GEPE, DPS Prepare Regulation and guidelines for coordination GEPE, committee CCU, DNSP Minister Discuss with partners CCU, DNSP GEPE, DPS Do meetings and disseminate recommendations CCU, DNSP GEPE, DPS Implement Provincial and Municipal health plan in provinces Prepare TORs and Contract PASS specialists team for TA CCU, DNSP, and support HAMSET GEPE, DPS Prepare national team (MOH specialists, architecture students and public health doctor) CCU, DNSP GEPE, DPS construct Mapa Sanitario CCU, DNSP GEPE, DPS Prepare Health plan in each province Prepare design specifications, tender and Build Housing for health professionals at CCU, municipal level HAMSET GEPE, DPS
66 Annex 7: Financial Management and Disbursement Arrangements ANGOLA: Municipal Health Service Strengthening Project (MHSS)
206. The financial management assessment was carried out because World Bank policy requires the borrower and project implementing entities to ―maintain financial management systems -- including accounting, financial reporting, and auditing systems -- adequate to ensure that they can provide IDA with accurate and timely information regarding project resources and expenditures.‖
207. The objective of the assessment was to determine whether the entity implementing the project has acceptable financial management arrangements. The arrangements include the entity‘s system of accounting, reporting, auditing, and internal controls, and are deemed acceptable if:
they ensure that funds are used only for the intended purposes in an efficient and economical way; they are capable of correctly recording all transactions and balances, and supporting the preparation of regular and reliable financial statements; they are capable of safeguarding the entity‘s assets; and they are subject to auditing arrangements acceptable to IDA.
208. World Bank policy requires that acceptable accounting and internal control systems are in place when project implementation begins. In practice, it is desirable to ensure that acceptable arrangements are in place no later than the date of Credit effectiveness. The assessment report was discussed with the Borrower
209. Summary of Assessment. The Ministry of Health will have the overall responsibility for the management of the project. The National Department of Public Health (DNSP) will be in charge of the day-to-day management of the project through the CCU. The DNSP‘s proposed arrangements were reviewed in accordance with the Financial Management Practices Manual issued by the Financial Management Board on November 3, 2005:
The overall risk rating for the project is Substantial. Several mitigating measures were proposed, including use of an existing project Central Coordinating Unit (CCU) for the day to day management of the project, the hiring of an International Financial Management Specialist for the project, modification of the existing CCU FM Manual to take into account interaction with municipal authorities, and the hiring of internal and external auditors specifically for the project; The project will have 100% IDA financing. The government will ensure that under each yearly budget proposal to its legislature, adequate arrangements are made by the government to assume such portion of the costs related to government‘s in kind contribution, required to achieve the objectives of the project (US$16.5 million over the life of the project). Co-financing has been secured from Total E&P Angola. IDA will finance all categories, except for Component 1, subcomponents 1.1(a), 1.4(b), and 1.4(c) which will be financed 100 percent by Total E&P Angola.
67 210. The residual risk after the proposed mitigating measures is expected to be moderate, as the bulk of these measures have been adopted for the ongoing HAMSET project and can very easily be taken on by the new MHSS Project.
211. Implementation Arrangements. The Ministry of Health will have the overall responsibility for the management of the project. The National Department of Public Health (DNSP) will be in charge of the day-to-day management of the project through the CCU. In 2006, the DNSP created the MHSS Central Coordinating Unit (CCU). The CCU is headed by a Coordinator who reports to the National Director of Public Health, and will be strengthened through the project by the addition of a Deputy Coordinator, an M&E Specialist, an Infrastructure Specialist, a Training Specialist, a Health Specialist, a Financial Management Specialist, a Financial Officer, a Procurement Specialist, a Procurement Officer, as well as supporting staff. A key responsibility of the FMS, internationally recruited under HAMSET and continuing with the MHSS, will be the hands-on training of the Project Financial Management Specialist.
212. The Financial Management and Procurement Specialists will be physically located within the Central Project Coordinating Unit (located within the National Department of Public Health), however that other specialists such as the Training Specialist, the Infrastructure Specialist, the Monitoring and Evaluation Specialist could be physically located in other departments of the MOH as this would allow other MOH staff to benefit from their experience, thus building capacity and ensuring a better sustainability of the Project. Although all the above mentioned staff would work in different offices, they will work as a team to coordinate Project implementation activities.
213. The CCU‘s FM responsibilities include the management of financial resources for MHSS implementation and the rational use of funds, the supervision of the financial management of MHSS funds, and the preparation of the quarterly financial management reports and annual audit reports to review financial management progress. The CCU will also be responsible for developing the withdrawal applications for submission to IDA. The CCU will also help municipalities prepare the annual MHSS budgets and ensure their inclusion in the overall municipal budget; and help municipalities mobilize resources, as needed.
214. The current internationally-recruited Financial Controller for the HAMSET project is expected to be retained, initially to manage the work and train a successor in the process, then later in implementation to act only as advisor to Angolans selected to satisfy the longer term staffing needs of the department.
215. Country Issues. The most recently completed FM-related ESW for Angola is still the combined Public Expenditure Management and Country Financial Accountability Review (PEMFAR) completed in 2004. It highlighted the existence of major institutional weaknesses which have aggravated the country‘s already weak fiscal stance. Unexplained discrepancies between stated government funds and actual revenue were deemed significant and the review further concluded that the pervasive deficiencies in the country‘s public financial management impaired good macroeconomic management. The situation is exacerbated by the existence of a dual public expenditure system, where ―conventional‖ expenditures are processed by the National Treasury Directorate, while ―unconventional‖ expenditures, aimed at facilitating transactions such as the servicing of key external debt, are centered on the national oil company, Sonangol. The review recommended the discontinuation of the ‗parallel‘ spending process, as the underlying reasons for its emergence (during the war) were no longer valid. Proposals were made for the way
68 forward, being primarily to strengthen the ―Conventional‖ leg and ‗ring-fencing‘ and eventually phasing out the ―Unconventional‖ portion.
216. The PEMFAR noted with appreciation government‘s efforts to make the system work better. Progress on the Government IFMIS (Integrated Financial Management Information System – or SIGFE in Portuguese – Sistema Integrado de Gestão das Finanças do Estado) is particularly noted. The system is gradually being rolled out to budget units and will eventually be the cornerstone of the public financial management system in the country.
217. A new Accounting Law and Chart of Accounts were promulgated, but the process of implementation is far from complete. Lastly, the review noted that ‗audit and control‘ systems, although regulated by law, do not operate efficiently in practice, as the National Inspectorate of Finance is weak and needs to be strengthened. A follow-up review is proposed for FY10 to provide an update of developments within the public financial management area in the country.
218. The IDA team sought additional insight into the accounting professionals market in the country by way of discussions with the established professional accounting firms in the country. Indications are that qualified accounting professionals are still thin on the ground, leading to rather pricey competition for those that are available. The most competitive sector is still ‗oil‘, as expected, and tends to get all the very best of what is available, locally and from the regional markets as well as Portugal and Brazil. The private sector takes the next ‗notch‘, meaning the public sector resorts to whatever is left over. It is generally felt that Financial Management is in a slightly better position than Procurement in terms of available human resources, but for both qualified Angolans are few and far between.
219. Recent developments seem to indicate that the authorities are now committed to improving the management of the economy. The last few months have seen an increasing willingness to publicly acknowledge the macroeconomic and transparency issues that affect the country. Important inroads have been made in granting the public access to sensitive documents and reports, and addressing the issues of quasi-fiscal and extra-budgetary spending. Nevertheless, focused efforts on improving public financial management systems and practices, as well as on strengthening the ―agencies of restraint‖ are still at the embryonic stage.
220. Governance and Accountability. The quality and capacity of the bureaucracy in Angola is very weak. A recent MIGA Country Risk Assessment indicates that the risks of Expropriation and Breach of Contract are average-to-high. Enforcement of contracts and recognition of property rights depend largely on informal mechanisms. The country currently ranks 176 out a sample of 178 countries in the 2008 Doing Business Report question on enforcing contracts.
221. In the Transparency International‘s Corruption Perception Index for 2007, Angola‘s score remained unchanged at 2.2, but it now ranks 147th (as opposed to 142nd from last year).
222. Conflict of interest and ethics rules for public servants are not observed/enforced. Implementation of laws and policies is distorted by corruption.
223. With this background, the ongoing Bank-financed EMTA project is supporting several capacity building initiatives, as well as the revision of the existing procurement legislation. But change will not be instantaneous, and therefore the following steps will be undertaken to minimize/identify early, the incidence of corruption during implementation of the project:
69 Financial Management and Accounting system- due to perceived weaknesses in the country systems, a reinforced CCU will be engaged to handle the administration and financial management of the project. The CCU will introduce a fully computerized accounting system to improve control and reduce errors resulting from manual processing of data and transactions, as well as improve the audit trail.
Audit - The TOR s for both internal and external auditors will include specific responsibilities towards the detection and reporting of fraud and corruption in project activities.
224. Summary risk analysis. The following are necessary features of a strong financial management system:
the CCU should have an adequate number and mix of skilled and experienced staff; the internal control system should ensure the conduct of an orderly and efficient payment and procurement process, and proper recording; the accounting system should support the project‘s requests for funding and meet its reporting obligations to fund providers including Government of Angola, IDA, and other donors; the system should be capable of providing financial data to measure performance when linked to the outputs of the project; and an independent, qualified auditor should be appointed to review the Project‘s financial statements and internal controls.
225. Risks and risk mitigation measures. The table below lists the key risks identified for the proposed project. The CCU will face these risks in achieving the above objectives, due to the weak control environment. A carefully determined risk management action has been identified for each, to mitigate the negative effects of the particular risk, and ensure positive results:
Table 18: Summary Risk Table Risk Risk Risk Mitigation Measures Residual Condition of Remarks Rating incorporated in Risk Effectiveness, Project Design Board or Negotiation (Yes or No) Inherent Risks Country Level Governance issues have H Appropriately qualified and H Yes, To be addressed at Project previously been identified experienced staff will be Effectiveness Level. (in the Transparency recruited to manage the International‘s Corruption fiduciary aspects of the project. Perception Index for 2009, Internal control procedures will Angola‘s score now ranks be documented in a procedure 162th out of 180 countries, manual and staff will ensure compared to 147th in those guidelines are adhered to previous year) and hence religiously there is a risk that funds may not be used in an efficient and economical way and exclusively for purposes intended.
70 Implementing Entity The government may not be S This is a possibility given the M No able to meet the costs related competing requirements on to its in-kind contribution treasury, and the under the form of unpredictability of government pharmaceuticals. flows. However, the risk is modest because economic growth is expected to resume in 2010 and Angola‘s medium- term economic prospects are good, with GDP projected to grow by 6.5% per annum from 2010 to 2012. This risk is mitigated by including in the project the financing of a buffer stock of pharmaceuticals for an amount of US$5.2 million.
Program Level The project may be unable S Due to agreed poor capacity in M Yes, As a condition of to find and engage each municipality, fiduciary Effectiveness. effectiveness, the MOH appropriately qualified staff management will be largely will have recruited to manage implementation centralized in a PIU. This qualified staff for the within each municipality. enables the hiring of qualified PIU, including specialist staff at commercially international specialists competitive remuneration. for financial and procurement management, a public health specialist, and a training specialist with qualifications and experience, and to terms of reference, satisfactory to IDA. Overall Inherent Risk S S
Control Risk 1. Budgeting H Planning process will be M During Joint project consultative and in line with Implementation Reviews. Risk that budget process agreed project objectives, and may not be based on valid coordinated by the qualified assumptions and procedures FM Specialist. for approvals and variations may not be clearly laid out or followed. 2. Accounting: S A Financial Management M Yes FM Specialist already in Risk that acceptable Specialist to be hired before place in HAMSET, but accounting standards may effectiveness, and accounting Financial Management not be used, as well as poor to be on an established Specialist to be hired control due to lack of accounting software. specifically for the project qualified accounting staff. to be in place prior to effectiveness. Computerized accounting system for the CCU already in place. 3. Internal Control: risk S The policies and procedures are M Yes CCU FM manual already that accounting policies and to be captured in a approved by the Bank, procedures to be applied FM/Accounting Procedures but the same manual to be may not be clearly defined, Manual acceptable to IDA, and adapted for use by the and that where available, strict adhered to be monitored new project prior to risk that desired procedures by qualified staff. effectiveness may not be followed consistently.
71 4. Funds Flow H Close to 90% of all M No. While no funds can flow procurements and till the DA is opened, this Funds may not reach disbursements will be handled is not usually made a intended beneficiaries in a centrally, with only the goods condition of timely manner. or services being distributed to effectiveness. the municipalities. Amounts to be transferred to regions will primarily be for per diems and will be known for specified names in specified amounts, as opposed to advances to the regions. 5. Reporting and S Reporting requirements will be M Yes Agreements on formats Monitoring- set out within FM manual to be for IFRs and content of Risk that there may be no revised and approved by IDA. Annual Financial regular FM reporting These will include quarterly Statements to be reached comparing performance to un-audited IFRs, as well as at negotiation. budget, and that if available, annual financial reports. Draft reports may not effectively IFR formats have been used by management. provided to the CCU. 6. External Audit- S The audit of the project M Yes and No Appointment of the The Supreme Audit function activities will be covered by a auditors is a dated in Angola is still developing, firm of auditors recruited for covenant to ensure that and does not yet possess the the purpose on TORs they are in place within 3 necessary human capacity to satisfactory to IDA. The client months of credit discharge its statutory duties has been provided with draft effectiveness. The TORs satisfactorily. Risk that the TORs. for the appointment of annual audit may not meet auditors will be agreed IDA requirements. with IDA at negotiation. Overall Control Risk S M Overall Risk Rating for the S M Project Risk Rating – H (High Risk), S (Substantial Risk), M (Modest Risk),L (Low Risk) N (Negligible Risk)
Strengths and Weaknesses
226. Weaknesses. While the project will have a centralized CCU, the actual implementation will be dispersed in the selected municipalities, whose administration and financial management capacity is generally accepted as low. The project will thus be geographically dispersed, and would otherwise consist of several, small contracts per municipality. Because this situation has inherent weaknesses with regard to both execution and the accuracy and timeliness of information, which the CCU would need to collate and report on, as well as the effectiveness of internal checks and controls in the remote areas, it has been decided to centralize fiduciary management and reporting. Only goods and services already procured will be sent down to the municipalities. In addition, a critical component of the CCU‘s International Financial Management Specialist‘s role will therefore be the grooming and mentoring of FM staff within both the CCU and the beneficiary municipalities to improve their FM capacity and performance for the long term benefit of the country.
227. Strengths. The CCU will be benefit from the assistance of the existing HAMSET project implementation unit that has been successfully managing an ongoing Bank financed project in the same sector. FM staff from the CCU will thus have the necessary experience of working with the Bank, as well as dealing with the government in terms of both actual implementation and sourcing the in-kind counterpart contribution.
72 Financial Management
228. Budgeting. The project will prepare annual budgets, which will be in line with the project development objectives and the government‘s overall health delivery policy. The budgeting process will be consultative to ensure accommodation of the views of all key players, will include all project activities, and be completed in line with the government‘s budget preparation timetables. Budget management will be the responsibility of the Financial Management Specialist, and budget implementation will be carefully monitored through the quarterly interim unaudited financial reports (see below), which will measure actual performance against target for each period. The government will ensure that under each yearly budget proposal to its legislature, adequate arrangements are made by the government to assume the portion of the costs related to government‘s in kind contribution, required to achieve the objectives of the project.
229. Accounting. As with the ongoing HAMSET project, accounting will be in accordance with international accounting standards, and accounting processing will be on an acceptable platform, in this case the same SAC 3.0 software that is in use for the current project. Staffing will include a qualified FM Specialist supported by HAMSET‘s internationally recruited FM Specialist. For capturing FM information, the existing chart of accounts for HAMSET, will be adapted and designed to include all project activities. The design will facilitate easy reporting by project component and project categories.
230. Internal Control. Per above, approval and authorization controls for the CCU are well documented in the existing procedures manual, and compliance therewith is monitored by qualified accounting staff. The existing FM manual will be adopted for the new project, although some customization to incorporate interactions with provincial and municipal authorities will be necessary. Such modifications will need to be completed prior to effectiveness.
231. The existing procedures manual documents the major transaction cycles of the project, funds flow processes, accounting records, supporting documents and chart of accounts. It also summarizes authorization procedures, the financial reporting process, financial and accounting policies for the project, budgeting procedures, financial forecasting procedures, procurement and contract administration and management, as well as replenishment procedures for the Designated Account and the auditing arrangements.
232. Reporting and Monitoring. The project will produce interim un-audited financial reports (IFRs) on a quarterly basis, using formats to be agreed with IDA. Formal adoption and agreement with IDA on the IFR formats, as well as the formats for the Annual Financial Statements were agreed at negotiations.
233. The quarterly reports will be prepared and submitted to the Bank within 45 days of the end of each calendar quarter reported on. The financial reports will be designed to provide quality and timely information to project management, implementing agencies, and various stakeholders on project performance. These quarterly reports will include designated Account Activity statements, Summary Statement of DA expenditures Subject to Prior review, and not Subject to Prior review, Sources and Uses of Funds by Expenditure Category; Detailed Use of Funds by Project Component, Narrative explanation of the performance for the quarter, and comparison of actual expenditure with budgets; summary schedules of assets acquired under the project, as well as six monthly cash flow forecasts.
73 234. Internal Audit. There is no internal audit in the CCU at the moment. Due to the decentralized nature of the project‘s activities (several municipalities/regions), it is recommended that an internal audit firm be hired to carry out the duties of internal auditor. The firm will be hired using TORs acceptable to IDA, with a strong emphasis on value for money and physical verification of decentralized activities. The hiring of the internal auditor will be made a dated covenant in the legal agreement, to ensure that it is carried out in a timely manner and the auditors are in place within three months of effectiveness.
235. External Audit. The Ministry is subject to audit by the Tribunal, but a separate auditor with qualifications acceptable to IDA, will need to be hired to carry out the annual audit of the project. The TORs for the external audit engagement were agreed with IDA at negotiations. The audit will be conducted in accordance with International Standards on Auditing. Finalization of the audit arrangement needs to be made very early in implementation, thus the hiring of the auditors is a dated covenant to ensure they are in place within three months of effectiveness. One audit opinion covering all project financing will suffice. The audit report must be submitted to the IDA within six months of the end of the government‘s financial year. A management letter highlighting any deficiencies in the system of management and internal controls, incorporating the necessary responses by management, should also be submitted as part of the audit submission package.
Action Plan
Engage required FM staff (a Financial Management Specialist within the CCU to be hired for the new project– condition of credit effectiveness Complete modification/update of existing FM Procedures Manual - condition of credit effectiveness Contract project external auditors within 3 months of effectiveness Contract project internal auditor within 3 months of effectiveness
236. The accounting software is already in place and in use for the current project, hence no additional actions are required with respect to that.
Conditionalities
Effectiveness Conditions
Appointment of Financial Management Specialist Update of existing CCU Financial Management Procedures Manual
Disbursement Condition
No disbursement will be made under component 2 (Piloting demand-side incentives to encourage institutional deliveries) until no later than two years following the effective date: (i) the Recipient will have adopted the Voucher Scheme Manual in a manner and substance satisfactory to IDA; and (ii) the Recipient has issued an internal decree, satisfactory to IDA, regulating the voucher system.
74 Financial covenants
A financial management system, including records and accounts will be maintained by the implementing agency for the life of the MHSSP. Financial Statements will be prepared in a format acceptable to IDA, and will be adequate to reflect resources and expenditures of the MHSSP, in accordance with sound accounting practices. The Recipient shall prepare and furnish to IDA, not later than forty-five (45) days after the end of each calendar quarter, interim unaudited financial reports for the MHSSP covering the quarter, in form and substance satisfactory to IDA. The Recipient shall have its Financial Statements audited by an independent auditor competitively selected with qualifications and experience acceptable to IDA. Each audit of the Financial Statements shall cover the period of one Fiscal Year of the Recipient, commencing with the Fiscal Year in which the first withdrawal under the MHSSP was made. The audited Financial Statements for each such period shall be furnished to IDA not later than six months after the end of such period.
Dated covenants
Within 3 months of effectiveness of the credit, the CCU shall: (i) contract project external auditors; and (ii) contract project internal auditors. 237. Supervision plan. The project risk rating after implementation of the proposed risk mitigation measures is ‗moderate‘. In the first year of implementation, supervision will include an initial onsite visit to confirm readiness to disburse, thereafter quarterly desk reviews of the unaudited quarterly IFRs will be complemented by at least two onsite visits to the project for the first year. Subsequently, the number of onsite visits will depend on the evolving FM risk rating for the project.
Funds flow
238. Designated Account for Pooled Funds. The MOH, through the DNSP, will open and maintain a pooled Designated Account (DA) to receive the financial proceeds of the IDA Credit. The DA, which will be under the control of the DNSP‘ s CCU, will be established with a Commercial Bank acceptable to IDA, and will be maintained in US dollars. The ceiling for the DA will be determined separately, and advised through the Disbursement Letter.
239. Disbursements from IDA will finance 100 percent of goods, works, consultant services, training, and operating costs under Parts A1b, A2, A3, A4a, A5, B, C1, C2, and C3 of the Project as indicated in the Financing Agreement.
240. Designated Account – Total E&P Angola: to be managed by the CCU: Denominated in $US, disbursements from the Total E&P Angola grant will be deposited in this account to finance 100 percent of training, works and goods under Parts A1a and A4b as indicated in the Financing Agreement.
241. The funds flow arrangement is illustrated in Figure 5 below:
75 Figure 5: Funds Flow Arrangements
IDA Credit Account Total (WB - USA)
US $ Designated Designated Account (WB funds Account managed by DNSP – Total Commercial Bank, Luanda)
CCU handles payments to all Municipality suppliers of goods and Commercial bank provides services. surrenders cashed justification for vouchers for advances replenishment of account
Transfers to Municipalities/ Regions (***) with respect to Transfers to commercial bank branches payments of specific amounts to Suppliers of in the Provinces for the transport nominated staff members. goods and vouchers scheme. services
Staff collect their per diems Transport providers and women and allowances from cash vouchers at commercial participating institutions. banks.
242. Payments to suppliers are generally made from the US$ account. Transfers from the Designated Account to the Municipalities will relate only to allowances to be paid to staff. These will be based on an approved list showing the computations and exact amount required, against each listed beneficiary. There will be no general advances to the provinces. Transfers to implementing institutions, such as the training colleges, will be for invoiced training costs only. Stipends for nurses on training who have no ‗own‘ bank accounts can also be made to the institutions, supported by a detailed remittance advice listing the individual beneficiaries.
243. Regarding the pilot voucher scheme to encourage institutional deliveries, its overall management would be contracted to an NGO. The contractor‘s responsibility would be to: (i) undertake communication activities to promote the transport and mother voucher schemes to beneficiaries, and explain the rules to health centers, the hospital, and the municipal administration; (ii) design the transport voucher ensuring the minimum security features to reduce fraud, and make
76 it available in health centers; (iii) help the hospital to design delivery certificates; (iv) design, in line to the MHSS, the information system to capture information on the total vouchers, number of users, mothers and drivers, age of users and problems related to the application of the scheme; (v) ensure that the municipality opens a bank account where voucher funds will be transferred from the MHSS project CCU in Luanda or from the DPS; (vi) help determine responsibilities for payment of vouchers including appropriate accounting mechanism, preparation of SOEs, and maintaining of sufficient funds on account for regular payment of vouchers for transport; (vii) undertake a risk analysis covering: (a) the cultural factors that could affect the success of a subsidy scheme: (b) the legal and regulatory issues that could affect its success; (c) the institutional opportunities and constraints; (d) increase in total pregnancies per woman; and (e) other types of risks the incentive scheme could face. It would propose ways of mitigating these risks.
244. The NGO will record all advances to commercial bank branches and on a monthly basis will collect and record the funds used to pay vouchers. The NGO will prepare and submit a monthly report to the project financial management unit that will contain information of advances and uses of funds on pilot voucher schemes. The information provided in those reports will serve as a basis for disbursement claims. The NGO has the responsibility of maintaining all necessary records and supporting documentation of the pilot voucher scheme.
245. Transfers will be made to selected commercial bank branches within the target municipalities upon agreement with the institutions (referred to as partner banking institutions). The annual ‗forecast maternity outturns‘ for each area will be used to estimate the projected births for the area in any given year. Using the unit transportation charge for each maternity trip agreed with the transport providers association in the area, an advance equivalent to six months‘ births will be made to the local branch of the partner bank. The local health service office in the area makes the vouchers, good to the value of the agreed unit transport charge, available to pregnant women prior to delivery. On the day of delivery, the expectant mother uses the voucher to procure transport to the delivery hospital. The delivery room clerks will sign and stamp the voucher upon admitting the patient, whereupon the transport operator can present the voucher to the partner bank and exchange it for cash equivalent. More details of the transport incentive scheme can be found In Annex 18.
246. Disbursement Arrangements. IDA will deposit into the Designated Account its contribution. Disbursements from the Designated Account will be made on the basis of quarterly IFRs. The IFRs will be submitted and reviewed by IDA for disbursement purposes. Detailed disbursement procedures will be described in the Project Accounting Manual of Procedures.
247. Total E&P Angola will finance 100 percent of training expenses under Component 1, subcomponent 1.1(a) of the Project (US$3.3 million); and 100 percent of the rehabilitation and construction of 4 delivery rooms (for pre and post delivery, and child care) in health centers and posts in Malange (US$520,000) under subcomponent 1.4 (b); and solar kits for maternal and child health care (US$720,000) under subcomponent 1.4 (c).
248. The project will use report-based disbursements. This method relies on the FM team‘s experience with bank reporting, including timely submission of IFRs. The team worked with transaction based disbursement during the life of the HAMSET project, but is expected to be able to cope with the more flexible method of replenishing their Designated Account. The Bank will
77 issue the ―Disbursement Letter‖ which will specify the additional instructions for withdrawal of the proceeds of the Credit.
249. The contribution of each donor is as follows:
Allocation of Financing by Disbursement Category Percentage of Total expenditures to be Category IDA (US$) E&P financed (inclusive Angola of taxes) Goods, civil works and Training for Part 1.1 (a), 1.4 4,500,000 0 (b), 1.4 (c) Goods, consulting services, training expenditure and 49,230,000 works for Part 1, except training for Part 1.1 (a) , and 100 goods and works for Part 1.4 (b) and 1.4 (c) 740,000 100 Cash transfers and consulting services under Part 2 17,330,000 100 Goods, services, operating costs and training for Part 3 3,500,000 Unallocated 70,800,000 4,500,000 Total financing
250. Conclusions of the FM Assessment. The proposed FM arrangements for the Municipal Health Service Strengthening Project, as reinforced by the FM Action Plan above, meet the minimum requirements for financial management under OP/BP 10.02.
78
Annex 8: Procurement Arrangements ANGOLA: Municipal Health Service Strengthening Project (MHSS)
General
251. Procurement for the Municipal Health Service Strengthening Project will be carried out in accordance with the World Bank‘s "Guidelines: Procurement Under IBRD Loans and IDA Credits" dated May 2004, revised October 2006; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" dated May 2004, revised October 2006, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the Credit, the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.
252. The last Country Procurement Assessment Review (CPAR) for Angola was conducted in October 2002. The Action Plan of the CPAR provided for (i) Identifying a champion to spearhead the Procurement reform and organize a high-level workshop; (ii) Activate/empower the task force to pilot the reform implementation and the creation of a comprehensive procurement framework; (iii) Review procurement legal and regulatory framework; (iv) Establish a directorate at Ministry of Finance to undertake procurement policy formulation and procurement analysis; (v) Introduce record keeping to establish a transparent procurement system in at least three Ministries during a first year pilot program; (vi) Propose sound reorganization of procurement processing and train procurement staff in pilot ministries and (vii) Strengthen National Inspectorate of Finance, the High Authority Against Corruption and the external controls by the Tribunal of Accounts.
253. The Government of Angola is currently reforming its own Procurement Regulations and Procedures, following the Bank 2002 CPAR. The Bank is supporting the Procurement Reform under the Economic Management Technical Assistance Project (EMTA). The selection process for an international firm to aid the Government in the reform was initiated in 2005. This is an on-going work and the Consultants have to date produced several drafts and once the work is finalized the procedures and regulations should be aligned with international best practices. A procurement regulatory body is also expected to be established in the framework of the on-going reform.
254. The Ministry of Health (MOH) will have the overall responsibility for the implementation and coordination of activities under the project. The National Directorate of Public Health (DNSP) will be in charge of managing the day-to-day activities of the project, through a Central Coordinating Unit (CCU). The MOH is at present implementing the Bank-financed HIV/AIDS, Malaria and Tuberculosis Control (HAMSET) project and has a Closing Date of June 30, 2010. The staff for the CCU, including financial management, procurement and monitoring and evaluation, will be contracted by effectiveness. The MHSS Procurement Specialist will receive support from the HAMSET internationally-recruited Procurement Specialist.
255. Procurement of Works. Works procured under this project would include the rehabilitation and construction of delivery rooms, construction of houses for health professionals and
79 improvements of water and sewage facilities, among other infrastructure. The procurement will be carried out using the World Bank‘s Standard Bidding Documents (SBD) for all International Competitive Bidding (ICB) contracts. National Competitive Bidding (NCB) documents in Portuguese language, translated documents from the ICB version will be used as agreed upon by the World Bank. For contracts estimated to cost less than US$3,000,000 equivalent per contract, NCB procedures will apply. Small simple works estimated to cost less than US$100,000 equivalent per contract may be procured by requesting at least three written quotations from qualified contractors. Community Participation in Procurement method may be used in remote areas where small contractors are not likely to be identified and unskilled workers would be suitable for the rehabilitation of minor health facilities. The unskilled workers would be hired in the communities close to the works, such as bricklayers, carpenters and locksmiths.
256. Procurement of Goods. Goods procured under this project would include: office furniture, office equipment, information technology equipment, vehicles, motorcycles, quad bikes, house furniture and appliances, laboratory equipment, training manuals, solar kits, radios, kits for deliveries, kits for community health workers, and equipment for hospital waste disposal, among others. The procurement will be done using the World Bank‘s SBD for all ICB. National Competitive Bidding (NCB) documents in Portuguese language, translated documents from the ICB version will be used as agreed upon by the World Bank, for Contracts estimated to cost less than US$250,000 equivalent per contract. Small value goods estimated to cost less than US$75,000 equivalent per contract may be procured under shopping procedures, with the solicitation of written quotations from at least three reputable suppliers. UN Agencies and direct contracting may also be considered with World Bank prior review and approval, for the procurement of vehicles, ambulance and specialized health sector goods. Because of conflict of interest, solar kits will not be procured from Total E&P Angola.
257. Selection of Consultants. Consultants‘ services required would cover consultancies for: quality control of health waste management, social assessment of characteristics that influence the demand for institutional deliveries, community awareness campaign, strengthening of Provincial Health Departments, preparation of Human Resources Development Plan, Medium-Term Expenditure framework, Infrastructure Plan, strengthening Monitoring and Evaluation capacity of MOH, impact evaluation of pilot for institutional deliveries, financial audits, and mid-term and final evaluations, among others.
258. All consulting service contracts costing more than US$200,000 equivalent for firms will be awarded through Quality and Cost Based Selection (QCBS) method. Contracts for highly specialized assignments estimated to cost less than US$200,000 equivalent may be contracted through Consultants‘ Qualification Selection (CQS).
259. Least-Cost Selection (LCS) will be used for selecting consultants for assignments of a standard or routine nature (audit services, works supervision) where well-established practices and standards exist and are estimated to cost less than US$200,000. Consulting firms for services, which meet the requirements under paragraph 3.2 of the Consultant Guidelines, would be selected through Quality-Based Selection (QBS).
260. Single Source Selection (SSS) may be employed with prior approval from the World Bank and will be in accordance with paragraphs 3.9 to 3.12 of the Consultant Guidelines. A survey of Maternal Health Care indicators may be entrusted to the World Health Organization (WHO), based
80 on their exceptional experience in this field and the need to use a methodology developed by WHO.
261. All services of individual consultants (IC) will be procured under individual contracts in accordance with the provisions of paragraphs 5.1 to 5.4 of the Guidelines.
262. Short lists of consultants for services estimated to cost less than US$100,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines.
263. Training. This category would cover all costs related to the carrying out of study tours, training courses and workshops, i.e. hiring of venues and related expenses, stationery, and resources required to deliver the workshops as well as costs associated with financing the participation in short-courses, seminars and conferences including associated per diem and travel costs. Training programs would be part of the annual procurement plan. Prior review of training plans, including proposed budget, agenda, participants, location of training and other relevant details, will be required only on annual basis.
264. Training Institutes. For the provision of training at provincial and central levels to nurses, midwives, community health workers, traditional birth attendants and traditional healers, the Government-owned Instituto Medio de Saúde (IMS) and Escolas Tecnica Provinciais de Saúde (ETPs) have been identified as possessing experience of exceptional worth and will be selected on single source for the provision of training activities. The IMS and ETPs will be reimbursed for expenditures required to defray the cost incurred in the delivery of agreed training sessions, inclusive of a nominal management fee. These expenditures will be included on the DNSP annual training program.
265. Operating Costs. Operating costs shall consist of the incremental expenses incurred on account of the Project implementation, management and monitoring, including: (a) office supplies; (b) office utilities and communications expenses; (c) office rental expenses; (d) Project vehicles‘ maintenance costs, fuel and spare parts; (e) travel expenses and per diems for official Project staff (excluding salaries of Recipient‘s civil servants); and (f) operation and maintenance of office equipment, financed with the proceeds of the Credit. The operating cost items will be procured using the existing MOH administrative procedures, similar to the ones in place for the HAMSET Project, which were reviewed and found acceptable to the Bank.
266. The procurement procedures and SBDs to be used for each procurement method, as well as model contracts for works and goods procured, and selection of Consulting Services are included in the Operations Procurement Manual prepared by the implementing agency which was agreed prior to negotiations. The Operations Manual will be an update of the HAMSET Manual.
B. Assessment of the agency’s capacity to implement procurement
267. Procurement activities for the Project will be carried out by a Central Coordination Unit (CCU) created within the DNSP, in its capacity of Implementing Agency and responsible for the overall coordination of activities under the Project. The CCU Coordinator will respond to the Director of Public Health as the Project Coordinator. The Deputy Coordinator will be responsible for the day-to-day coordination of the unit.
81 268. The core five staff of CCU, will be recruited by effectiveness. The Procurement Specialist will receive support from the HAMSET internationally-recruited Procurement Specialist.
269. An assessment of the capacity of the Implementing Agency to implement procurement actions for the project was carried out by Antonio Chamuço, Procurement Specialist, during appraisal. The assessment reviewed the organizational structure for implementing the project and the interaction between the project‘s staff responsible for procurement and the staff responsible for Financial Management as well as the coordination of both HAMSET and MHSS projects.
270. The assessment revealed that the available capacity for carrying out procurement is adequate for the CCU to carry out procurement for the MHSS project. The outstanding activities under HAMSET project are limited in quantity and are not of a complex nature. This will leave sufficient time for the HAMSET Internationally-recruited FM Specialist to give support to the MHSS Procurement Specialist.
271. The key issues and risks concerning procurement for project implementation of the project have been identified and include (i) the retention of current staff at HAMSET responsible for procurement and financial management, and (ii) the availability of adequate procedures manual to ensure that procurement activities will be carried out in a manner consistent with the Financing Agreement. In addition, to provide for adequate control mechanisms and assurance that funds are used for the purpose intended, procurement audits will be carried out by the Borrower. Furthermore, to enhance oversight and accountability, only activities agreed in the Procurement Plan will constitute eligible expenditure under the Project. Moreover, an internationally recruited Procurement Advisor should be retained by DNSP, on a retainer contract, throughout the lifespan of the Project. The corrective measures which have been agreed are listed in the Action Plan below:
Table 19: Procurement Management Action Plan to Mitigate Procurement Risk Risk Action Deadline 1. Capacity to manage MHSS Procurement Specialist to procurement receive support from HAMSET Effectiveness inadequate. internationally-recruited Procurement Specialist. 2. Procedures for Update the HAMSET Procurement procurement not laid Manual to incorporate applicable out properly; procedures under the MHSS Project, as part of the operations manual. The draft Manual has been reviewed and it Effectiveness found substantially satisfactory. There are items that need to be addressed, however for the purpose of fulfilling the effectiveness condition. 3. Project proceeds not Carry out Procurement Audits to During Program used for the purposes ensure that proceedings of the Credit implementation, intended; as used in accordance with the every two years provisions of the legal agreement.
82 Table 19: Procurement Management Action Plan to Mitigate Procurement Risk Risk Action Deadline 4. Expenditures Procurement Plan (PP) should be Continuous, at incurred not updated at least once annual or as least during systematically agreed required. Only expenditures for project with the Bank; activities in the PP a eligible for supervision financing.
272. The country context for procurement is rated substantial as per the last CPAR. The valuable experience gained by HAMSET staff and their absorption into the CCU of the MHSS, will enable MOH to be able to implement procurement activities in a manner satisfactory to IDA. The overall project risk for procurement is therefore moderate.
C. Procurement Plan
273. The Borrower developed a procurement plan for project implementation which provides the basis for the procurement methods. This plan is available at the DNSP of the MOH in Luanda. It will also be available in the project‘s database and on the World Bank‘s external website. The Procurement Plan will be updated in agreement with the Project Team annually or as required to reflect the actual project implementation needs and improvements in institutional capacity, and should cover at least the next 18 months.
D. Procurement Audits
274. Given the country context above indicated, the need for a more systematic ex-post review is substantial. In addition to the semi-annual supervision missions by the Bank, the Government will carry out procurement audits of the project every two years. These audits will be carried out under terms and conditions and by independent consultants whose qualifications are acceptable to the Bank. The audits will include an action plan to improve performance, where required, which will be submitted to the Bank and discussed with Government.
83 E. Frequency of Procurement Supervision
275. In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment of the Implementing Agency has recommended semi-annual supervision missions to visit the field to carry out post review of procurement actions. The Supervision missions will also include on-site visits, at least once every year.
276. The thresholds for the use of the various procurement and selections methods are summarized below:
Table 20: Procurement Thresholds Expenditure Contract Value Procurement Contracts Subject to Category Threshold (US$) Method Prior Review (US$) *) 1. Works >3,000,000 ICB All 100,000 – 3,000,000 NCB First three contracts <100,000 3 quotations None (small works) DC All 2. Goods and >250,000 ICB All Services (other than 75,000-250,000 NCB First three contracts Consultants‘ <75,000 Shopping None Services) DC All 3. Consultants‘ >200,000 QCBS All Services <200,000 LCS, QBS and First three contracts Firms CQS All >100,000 SSS All Individuals <100,000 IC First three contracts IC All SSS *) During the updates of the Procurement Plan the Bank will determine if prior review is required for a sample of contracts with estimated cost below the mandatory prior review threshold.
F. Details of the Procurement Arrangements47 Involving International Competition
1. Goods, Works, and Non Consulting Services
(a) List of contract packages to be procured:
Review Expected Procurem Prequali Domestic Contract Estimated by Bank Bid- Ref. No. ent fication Preference (Description) Cost (Prior / Opening Method (yes/no) (yes/no) Post) Date
MHSS/G-05 Buffer stock of Essential 4,971,938 ICB No No Prior Feb. 2011 Drugs MHSS/G-13 Procurement Kits for 4,884,239 ICB No No Prior Feb. 2011 normal delivery
47 Procurement Plan dated November 2, 2009
84 Review Expected Procurem Prequali Domestic Contract Estimated by Bank Bid- Ref. No. ent fication Preference (Description) Cost (Prior / Opening Method (yes/no) (yes/no) Post) Date
MHSS/G-08 Vehicles -Ambulances/ 3,121,200 ICB No No Prior Mar. 2011 and 4x4 Station Wagons MHSS/W- Housing for Health 7,600,000 ICB No Yes Prior June 2011 02 Professionals
MHSS/G-14 Procurement of delivery 1,953,696 ICB No No Prior June 2011 Kits for caesarean Procurement for Clean MHSS/G-16 delivery Kits for TBAs 882,020 ICB No No Prior June 2011 and Mothers Procurement and installation of Lot 1- MHSS/G-12 Mobile radio, Lot2 Fixed 834,000 ICB No No Prior Sept. 2011 Radios with antenna(18 + 23) Procure and installation of: Lot 1-Solar kits for MHSS/G-07 (each team) and Lot 2- 738,400 ICB No No Prior Sept.2011 Solar Mobile Kits Delivery rooms(72+23) Equipment for PNC/FP MHSS/G-22 delivery IMCI rooms and 635,500 ICB No No Prior Oct. 2011 Provincial maternities Printing and distribution of FP, PNC, Delivery, MHSS/G-01 486,000 ICB No No Prior Dec. 2010 Pediatric Care, EDP manuals and IEC posters MHSS/G-09 Motorcycles 443,840 ICB No No Prior Dec. 2011 Procurement of Basic MHSS/G-18 Materials equipments for 324,000 ICB No No Prior Dec. 2011 HWMD MHSS/G-10 Quad vehicles 288,000 ICB No No Prior Dec. 2011 MHSS/G-19 Stationary(kits) 234,000 NCB No No Post Dec. 2010 MHSS/G-15 Kits for CHWs 205,920 ICB No No Prior Dec. 2011 Procurement for Clean cut MHSS/G-17 162,000 NCB No No Post Dec. 2010 Kits for THs Procurement of Laptop MHSS/G-21 67,200 NCB No No Post Dec. 2010 Computers Telemedicine Room MHSS/G-04 60,000 NCB No No Prior Jan. 2011 Equipment Kit MHSS/G-11 Bicycles for CHW 48,000 Shopping No No Post Nov. 2010 MHSS/G-06 Camping Kit 40,000 Shopping No No Post Dec. 2011 MHSS/G-02 Library Kit 21,600 Shopping No No Post Dec. 2010 MHSS/G-23 A review GIS Software 19,500 Shopping No No Post Oct. 2011 MHSS/G-24 GPS equipment 15,600 Shopping No No Post Oct. 2011 MHSS/G-03 Modem 4,600 Shopping No No Post Dec. 2010 MHSS/G-20 Training Manuals 2,480 Shopping No No Post Oct. 2010
85
(b) ICB contracts estimated to cost above $3,000,000 for works and US$250,000 for goods and services per contract and all direct contracting will be subject to prior review by the Bank.
2. Consulting Services
(a) List of consulting assignments:
Review Expected Estimated Selection by Bank Ref. No. Description of Assignment Proposals Cost Method (Prior / Submission Post) MHSS/C- Base line and follow up Access and 1,250,00 QCBS Prior Mar 2012 26 Quality surveys (KPA & HFA) MHSS/C- Technical Assistance strengthening 379,500 QCBS Prior Mar. 2011 11 capacity of GEPE of MOH MHSS/C- 321,600 QCBS Prior Mar. 2011 12 TA to develop HRDP, PIP, MTEF MHSS/C- Annual Financial audit 500,000 QCBS Prior Dec. 2010 13 Consultant for design, construction MHSS/C- supervision of Works Housing for 800,000 QCBS Prior Dec. 2010 22 Health Professionals MHSS/C- Supervision and quality control on 190,000 QCBS Prior Dec. 2010 25 HWMD Design and implementation of MHSS/C- community based awareness and BCC 295,000 QCBS Prior Jan. 2011 16 intervention Study on bottlenecks in drug MHSS/C- acquisition, planning, distribution, 76,400 CQS Prior June 2012 21 budgeting and logistics MHSS/C- 420,000 IC Prior June 2010 01 Project Coordinator MHSS/C- Consultant M&E 420,000 IC Prior June 2010 02 MHSS/C- Training and health systems 420,000 IC Prior June 2010 03 coordinator MHSS/C- Infrastructure specialist 294,000 IC Prior June 2010 04 MHSS/C- 420,000 IC Prior June 2010 05 Procurement specialist MHSS/C- 490,000 IC Prior June 2010 06 Financial Management Specialist MHSS/C- 500,000 IC Prior June 2010 07 Procurement Advisor MHSS/C- 500,000 IC Prior June 2010 08 Financial Management specialist MHSS/C- Expert for supervision and quality 190,000 IC Prior June 2010 19 control and HWMD MHSS/C- Specialist to develop qualitative 52,000 IC Prior June 2010
86 Review Expected Estimated Selection by Bank Ref. No. Description of Assignment Proposals Cost Method (Prior / Submission Post) 20 studies Specialist to design and implement MHSS/C- community based awareness and BCC 295,000 IC Prior Feb 2011 09 intervention MHSS/C- Social Sector TA Consultant 188,000 IC Prior Apr 2011 17 MHSS/C- Preparation of Sanitary Map and 188,000 IC Prior Apr 2011 18 Health Plan
(b) Consultancy services estimated to cost above $200,000 per contract for firms and US$100,000 equivalent per contract for individuals and all single source selection of consultants (firms and individuals) will be subject to prior review by the Bank.
(c) Short lists composed entirely of national consultants: Short lists of consultants for services estimated to cost less than $200,000, equivalent per contract for Construction Supervision and $100,000 equivalent per contract, for all other type of assignments, may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines.
87 Annex 9: Economic and Financial Analysis ANGOLA: Municipal Health Service Strengthening Project (MHSS)
277. This annex provides the economic analysis of the MHSS. It reviews the project rationale, the justification for Bank and government involvement, the cost-effectiveness of project approach and interventions, and the sustainability aspects of project components and thrusts. The analysis confirms the overall soundness of the project. The country as a whole has improved some health indicators, but these continue to be woeful. Thus, seven years after the civil war ended, there continues to be justification for government involvement in the sector, and for Bank support not only for financing, but for technical support and innovation. The economic analysis demonstrates the cost-effectiveness of the chosen project approach, as well as the specific health interventions to be supported by the project, underpinned as they were by a thorough economic modeling using the marginal budgeting for bottlenecks (MBB) framework (World Bank, 2007). The analysis also highlights the potential benefits to be generated by the project, and its focus on disadvantaged provinces. Finally, the analysis documents some of the continuing challenges in health financing that hamper service delivery, and which the project and other Bank non-health instruments and programs should deal with.
A. Review of Project Rationale
278. Poor health status indicators are a sequel of the prolonged civil war. The independence struggle and the civil war have had a severe impact on all aspects of society. During the war, about one million Angolans were killed, 4.5 million, or one-third of the total population, were internally displaced. Many concentrated in Luanda and other big cities, and 450,000 fled the country. Even though the civil war ended in 2002 and much progress has been made, there are still refugees and internally displaced people who live in extreme poverty. The majority of the population still lives in harsh living conditions. Poor water and sanitation cause disease outbreaks, such as the 2006 cholera epidemic, that have resulted in thousands of deaths.
279. The epidemiological profile in Angola features a high prevalence of communicable diseases and high child and maternal mortality. The infant mortality rate is 154 per 1000 live births; the under-5 mortality rate is 260 per 1000 live births (MICS 2001); the total fertility rate is estimated to be 7.2 births per woman (MICS 2001); and the average life expectancy is only 40 years. The maternal mortality ratio is reported by WHO at 1,700 per 100,000 (2003), one of the highest in the world. This compares unfavorably with other Sub-Saharan African countries, which themselves have significantly higher rates compared to the rest of the world (Table 22). One in every seven pregnant women dies from avoidable reasons. Angola was ranked 166th out of 177 counties in the UNDP‘s Human Development Index.
88
Table 21: Key health outcome indicators Sub- Saharan Indicator Angola Average Life expectancy at birth (years - 2003) 40 49 Fertility rate (2002) 7.0 5.0 Infant mortality rate (per 1000 live births - 2000) 154 92 Under-five mortality rate (per 1000 live births - 2000) 260 171 Maternal mortality ratio (estimates) 1,700 914 Contraceptive prevalence/100,000 (2003) 6.0 22.9 GDP/Capita US$ 975 1,073 Source: MICS 2001 and World Development Indicator 2006
280. Health status has not improved over time, even after the peace agreement. For example, as shown in Figures 7 and 8, although the average infant mortality rate and under-five mortality rate of the Sub-Saharan Africa region and the world as a whole have been declining consistently, child mortality in Angola has stagnated since 1980, showing no sign of improvement.
Figure 6: IMR in Angola and Sub-Saharan Africa
250
200
150 Angola IMR Sub-Saharan IMR 100 World IMR
per 1,000 live births live 1,000 per 50
0 1960 1970 1980 1990 1995 2000 2004
89 Figure 7: Under-five mortality rates in Angola and Sub-Saharan Africa
400
350
300
250 Angola U-5 MR 200 Sub-Saharan U5MR
150 World U5MR
Per 1,000 live births live 1,000 Per 100
50
0 1960 1970 1980 1990 1995 2000 2004
Source: World Bank: World Development Indicators 2006
281. Inequalities are widening. Although Angola has an average per capita income of US$740, relatively high for sub-Saharan Africa, 68 percent of the population lives below the poverty line of $1.70 per day, with 28 percent living in extreme poverty on less than $0.70 per day. Urban poverty is rising, mainly due to the influx of displaced people into cities and the lack of job opportunities.
282. Women‘s level of illiteracy (46%) is far higher than that of men (16%). The situation is even worse for rural women, 66 percent of whom are illiterate. Most women only have access to unskilled jobs, mainly in the informal sector (where two-thirds of the jobs are done by women).
283. Angola needs additional health investments for the country to reach the health MDGs. The government has formulated a number of strategic documents such as (i) The Government Program 2009-2012 (with a section on health); (ii) the Health Sector Development Plan (currently being updated); (iii) the Municipal Health Service Strengthening Plan48; and (iv) the Plan for the Accelerated Reduction of Maternal and Child Mortality in Angola. These documents provide the direction in which the health sector should be heading. However, they usually do not link expected outcomes with effective and efficient spending and do not include detailed implementation arrangements. As a result, resources are not being used optimally and better health status has not been achieved.
284. The MHSS will help Angola ensure that the rebuilding efforts are effective, and resources well used. To that effect, the project is designed such that:
Money is spent toward solving the main health problems, such as high child and maternal mortality and the high level of infectious diseases; Money is spent on cost-effective services, which have an impact on the main health problems; Money is spent on workable and integrated service delivery arrangements; Money is spent on the necessary inputs of the service delivery system; and
48 Revitalização dos Serviços Municipais de Saúde
90 Money is spent on the frontline of services and the removal of bottlenecks of expending service coverage.
285. In its Strategic Plan for the Accelerated Reduction of Maternal and Child Mortality in Angola (2004-2008), the MOH prioritized an essential package of interventions as its means to reduce child and maternal mortality. The package is organized by service delivery mode: (i) primary health services; (ii) mobile and advance health teams; and (iii) community health agents).
286. The interventions included in the package are proven to be cost-effective and with high impact on child and maternal mortality. They are very much in line with the international best-buy list of interventions. Money will be well spent to finance these interventions, if they are delivered properly.
287. The project will help Angola invest in effective service delivery modes. The MHSS is designed to deliver health services in an integrated manner that involves: (i) facility-based clinical care; (ii) population-based outreach services; and (iii) community-based care.
288. Government involvement is highly justifiable, given the project's focus on poor and remote provinces, the overwhelming incidence of communicable diseases in these provinces, the absence of private providers, and the need for the government to drive the health reform process and steward the sector, both at the national and provincial levels. The project will focus on the provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige. No significant private sector providers currently operate in these areas, though non-profit NGOs do assist in certain health activities. Selected health indicators for the provinces are presented below.
Table 22: Selected health indicators in the five MHSS provinces compared to national average Bengo Malanje Lunda Moxico Uige Angola Norte % prevalence of fever 61.1 55.9 42.3 25.1 38.8 40.0 % prevalence of diarrhea 35.3 33.7 32.4 19.5 26.3 26.2 % prevalence of ARI49 18.3 4.8 1.7 4.8 3.9 7.0 % exclusive breastfeeding 16.2 17.0 14.9 10.4 37.0 63.9 % women receiving ANC50 80.1 67.7 67.7 71.4 67.7 79.8 % assisted deliveries 36.4 33.5 33.5 35.0 33.5 47.3 % children immunized with 100.0 60.0 68.0 37.0 100.0 81.0 pentavalent vaccine51
289. Table 23 shows that the burden of disease or the implementation of key health interventions in these provinces is generally worse than the national average. Thus, preventive and promotional health interventions (e.g. IEC) supported by the project will have significant externalities. Maternal and child health interventions, though individualized for the most part, are all considered socially meritorious. In addition, all are oriented at currently disadvantaged population groups and, therefore, have clear anti-poverty objectives. These services tend to be under-provided by the private sector operating under market forces, and therefore indicate a clear government
49 ARI = Acute Respiratory Infection 50 ANC – Ante-Natal Care 51 Diphtheria, Pertussis, Tetanus
91 involvement in their financing and stewardship. The project encourages contracting out specific service delivery to non-profit providers and community-based organizations, where they are available, and where it can be clearly demonstrated that this is a cost-effective approach under public/private partnership arrangements. Nevertheless, it is clear that in Angola as in other poor countries, the government is needed to drive the process of change in service delivery and financing, and to provide leadership and stewardship, both at the national and the provincial levels.
B. Justification for Bank Involvement and Project Alternatives Considered
290. The project is in line with the Government Program and the ISN. The project's poverty orientation (focusing on five poor provinces) is in line with Angola‘s poverty-eradication strategy as specified in the Government Program 2009-2012 and the Bank's ISN. The programmed institution-building activities that will be conducted in Bengo, Malange, Lunda Norte, Moxico, and Uige also support the government's efforts to increasingly decentralize social services and strengthen the capacity of municipalities. The Bank brings to bear its technical leadership in this project, which the government and other donors recognize. The Bank combines policy reform, impact evaluation, and large-scale implementation experience that the project can use. In this process, this project will work closely with the Bank's existing macroeconomic instruments so that the project's sector reform thrusts get firmer traction.
291. The preparation team considered alternative approaches for the project, and concluded that the current design reflects the best feasible approach, taking into account the actual situation in Angola as well as what the national and provincial governments aim to achieve. The alternatives considered are as follows:
. Why not HAMSET II? Through HAMSET, the Bank has been the first external financier to help the government control HIV/AIDS, TB, and malaria. This has led the way to further funding from the Global Fund and the US President‘s Malaria Initiative, as well as increased financing for HIV/AIDS control from the government itself. On the other hand, maternal and child health indicators are appalling, justifying the strategic decision to give priority to investing in the improvement of these health outcomes.
. No project alternative. The ―no project‖ alternative is not desirable because child and maternal mortality are very high in Angola, and malaria devastating. Without an operation that introduces an integrated service delivery model, Angola‘s chances of reaching the MDGs in 2015 would be slim.
292. The following project features should be highlighted for their cost-effective elements: (i) the focus on a few key interventions that have a significantly large impact on reducing disease burden, rather than outright provision of a comprehensive package; and (ii) the conduct of impact evaluation to demonstrate the cost-effectiveness of service delivery packages, and to compare ex- ante (assumed) vs. ex-post (actual) costs.
293. Project interventions have been shown to be the most cost-effective packages. The project design process relied heavily on the analytic work, conducted as part of the PER, which identified and costed out the packages of supply interventions that could best reduce the burden of disease in the country. This modeling exercise presented five steps, their respective impact on mortality, and additional cost per capita, as follows:
92 Step 1: Undertake social mobilization and behavioral interventions as well as supply essential materials to households through community-based interventions;
Step 2: Organize outreach and mobile teams to provide a set of standardized services to populations without access to health facilities;
Step 3: Expand the primary health care network to provide preventive and basic curative care;
Step 4: Strengthen the first-level referral care that can provide comprehensive and emergency health care;
Step 5: Improve the second-level referral care that can provide specialized care.
294. Table 24 illustrates the impacts on under-five and maternal mortality reduction and additional cost per capital of these four options. These are "ex-ante" impact and cost figures, but the intention of the project is to validate these during project implementation.
Table 23: Impact on Under-Five and Maternal Mortality Reduction and Additional Cost Per Capita of Four Health Service Delivery Steps in Angola Reduction Reduction Reduction Cost (US$ per in IMR in U5MR in MMR capita per year) Step 1: Undertake community-based social 29% 39% 1% 2.51 mobilization and behavioral interventions Step 2: Scale up population-based outreach 9% 8% 9% 1.05 services Step 3: Expand primary health care 17% 23% 1% 3.05 Step 4: Strengthen the first level referral 2% 2% 3% 0.97 care Step 5: Improve the second level referral 1% 1% 3% 0.89 care All five steps 51% 62% 17% 8.48 Source: PER (2007).
93 C. Sustainability of Project Investments
295. First, sustainability efforts will focus on demonstrating the feasibility of implementing the basic package of services cost-effectively in poor provinces. Given the high level of poverty in the five provinces where the project will be located, the project focuses less on the financial sustainability of project inputs through direct household contributions or other alternative local financing. Rather, the project will focus on four critical ingredients of sustainability. First, on the supply side, the project will promote institutional sustainability by showing that the basic package of services can be delivered cost-effectively in the five provinces. To achieve this, health services in the five provinces will have to be reconfigured so that they cater increasingly to community and outreach services. A key challenge in this regard - and which has significant budgetary implications - is the provision of adequate staff training, remuneration, incentives, transport, and supervision support.
296. Second, sustainability efforts will also be directed to achieving policy support at the national level for the demonstrated improvements in health coverage and outcomes. This policy reform project is non-threatening as it is based on an agreed-upon agenda, and is supported by evidence, both through the modeling exercise that was conducted as part of analytical work, and also through the impact evaluation work that will be done as the project proceeds.
297. Third, the project will support demand-side household behavior change interventions. On the demand side, the project will promote positive change in household and community behavior in order to sustain their interest in, and increase their demand for, the health services in the project. Towards this end, the acquisition of health knowledge will be promoted through IEC activities. Community involvement in decision-making will also be enhanced. Finally, the social assessment documents cultural and social impediments to household demand for health services, and to propose ways of easing these obstacles.
298. Fourth, the government will have the means to sustain and increase spending in the health sector. Angola‘s economic outlook is promising. Angola‘s economy has been growing strongly at close to 20 percent per annum over the last three years. Economic growth is likely to continue with the output of crude oil forecast to reach 2.1 million barrels/day in 2010, although production could rise at a slower rate because of OPEC quotas.
299. Rising oil output, along with expansion in agriculture, manufacturing and construction, will drive strong real GDP growth. Although GDP is decreased by 0.6% in 2009, economic growth is expected to resume and Angola‘s medium-term economic prospects are good. The Bank projects GDP to grow around 6.5% from 2010-2012.
94 Annex 10: Safeguard Policy Issues ANGOLA: Municipal Health Service Strengthening Project (MHSS)
300. The MHSS is classified as Category ―B‖ for environmental screening purposes. A partial environmental and social analysis is considered appropriate to address specific environmental and social issues associated with the provision of medical supplies, which triggers concerns about healthcare waste management and the construction of staff housing, and which raises potential issues about land acquisition and resettlement and construction or rehabilitation of buildings. A stand-alone Environmental and Social Management Framework has been prepared to provide an environmental and social screening process to allow for the identification, assessment and mitigation of potential negative environmental and social impacts related to the project.
301. An assessment of current health care waste management and disposal systems, carried out under the HAMSET project, showed that the current state of waste management is inadequate. Current practices in health care waste and contaminated health care waste handling, storage and disposal, in particular, raise environmental and social concerns. The need for sound management and disposal of contaminated health care waste is of paramount importance because health-related activities produce waste on daily basis as a result of preventive and curative service delivery. Waste produced is in the form of sharps (needles, syringes, scalpels etc.), non-sharps, blood and other infected and non-infected materials, chemicals, pharmaceuticals and medical devices. Health workers, waste handlers, users of health facilities and the general public are all exposed to health care related waste and may become infected, as a result of poor management.
302. The MHSS team will actively monitor ongoing activities for compliance with the requirements and recommendations of this assessment, and modify or end activities that are not in compliance. If additional activities are added to this project that are not described in this project document, an amended EA will be prepared and approved prior to implementation of those activities.
303. The project will not be considering the malaria control component as per the government‘s request during preparation. The MOH has sufficient financing from other donors for all indoor residual spraying activities (pesticides or spraying equipments), thus no need for a Vector Management Plan.
304. Health Care Waste Management Plan. The Healthcare Waste Management Plan developed under the HAMSET Project was updated to fit the needs of the MHSS project and disclosed prior to appraisal. It will be used and monitored during project implementation.
305. Current practices in health care waste and contaminated health care waste handling, storage and disposal still raise some environmental concerns. Poor practices in healthcare waste management can lead to negative effects such as hospital acquired infections, development of drug resistant bacteria, disease transmission from infected needles, or negative health effects from the release of toxic substances.
306. At present, there are no available national environmental and social policies and regulations that speak to safe handling, storage and disposal of waste in general, and health care waste in particular. A sound policy and regulatory environment needs to be put in place so that the
95 government can have the means and capacity to enforce safeguard policies and regulations pertaining to health care waste, and monitor required mitigation measures.
307. The MHSS project adheres to the key objectives and activities of the National Health Care Waste Management Strategy. The MHSS project will make use of the lessons learned from the implementation of the HCWMP during the HAMSET project to foster a sound management of health care waste at the national level. The MHSS project will emphasize the implementation of this action plan in the targeted five targeted provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige.
308. The approach adopted by this project is to build on the progress already achieved under the HAMSET project to help the government improve healthcare waste disposal in the project area and throughout the country. HAMSET facilitated the implementation of the plan, including capacity building, mitigation measures and their timely monitoring. Financing for priority actions of the Plan were included in the MHSS project.
309. The HCWM Plan was updated in March 2009, and revised to reflect the current realities faced in the targeted provinces. It will be applied through the life of the MHSS project. It involves fairly intensive training and capacity building activities, review of legal and institutional framework, and provision of protective clothing and biosafety kits, provision of basic equipments and technical support, and specific monitoring actions. Financing for activities of the HCWM Plan are included under the MHSS under Component 1, Subcomponent 4 – Improvement of hospital waste disposal. MHSS is committing up to US$ 995,000 to facilitate the implementation of the plan. This is significantly higher (over four times) than the allocated budget under the HAMSET project. Additional sources of financing would also be sought, including from the government budget itself.
310. The Ministry of Health, the Ministry of Urbanism and Environment, the provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige, and municipalities within these provinces, health facility directors, health workers, and patients are the key stakeholders under this project. The Medical Waste Management Plan (MWMP) and The Environmental and Social Management Framework (ESMF) were published by the Bank in Infoshop on November 25, 2009, and on the MOH website on April 21, 2010. Comments and inputs from the general public and key stakeholders will be incorporated in the final draft that will also be disclosed to the public.
311. Despite the somewhat inadequate picture of current health care waste management practices and context, there is reasonably fertile ground for success for the health care waste management plan. The current commitment of the central, provincial and local government to the National Health Care Waste Management strategy is encouraging. This strategy was developed by the Ministry of Health in conjunction with the Ministry of Urbanism and Environment and designed to revamp current management practices of waste, in general, and health care waste in particular, through the establishment a new centralized incineration center for infectious health care waste. The government is also contracting three new private waste management service providers to complement the activities of the existing private service provider, URBANA 2000, and broaden coverage of the waste management and disposal activities in a safe and timely fashion. Furthermore, there are a number of NGOs in the country that are very active in the area of environmental health, and have been playing a crucial role in public awareness and in behavior change activities targeted at medical staff, cleaning personnel and the general public.
96 Land Assessment for civil works
312. The MHSS project is proposing to rehabilitate or build 36 delivery rooms in health centers and posts and construct new houses for medical staff in 18 municipalities. In discussions with government officials, the team has been assured that all houses would be built on government land without the presence of squatters. The land legal status will be documented in the provided Land Acquisition and Resettlement Assessment Form. The MHSS Project Coordinator will be responsible for ensuring that the land and asset issues are dealt with properly, with assistance from the Municipal Administrator. The Municipal Administrator will identify government land to be used for construction under the project. He or she will conduct an assessment of the land and will send the form to the MHSS project coordinator certifying that the land identified is government land and is free of squatters. This will be verified with the submission of completed Land Assessment Forms. The team provided the government with translated copies of the Land Acquisition Assessment Forms and asked to have them completed and signed to document the legal description of the land, location, occupation, use. The ESMF copies of signed forms for each site, verifying that no resettlement will occur, will be kept by the Project Coordinator.
313. Should there be a case where the land does not belong to the government and/or there would be squatters, it would be immediately rejected by the MHSS project coordinator who would request the Municipal Administrator to find alternative land.
314. To prevent environmental impacts due to the construction or rehabilitation of houses for medical staff and delivery rooms in health centers/posts, the ESMF addresses the General Environmental Management issues associated with civil works and includes an annex with Detailed Environmental Management Conditions for Construction Contracts to be integrated in each construction site to minimize potential environmental impacts associated with project activities.
315. As part of the ESMF review, the Task Team took the necessary actions to ensure due diligence in complying with all safeguard requirements. First, the team got full commitment from the government that proper mechanisms are in place to ensure that no involuntary resettlement, loss of livelihood or loss of access to land will occur. Second, no squatters will be negatively impacted by any project activities. Land with squatters, land used for pasture or other livelihood activities will not be considered for construction under this project.
97
Annex 11: Project Preparation and Supervision ANGOLA: Municipal Health Service Strengthening Project (MHSS)
Planned Actual PCN review June 17, 2008 June 18, 2008 Initial PID to PIC June 23, 2008 June 24, 2008 Initial ISDS to PIC June 23, 2008 June 24, 2008 Appraisal March 2, 2009 July 6, 200952 Negotiations February 15, 2010 April 23, 2010 Board/RVP approval June 3, 2010 Planned date of effectiveness September 15, 2010 Planned date of mid-term review December 31, 2012 Planned closing date December 31, 2015
Key institution responsible for preparation of the project: Ministry of Health
Bank staff and consultants who worked on the project included:
Name Title Unit Evarist Baimu Counsel LEGAF João Blasques de Oliveira Public Health Specialist Consultant Eduardo Brito Senior Counsel LEGAF Antonio Chamuço Procurement Specialist AFTPC Gabriela Cohen Social Sector Specialist Consultant Humberto Cossa Senior Health Specialist AFTHE Alberto Chueca Mora Country Manager AFMAO Jean-Jacques de St. Antoine Task Team Leader AFTHE Cassandra de Souza Operations Analyst AFTHE Ricardo Gazel Senior Economist AFTP1 Geraldine Geraldo Program Assistant AFMAO Mary Green Program Assistant AFTHE Kjetil Hansen Senior Public Sector Management Specialist AFTPR Abdelaziz Lagnaoui Senior Pest Management Specialist ENV Suzanne Morris Senior Finance Officer CTRFC Eva Ngegba Program Assistant AFTHE Jonathan Nyamukapa Senior Financial Management Specialist AFTFM Jenni Pajunen Junior Professional Officer AFMAO Monica Sawyer Country Officer AFCS2
Bank funds expended to date on project preparation: 1. Bank resources:US$172,500 2. Total: US$172,500
52 Date the Regional Operations Committee upgraded the March 2009 mission to appraisal.
98
Estimated Approval and Supervision costs: 1. Remaining costs to approval: US$10,000 2. Estimated annual supervision cost: US$100,000
99 Annex 12: Documents in the Project File
ANGOLA: Municipal Health Service Strengthening Project (MHSS)
1. World Bank. HIV/AIDS, Malaria And Tuberculosis Control Project (HAMSET) Project Appraisal Document.
2. European Union and World Bank. Angola Public Expenditure in the Health Sector (September 2008).
3. Ministry of Health of Angola. Strategic Plan For the Accelerated Reduction of Maternal And Child Mortality in Angola.
4. Ministry of Health. Revitalização dos Serviços Municipais de Saúde.
5. Ministry of Health. Revitalização dos Serviços Municipais de Saúde, Iº Encontro de Padronização Luanda, 7 de Maio De 2007.
6. Adérito De Castro Vide (Engineer) – Angola HAMSET Project: Health Care Waste Management Plan in Angola (November 2004)
7. UNICEF Angola. Making the World a Better Place for Children Striving for the Millennium Development Goals
100 Annex 13: Statement of Loans and Credits ANGOLA: Municipal Health Service Strengthening Project (MHSS)
Difference between expected and actual Original Amount in US$ Millions disbursements Project ID FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev‘d P105101 2010 AO-Local Dev. Program SIL (FY09) 0.00 81.70 0.00 0.00 0.00 79.54 0.00 0.00 P093699 2009 AO-Market Oriented Smallholder Agr 0.00 30.00 0.00 0.00 0.00 29.35 0.00 0.00 P096360 2009 AO-Water Sector Institutional Dvlp 0.00 57.00 0.00 0.00 0.00 53.60 13.03 0.00 P095229 2007 AO-MS ERL 2 0.00 102.00 0.00 0.00 0.00 79.40 83.93 0.00 P083180 2005 AO-HAMSET SIL (FY05) 0.00 21.00 0.00 0.00 0.00 4.12 3.56 0.00 P083333 2005 AO-Emerg MS Recovery ERL (FY05) 0.00 50.70 0.00 0.00 0.00 13.39 13.47 0.00 P072205 2003 AO-Econ Mgmt TA (FY03) 0.00 16.60 0.00 0.00 0.00 4.92 2.95 2.93 Total: 0.00 359.00 0.00 0.00 0.00 264.32 116.94 2.93
ANGOLA STATEMENT OF IFC‘s Held and Disbursed Portfolio In Millions of US Dollars
Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 1998 AEF Flecol 0.61 0.00 0.00 0.00 0.61 0.00 0.00 0.00 2005 CNO OSEL 10.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2003 EBA 0.00 0.70 0.00 0.00 0.00 0.70 0.00 0.00 2005 Nossa Seguros 0.00 0.00 1.00 0.00 0.00 0.00 1.00 0.00 Total portfolio: 10.61 0.70 1.00 0.00 0.61 0.70 1.00 0.00
Approvals Pending Commitment FY Approval Company Loan Equity Quasi Partic.
Total pending commitment: 0.00 0.00 0.00 0.00
101 Annex 14: Country at a Glance ANGOLA: Municipal Health Service Strengthening Project (MHSS)
102
103
Annex 15: Key High-Impact Health Interventions by Service Delivery Level ANGOLA: Municipal Health Service Strengthening Project (MHSS)
Table 24 : Key High-Impact Health Interventions Service Delivery Child Health Maternal Health Malaria Environmental HIV / AIDS TB Arrangements Health Breastfeeding Clean Delivery ITNs promotion Latrines Awareness - 1. Family promotion Condom general population Safe Water raising through Community Safe Water Handling Promotion Storage peer based and Storage promotion Oral Anti-malarials Handling education based health (including Chlorine) Contraceptive (chloroquine) for promotion (including Safe interventions Hand-Washing Promotion children less than 5 Chlorine) Sex Promotion promotion Supplementary and adults Hand-Washing Behavior change ITNs use promotion feeding for promotion (number of sexual children less than 5 malnourished Solid and Liquid partners ORT pregnant women Waste management Discuss Zinc treatment in promotion traditional norms, association with ORT rituals and taboos Advise on favoring Complementary and HIV/AIDS supplementary Feeding transmission Clean Delivery Temperature Condoms Management and marketing Kangaroo care Condom Promotion Mass media campaigns Support to orphans
Supervision of Health Supervision of Supervision of Healthy homes Supervision of TB awareness 2. Population Promoters Health Promoters Health Promoters environment Health Promoters raising based outreach Family Planning Family Planning promotion Management Case Iron and Foliate (Depo-Provera, ) Indoor Identification Support and identification services supplementation Iron and Foliate Insecticide spraying Management of care TB DOTS Tetanus Toxoid acid supplementation Surveys/HMIS mosquito breeding First Aid follow-up BCG, Measles, DPT3 to pregnant women places Universal Vitamin A Births planning Indoor Precautions supplementation and complications Insecticide spraying. HIB vaccine readiness Control of ACT anti-malarials for ITNs pregnant insects, rodents etc children less than 5 women Food safety Supervised ORS Prenatal care, measures Surveys/HMIS postnatal care Education on Surveys/HMIS prevention of accidents and illnesses Surveys/HMIS 3. Clinical Assisted deliveries Assisted ACT UP TT of STI TB services Antibiotics for deliveries HAART identification and pneumonia (ARI tt) Antibiotics for follow up DOTS initiation Antibiotic treatment premature rapture of PMTCT a. primary for dysentery membrane (PRM) Treatment of clinical care Resuscitation Tt of STI Opportunistic Treatment of Severe Basic to infections Anemia comprehensive EOC UP Vitamin A treatment Post-abortion Treatment of neonatal care sepsis Norplant PMTCT IUD insertion Severe malaria b. referral Management of severe CEOC Management of Management Management clinical care prematurity/LBW and Blood Safety complicated Malaria of resistant AIDS of Multi drug neonatal sepsis Resistant TB Management of complicated Malaria
104 Annex 16: Terms of Reference for the Development of a Human Resources Development Plan ANGOLA: Municipal Health Service Strengthening Project (MHSS)
316. Background. At an aggregate level, the human resources for health (HRH) indicators for Angola are similar to those of other Sub-Saharan countries (SSA). Likewise, the distribution of HRH is imbalanced across regions and between urban and rural areas. As a result of the war that afflicted the country for approximately three decades, many health staff moved to Luanda, the capital, in search of refuge. In 2004, the proportion of doctors and nurses working and living in Luanda was thought to be 70% and 30 % respectively. However, during the last 2-3 years the situation seems to have changed considerably. According to the results of a survey conducted on health facilities that provide obstetric and neonatal, the number of doctors in most provinces and municipalities increased significantly53.
317. In 2004, Angola HRH indicators were worse than its immediate neighbors with the exception of the Democratic Republic of Congo that has lower indicators (Table 1). These aggregate indicators should be interpreted with caution as they do not provide a full picture of the country-wide availability of HRH and other characteristics, e.g. productivity. Also, data on HRH is not readily available and often the figures are not consistent.
Table 25: HRH data in Angola and selected SADC countries per 10,000 persons54 Number of health Physician/ Nurse and Health Population professionals Doctors Nurses Inhab. midwife/Inhab. Profess./Inhab. Angola 16,577,000 21,537 1,165 18,977 0.70 11.45 12.99 Botswana 1,858,000 6,668 715 4,753 3.85 25.58 35.89 DRC 60,644,000 37,017 5,827 28,789 0.96 4.75 6.10 Namibia 2,047,000 7,741 598 6,145 2.92 30.02 37.82 South Africa 48,282,000 292,602 34,829 184,459 7.21 38.20 60.60 Zambia 11,696,000 28,134 1,264 22,010 1.08 18.82 24.05 Zimbabwe 13,228,000 13,960 2,086 9,357 1.58 7.07 10.55 Average of SSA 2.17 11.72 26.26
318. According to MOH official sources, 2,500 physicians were working in Angola in 2008. Of these 1,200 are Angolan nationals. The number of nurses was estimated at 36,000 nurses and other health and medical technicians at 4,000 adding to a total number of 42,500 health professionals.
319. Data derived from the 2007-2008 survey ―A Situação do Atendimento Obstétrico em Angola‖ shows the HRH available in all facilities that provide obstetric and neonatal care. While the data does not cover the entirety of HRH of the sector, it provides interesting clues about the current context of HRH in Angola, in particular because it also captures data from private providers, both for profit and not-for-profit (Table 2).
320. Medical personnel. The first important observation is that in Angola today, there are more doctors outside Luanda than there were some 3-5 years ago. For example, out of the 983 identified in the surveyed facilities, 668 (70%) work at provincial level. Of these, 445 (65%) are medical
53 Situação do Atendimento Obstétrico em Angola, UNICEF 54 http://www.who.int/whosis/. The number of health professionals includes only nurses and midwives, physicians, pharmacist, dentists and other health workers. It excludes management and administrative staff. All statistics are for the year 2004.
105 specialists (obstetricians and gynecologists, general surgeons, pediatricians, neonatologists, and anesthesiologists) and 243 (35%) general practitioners. Interestingly, all provinces have more medical specialists than general practitioners except Cunene province where the number of general practitioners is slightly higher than that of specialists. This is an unusual pattern of distribution of medical specialists and it is the result of government decision to hire specialists from Cuba and other countries to fill the gap in the specialized clinical care at provincial level. One third of medical specialists (222 out of 667) work in Luanda. In general Luanda is better supplied by medical and other health specialties as shown in Table 27 Luanda has about 36% of the total population of the country (5.2 million) distributed in 9 municipalities. However not all inhabitants of Luanda benefit equally from the services of these specialists as most doctors (192 out of 222) work in two municipalities only (Ingombotas and Kilamba Kiaxi).
Table 26: Health staff in facilities providing obstetric and neonatal care. Total No. University Basic Medical General of Level Mid Level Level Mid- Laboratory Province Specialists Practitioners Doctors Nurses Nurses Nurses wives Technicians Total Bengo 10 10 20 3 34 246 8 28 339 Benguela 63 36 99 2 722 901 75 111 1910 Bié 23 37 60 0 452 882 5 35 1434 Cabinda 32 5 37 7 124 151 13 71 403 Cunene 24 29 53 0 45 471 17 25 611 Huambo 30 14 44 9 987 1145 79 74 2338 Huíla 49 23 72 6 182 627 1 88 976 Kwando- Kubango 33 5 38 7 13 164 38 24 284 Kwanza Norte 11 7 18 0 51 174 9 10 262 Kwanza Sul 32 17 49 0 31 482 1 41 604 Luanda 222 73 295 25 1140 1601 177 429 3667 Lunda Norte 24 18 42 3 10 431 100 44 630 Lunda Sul 39 12 51 9 12 425 24 28 549 Malange 6 2 8 0 85 304 4 14 415 Moxico 8 4 12 8 149 301 8 12 490 Namibe 22 6 28 2 108 349 4 56 547 Uíge 24 9 33 0 15 852 61 70 1031 Zaire 15 9 24 4 50 309 1 23 411 Total 667 316 983 85 4210 9815 625 1183 16901
321. The five provinces of the Municipal Health Services Strengthening (MHSS) project are reasonably served by both medical specialists and general practitioners. More importantly, all municipalities of these provinces, with the exception of Malange have both medical specialists and generalists. This is a major achievement of the Angola MOH. While this achievement should be commended some caution should also be exercised as it appears that too many specialists are delivering care that could also be delivered by non specialists. Excessive reliance on specialized care may unnecessarily drive up health care costs.
322. Nurses and midwives. According to the survey, there are 14,735 nurses and midwives working in surveyed facilities. Of these 9,815 (66.6%) are basic level nurses, 4210 (28.6%) are mid-level nurses, 625 (4.2%) are midwives, and 85 (0.6%) are university level nurses. The
106 distribution of basic nurses and mid level nurses across provinces seems reasonable (Table 29). The distribution of midwives is imbalanced: some provinces have more than 100 midwives and others have less than five. More importantly, there seems to be a distortion of the composition of the medical teams between and within provinces. For example, the ratio of midwives to Obstetricians varies between 0.1:1 (Huíla) to almost 13:1 (Kwando-Kubango). Relatively to basic nurses there seems to be a better nurse to doctors ratios, however in some provinces there are more than 25 nurses per doctor, including Malange and Moxico (38:1 and 25:1 respectively). This relationship suggests an excess of nursing staff in these provinces.
323. Laboratory staff. In general, laboratory technicians are distributed more evenly between provinces. Like other medical cadres Luanda has 36% of the total number of laboratory technicians (1,183).
324. Production of health staff. The training of doctors is ensured by the Ministry of Education. There are also private universities that train physicians. As for other health cadres, the training is offered by training institutions of the Ministry of health located in Luanda and at provincial level. Despite the fact that Angola has a university level training institution (Instituto Superior de Enfermagem – ISE), the number of nurses with a university degree is relatively low (Table 30). Other private training institutions also play a role in the training of health staff. Recently concerns about the quality of training of nurses and midwives have been raised by health providers and the MOH.
325. The current output of medical schools (public and private) indicates that Angola may take considerable time to produce enough qualified doctors to match the country needs. This is why the government is resorting to contracting doctors from Cuba and other countries to fill the gap. The long term solution will be to increase the output and effectiveness of the training in medical schools and other health training institutions.
326. Management of HRH. The management of HRH is as critical as is the training if effective healthcare delivery and good quality care is to be achieved. Anecdotal observations indicate that productivity of the staff in public facilities is low. This could be attributed to excessive number of staff in some facilities and or the lack of motivation. Issues of system organization, clear job description, career progression and reward systems are important elements for the optimal performance of the staff. In addition, professional values and behavioral aspects of health staff are particularly important and can make significant difference in the acceptability and increased demand for services by the people.
327. An area that has received less attention from ministries of health in the region including Angola, is the administration and management career in the health sector. Generally all management positions in the MOH are taken by doctors and or other health professionals with varying degrees of exposure to management and administration concepts. Improving the management of the health sector and its programs is warranted to ensure good use of the resources.
328. MOH Strategy for HRH. The MOH has recently developed a strategy for HRH. The strategy provides the overall direction to improve staffing of health facilities and standardize the qualifications and careers of health staff in Angola. However the strategy is yet to be translated into a comprehensive and costed mid-term human resources development plan for the sector. Developing such a plan is a challenging endeavor, particularly in the context of Angola. The MOH
107 intends to develop the plan but it has limited capacity to do so. The MOH will contract the services of a consultant to help review its HRH strategy and help the MOH prepare a comprehensive medium-term human resources development plan.. The Bank can support this process under the MHSS project. Also the Bank has a comparative advantage in health systems and can also tap on existing experts and experiences in the region related to HRH.
329. Purpose. The purpose of the consultancy is to facilitate the process and provide analytical inputs and help prepare a comprehensive, costed HRH development plan for the health sector in Angola taking into consideration the government reform policy. More specifically the consultancy will consist of three main stages: (i) assist the MOH in undertaking a thorough and detailed analysis of the HRH situation in Angola covering the availability, distribution, productivity and management of health staff; (ii) review and adapt the MOH‘s HRH strategy to formulate a mid- term HRH development plan and estimate its costs; and (iii) advise on institutional arrangements needed to strengthen the management of human resources in the MOH.
330. Scope of work. The specific tasks of the consultant would be to:
(i) Undertake a desk review of key policy documentation of the health sector in Angola, including the overall national health strategy, the HRH strategy, and other relevant documents. (ii) Analyze the current availability and distribution of HRH in the country. (iii) Analyze the factors driving the current distribution of health staff and their productivity (iv) Review the composition of the health teams in provinces up to the level of health centers. (v) Make recommendations to the HRH strategy of the MOH in line with the analysis of the current HRH situation, in particular regarding staff productivity, posting in remote areas, and career progression. (vi) Develop an HRH mid-term plan, with corresponding costs estimates (vii) Provide 2-3 scenarios for the HRH plan.
331. Process. The consultant will work under the coordination of the Directorate of Human Resources to whom he/she will report regularly. The consultant should use a participatory process involving key stakeholders in the health sector and in other line ministries such as MOF, MAPESS, and other ministries if necessary. A MOH counterpart should be nominated to follow up the process on a daily basis and to facilitate the work of the consultant‘s team.
332. Two workshops will be held throughout the process. The first will be to present the report on the analysis of the HRH situation and discuss the strategic diagnosis. This workshop‘s main objective will be to validate the analysis and the main conclusions. A second workshop will be held to present and discuss the main components of the HRH strategy and mid-term plan and its costs implications. The main objective of the second workshop will be to obtain consensus on the key strategic options to address HRH issues in the sector.
333. Requirements. The consultancy should be done by a multidisciplinary team ideally composed of: a facilitator or project manager, a senior human resources management expert, and a health economist and or public health specialist. Other short-term consultants would be used as needed throughout the process.
108 334. The lead consultant should possess a good track record of similar assignments in developing countries in the Africa region. Proficiency in Portuguese is a key requirement to allow for maximum interaction with MOH counterparts. The report should be written in Portuguese, with a translation in English.
335. Deliverables. The following are the deliverables of the consultancy:
(i) A comprehensive report on the analysis of the HRH situation in Angola with an executive summary. The report should also be provided in a CD ROM format. (ii) A Power Point presentation of the main analytical report to be presented at the first workshop. (iii) An issues paper for the second workshop. (iv) A draft HRH mid-term development plan. (v) The organization and implementation of two workshops. (vi) A final HRH development plan
336. Time frame. The consultancy would last12 months from the situation analysis to the draft mid-term HRH development plan. It is expected that the consultancy will be contracted no later than September 30, 2010.
109 Annex 17: Terms of Reference for the Development of a Health Infrastructure Development Plan ANGOLA: Municipal Health Service Strengthening Project (MHSS)
337. Background. After nearly three decades of war Angola‘s health infrastructure remains severely damaged or destroyed as a direct consequence of the war and lack of maintenance. In addition, during that period there were virtually no investments in new health infrastructure, which has led to the contraction of the health network. The facilities were functioning with inadequate or deteriorated equipment resulting in reduced quality of health care services.
338. With the advent of peace in 2002, the government started an ambitious reconstruction program to rebuild the country‘s infrastructure as part of its socio-economic development program. The reconstruction program includes the reconstruction and expansion of the health network and is financed by the government and external sources, including significant financing from China, as well as support from the EU. In the context of the reconstruction program, the Bank supports the Emergency Multisectoral and Rehabilitation Program (EMRP), which also includes a health component. The health component of the EMRP contemplated the rehabilitation and reconstruction of health facilities in the target provinces of Bié, Kwanza Norte, Malange and Moxico. While the government has succeeded in allocating more funds to rehabilitate and or build new health infrastructure, the precise status of the country‘s health infrastructure is not fully known.
339. In 2007, the MOH started to undertake a sanitary mapping of the country to better characterize the situation of the health infrastructure. The aims of the exercise was to: (i) identify the precise status of each health facility, including its equipment, staff and the population served; and (ii) to develop an investment program based on the findings of the mapping exercise. The MOH started the mapping exercise in five provinces supported by the EU, namely Benguela, Bié, Huambo, Huíla and Luanda. The mapping was implemented between March 2007 and June 2008. The exercise provided detailed information about the physical status of every facility in each of the five provinces and allowed the planning of infrastructure investments to rebuild the health facilities and other related infrastructure in accordance with government plans. These plans have been discussed with the provincial authorities and have been endorsed by the respective governors.
340. The MOH considers the sanitary mapping a good tool to help make decisions about infrastructure investments and wants to ensure that the exercise covers the rest of the provinces. Thus the MOH is seeking support to continue this exercise in the remaining 13 provinces of the country. In this context it asked the Bank to support the mapping in the five provinces under the Municipal Health Services Strengthening (MHSS) project financed by the Bank, and Total E&P Angola.
341. Mapping of health facilities in the five provinces supported by the EU. The sanitary mapping consisted of an exhaustive assessment of the physical condition, maintenance and functionality of the equipment, and the staffing pattern for every health facility. To do this task, the MOH created multidisciplinary teams in each province. Through a competitive process, it contracted a firm to conduct the data collection and analysis. The role of the firm was to design a data base for the mapping, supervise the data collection, undertake the analysis of the data, produce the reports and present the final result to the local government and the MOH at central level. The process was carried out in a participatory process. Workshops were held to present the results of
110 the mapping and validate the findings. A second workshop was held to discuss the first draft of the infrastructure investment program.
342. The investment plans were adopted by the provincial governments and will form the basis for the Public Investment Program of the Provincial Governments and also of the central level MOH. But developing only a health infrastructure program would not suffice without other critical inputs such as personnel, medicines and logistics. The MOH has a human resources strategy which should be taken into account when developing the infrastructure plan. In addition it is necessary to anticipate the recurrent cost implications of the investment in infrastructure and how this will impact the budget of the MOH and the government in the medium and long term.
343. Purpose. The purpose of this assignment is to assist the five provinces of the Municipal Health Service Strengthening (MHSS) project to carry out a health mapping, including the development of a comprehensive and costed health investment program for the period 2010-2020. This assignment is a continuation of a similar program carried out under the Health Sector Support Program (HSSP) funded by the European Commission (EC). Other provinces of the country will also do the same with support of government and other partners.
344. Scope of Work. The main objective of the consultancy is to undertake the sanitary mapping of the five provinces of the MHSS with the objective of developing a comprehensive and robust provincial infrastructure investment program for the period 2010-2019. The investment program should also contemplate medical and non-medical equipment in accordance with the national norms and regulations. The consultant should develop criteria to guide investment decisions by the provincial government that take into account the medium term development program of the government. In addition, the consultant should, in consultation with relevant provincial authorities and communities, identify priorities on the basis of other considerations such as disease burden, population size, access, and equity. In the process, due consideration should be given to economic efficiency as well as the need to improve the quality of care.
345. The consultant should also develop the first five years implementation plan of the infrastructure plan, which will subsequently be made operational through government annual work program.
346. Tasks. The consultant will perform the following tasks:
(i) Review the mapping that has been done with support from the EU. In the process the consultant will interact with relevant Departments of the MOH, namely the Gabinete de Estudos Planeamenteo e Estatística (GEPE), Direcção Nacional de Saúde Pública (DNSP), Direcção Nacional de Recursos Humanos (DNRH) and the Direcção of Equipamentos and Medicamentos. (ii) Prepare the health mapping with the relevant provincial authorities, including the training of provincial and municipal staff to collect, enter, and analyze the data. (iii) Carry out the health mapping in the provinces of Bengo, Lunda Norte, Malange, Moxico and Uíge. (iv) Discuss the work plan with the provincial authorities to whom the consultant should regularly report.
111 (v) Develop a data base for infrastructure to be regularly updated by the Provincial Health Directorate and train provincial health staff to manage it. (vi) Write a report on the mapping and present it to the Provincial Health Directorate and government in a workshop to get feedback and to validate the findings. (vii) Develop a draft costed infrastructure investment program for 2010-1019, including 2 or 3 scenarios in line with MDGs and resources available. (viii) Organize a workshop to present the investment program to the provincial government and other stakeholders. (ix) Write reports of the proceedings of the workshops. (x) Write an investment program document for each of the provinces and prepare power point presentations.
347. Deliverables. Deliverables will be as follows.
(i) A comprehensive report on the health infrastructure situation of no more than 25 pages plus annexes, with a clear identification of the strategic issues that need to be addressed. Prepare power point presentations for the consensus workshop. (ii) Infrastructure Investment Program for each province for 2010-2019. (iii) Implementation plan of the investment program for the first five years, including a monitoring and evaluation framework.
348. Timeframe. The consultancy will be done in a maximum of 24 months including the completion of the report. The consultancy is expected to start around April 2010.
349. Requirements and qualifications. The consultancy will be carried out by a team of experts consisting of the following professionals:
(i) Public Health Specialists with a Ph.D. or Masters degree and a minimum of 10 years of experience in health planning. Preference will be given to those with working experience in a developing country. (ii) Hospital Architect or Civil Engineering Specialists with 10 years experience in planning and development of health facilities design and implementation of civil works. Experience of similar assignments in the region is preferable. (iii) Medical Engineering or Hospital Equipment Specialists with at least 5 years of experience. Knowledge and experience of developing countries will constitute an added value.
350. Other relevant information. The consultants will work on the premises of the MOH and will report directly to the Director of GEPE of the MOH. They will also interact closely with the Director of DNSP.
112 Annex 18: Voucher Scheme to Encourage Institutional Deliveries ANGOLA: Municipal Health Service Strengthening Project (MHSS)
351. The MOH will pilot vouchers to pregnant women to deliver in a health facility.
352. Nature of the vouchers. Vouchers would consist of (i) transport vouchers of US$10 equivalent; and (ii) an incentive voucher for the mother of US$15.
353. Eligibility criteria. Vouchers are available to pregnant women living within the selected municipalities.
354. Geographical scope and duration. The pilot would be implemented in two municipalities of two provinces in the second year, and then an evaluation will be done to extract lessons learned that will contribute towards helping the government decide on whether to extend to the other municipalities in subsequent years – using other funding sources. The pilot could be implemented first in Uige in the municipality of Negage as the intervention municipality and Sanza Pombo as the control municipality. Negage has the capacity to do comprehensive EmOnC, because it has a full team of ObGyn, surgeon, operating theatre, basic blood transfusion capacity and an Angolan medical doctor as clinical director of the hospital that could help in implementing the voucher at the hospital level (certification of institutional delivery). For purposes of supervision, both municipalities are easy to reach. It is also proposed that the second municipality of intervention would be Caculama, in the province of Malange, with two municipalities serving as control measures. Piloting the scheme in two different provinces and municipalities should increase the scalability of the results for the possible future expansion of the program and help understand better how the different local economic, social, ethnic and cultural conditions impact the scheme.
355. Expected results. With a population of 153,971, Negage can expect 6,929 deliveries (4.5% of population). If 75 percent of deliveries take place in the municipal hospital, this will amount to 5,196 deliveries.
356. With a population of 43,176, Caculama can expect can expect 1,942 deliveries (4.5% of the population). If 75% of the deliveries take place in the municipal hospital, this will amount to 1,457 deliveries.
357. Expected cost. The costs of the voucher system would include three types of costs: (i) the cost of the voucher; (ii) the administrative cost and (iii) the monitoring and evaluation cost. The cost of the voucher itself would be as follows.
Table 27: Cost of Vouchers Municipality Population Expected Institutional Cost per Cost over 2 deliveries deliveries year (US$) years (US$) Negage 153,971 6,929 5,197 129,919 259,838 Caculama 43,176 1,942 1,457 36,143 72,825 Total 197,147 8,871 6,654 166,062 332,663
358. In addition, the social marketing and administrative costs are estimated at US$347,200 and the monitoring and evaluation cost at US$100,000. Consequently, the total cost of the scheme would be about US$780,000.
113 359. Social marketing. Communities and hospitals would be sensitized about the scheme to ensure the support of the male community and local community leaders within the target areas. The ability of women to redeem their vouchers may be in the hands of other household members, therefore the target segments for the marketing campaign includes (i) the women between the age of 15-45 (ii) possible transport providers (iii) health workers (iv) other critical community members (e.g. fathers and community leaders).
360. The social assessment undertaken in Malange suggests that men, especially husbands of pregnant women, must be targeted with advocacy and health education activities to make them more involved in the early stages of the process of birth preparedness.
361. In practice, information sharing meetings for the selected target groups will be organized and posters about the scheme would be placed in the hospitals and other health facilities in Portuguese and local language ( Kikongo and Kinbumbo at least).
362. Hospitals will be prepared about the mechanics of the scheme (the need to provide two copies of a delivery certificate to each woman who delivers), but also about the fact that demand will increase and thus the need to increase productivity and at least maintain the quality of services. The hospitals that are impacted by the incentive scheme will also receive support through the first component of the MHSS project, that will help strengthen the health service delivery.
363. At community level, the role of CHWs and TBAs is very important and their involvement will be carefully taken into consideration. CHWs and TBAs will be informed about the scheme and encouraged to accompany pregnant women to the hospital. Creative partnerships with local NGOs, faith-based organizations, village committees, or women‘s groups when they exist, will help ensure the availability of local transport.
364. Implementation arrangements. The overall management of the scheme would be contracted to an NGO. The arrangements for the scheme are illustrated below.
114 Figure 8: Arrangements for Vouchers
Pregnant woman Pregnant Voucher Woman Driver Stamp Hospital
Delivery certificate Transport to mother Voucher Driver $10
Health Commercial Bank center Mother $15
365. The management scheme will be the simplest possible, yet robust enough to guarantee that the vouchers are paid on time and that the risks of fraud at the health facility level and by the drivers and mothers or their families are reduced.
366. The scheme is based on an administrative approach with mothers receiving the vouchers when arriving at the facility for delivery and ―paying‖ the driver of the car that has transported her. The mother then will receive her own voucher after delivering. Delivering will include, for the objective of this intervention having a live birth, a still birth, or a miscarriage.
367. The voucher will be redeemed for cash at a commercial bank55 in person by the driver and the beneficiary woman (who has given birth in a health facility), each showing a delivery certificate from the hospital.
368. Responsibilities of the implementing NGO. The contractor‘s responsibility will be to:
(i) undertake communication activities to promote the transport and mother voucher schemes to beneficiaries, and explain the rules to health centers, the hospital, and the municipal administration; (ii) design the transport voucher ensuring the minimum security features to reduce fraud, and make it available in health centers; (iii) help the hospital to design delivery certificates; (iv) design, in line with the MHSS, the information system to capture information on the total vouchers, number of users, mothers and drivers, age of users and problems related to the application of the scheme. (v) ensure that the municipality opens a bank account where voucher funds will be transferred from the MHSS project CCU in Luanda or from the DPS;
55 The voucher pilot will be implemented in the towns of Negage (Uige) where there is a commercial bank, and Caculama (Malange) where there is a commercial bank in Malange, less than an hour away.
115 (vi) help determine responsibilities for payment of vouchers including appropriate accounting mechanism, preparation of SOEs, and maintaining of sufficient funds on account for regular payment of vouchers for transport; (vii) undertake a risk analysis covering: (i) the cultural factors that could affect the success of a subsidy scheme; (ii) the legal and regulatory issues that could affect its success; (iii) the institutional opportunities and constraints; (iv) increase in total pregnancies per woman; and (v) other types of risks the incentive scheme could face. It would propose ways of mitigating these risks.
369. Handling of complaints. Errors in the Angola voucher systems could consist of errors of inclusion or exclusion resulting from errors in the registration process, human errors, or fraud. As a result, an applicant who is eligible does not receive the voucher or someone has received the voucher, but cannot exchange it for money. There can also be complaints about the poor quality of service provision or suspicion of corruption in the system. Thus there is a need for the project to include a mechanism to address complaints.
370. Complaints will be made in person by the beneficiary (pregnant woman, woman having given birth in a health facility, or the driver who brought her to the hospital). Complaints will be made to the Municipal Administrator who will then follow up with the relevant authority (the NGO administering the scheme, the hospital or health center, or the financial department of the Municipal Administration) and find a solution. If the complaint is not resolved at this point, it will go to another level: the Municipal Health Committee. The latter is composed of citizens appointed by the community, a member from the Municipal Administration, and a member from the Municipal Health Directorate.
371. The number of complaints is not expected to be large because there is only one simple eligibility criterion: you must be a pregnant woman to be eligible. Complaints on inclusion or exclusion tend to be more frequent when there is room for interpretation (level of income, area of residence, distance from a hospital etc.), which are not criteria in this pilot. However, even if there are few complaints, the pilot will have a system to deal with them. The possibility to complain about quality of care is an important means to help improve the quality of care.
372. Legal framework. The Recipient will issue an internal decree (Decreto Executivo) at Ministry level, regulating the voucher scheme under a pilot approach.
373. Implementation risks. Implementation risks include (i) deviation of funds for private gains; (ii) a program that does not function well at the beginning and loses credibility; and (iii) program stimulates demand, but supply does not follow. The first risk will be mitigated by close cash flow monitoring and control procedures, and audits focused on potentially vulnerable areas. The second risk will be mitigated by setting up clear institutional responsibilities, a well-designed project cycle, clear rules for the selection of beneficiaries, and a reliable management information system. The third risk will be addressed by increasing the existing capacity for institutional delivery. The overall risk will be mitigated by implementing the pilot in only two municipalities.
374. Monitoring and evaluation. M&E will also be contracted out. For its effective implementation the pilot will need to be based on a clear picture of the existing provision and its use, as well as evidence of the current health picture of maternal and neo-natal health in the given municipality.
116 375. The main outcomes of the scheme would be: (i) a decrease in the maternal mortality in the selected municipalities and a significant increase in institutional deliveries; (iii) a proper response from obstetric care services, including the provision of quality care; (iii) an efficient administration of the system; and (iv) no fraud.
376. The evaluation indicators are presented in Annex 3.
377. Voucher Scheme Manual. A Voucher Scheme Manual will be prepared that will, as a minimum, contain the following information: (a) the eligibility criteria for potential beneficiaries; (b) detailed conditions to be met by potential beneficiaries in order to receive the proposed benefits; (c) a mechanism for delivery of the proposed benefits; (d) institutional arrangements, including the Government of Angola's lines of authority and accountability; (e) the monitoring and evaluation system, including details on how to audit the scheme and how to handle complaints and appeals in a timely manner; and (f) information on the legal framework that would underpin the proposed scheme.
378. Service Agreements. The Government will conclude and thereafter implement, until it has expired in accordance with its terms, a service agreement, in form and substance satisfactory to IDA, with one or more Payment Service Providers acceptable to IDA for the payment of Cash Transfers to Beneficiaries (each a ―Service Agreement‖). The Government will ensure that each Service Agreement is: (i) submitted to IDA for its review and approval prior to its signature between the Government and a Payment Service Provider; and (ii) signed and effective before any proceeds of the Financing is transferred to the Payment Service Provider.
379. Each Service Agreement will include, inter alia, provisions to the following effects.
(i) Unless IDA will otherwise agree in writing, each Payment Service Provider will: (A) before its first receipt of funds for the payment of Cash Transfers under the Service Agreement, open and thereafter maintain for a term equal to the term of the Service Agreement, a separate designated account (the Voucher Scheme Account) for the exclusive purpose of depositing funds for Cash Transfers and disbursing funds for the delivery of Cash Transfer in accordance with the provisions of the Service Agreement and the Voucher Scheme Manual. The Voucher Scheme Account will be opened in a commercial bank acceptable to IDA, upon terms and conditions satisfactory to IDA, including inter alia a waiver of any rights said commercial bank or any third party may have to set off, or claim or otherwise appropriate the payment of, any amount from time to time deposited in the Voucher Scheme Account in satisfaction of any debt or claim owed to said commercial bank or third party by the Payment Service Provider, and (B) ensure that all amounts deposited from time to time in the Voucher Scheme Account are used exclusively to make Cash Transfer payments to Beneficiaries in accordance with the detailed provisions, procedures, sequencing and timing in relation thereto as set forth in the Voucher Scheme Manual.
(ii) The Payment Service Provider will maintain records and accounts, in form and substance satisfactory to IDA, adequate to record all expenditures incurred in the delivery of Cash Transfer payments, and will retain said records and accounts for at least the term of the Service Agreement plus two years, and will furnish such records or copies thereof to the Government and to IDA upon their respective request;
117 (iii) The Payment Service Provider will enable the Government and IDA to inspect its operations, including the Cash Transfers, and the Voucher Scheme Account, and to examine and make copies of all records and documents relating thereto.
(iv) The Payment Service Provider will prepare and furnish to the Government not later than six months after the end of their reporting year to which they relate, Financial Statements, in form and substance satisfactory to the Government, audited by an independent auditor, and the relevant audit report (with any information reasonably requested by the Government on the audit and the auditor). The Government will be allowed to communicate all such information to IDA if IDA will so request.
(v) The Payment Service Provider shall comply with the provisions of the Anti- Corruption Guidelines.
(vi) The Government will exercise its rights under each Service Agreement in such manner as to protect the interests of the Government and IDA and to accomplish the purposes of the Financing. Except as IDA will otherwise agree in writing, the Government will not assign, amend, abrogate or waive any Service Agreement or any of its provisions.
118 Annex 19: Governance and Accountability Action Plan ANGOLA: Municipal Health Service Strengthening Project (MHSS)
1. Country Context. In April 2002, after several failed peace processes, Africa‘s most protracted conflict, between the União Nacional da Independência Total de Angola (UNITA) and the Government of Angola ended. Peace appears to be robust, and UNITA has officially ceased to be a rebel movement and has transformed itself into a legal political party. The potential for Angola to move beyond reconstruction and to socially inclusive and equitable growth and development is greater than ever before. However, the country faces a range of challenges and many social and political risks. After over 30 years of conflict – the war for independence and a civil war - the country‘s institutional and human resource capacity is weak. Thus, perhaps the single biggest challenge the country faces is ensuring that the governance system is strengthened, the benefits of mineral wealth are shared widely, that poverty and inequalities are reduced, and the institutional and human resource capacities are strengthened so that services can be delivered in a more sustainable fashion.
2. To address the challenges and consolidate peace and national reconciliation, the government has started to implement programs aimed at restoring order and security, addressing the needs of the most vulnerable groups, revitalizing the economy, restarting essential social services, and reinstating critical infrastructure. The government is undertaking economic reforms and tackling issues of governance, it is improving oversight over government revenues, and increasing control over public expenditures.
3. With proper investments, reforms of policies and institutions, and good governance, Angola will be able to use its rapidly growing wealth to reduce inequities and to improve quality of life for all its citizens. With a sounder business climate, it will be able to attract private investment in manufacturing, agriculture, and services – areas of the economy that have seen little investment since independence. However, to realize its potential, Angola needs improved governance, focused attention to build institutional capacity, better financial management, and greater transparency in mobilization and use of public funds. More needs to be done to involve the poor and socially marginalized groups in decisions on public spending, and in monitoring the use and effectiveness of funds to ensure that growth is equitable.
4. Political Context. The government has successfully maintained peace in Angola since the end of the civil conflict. The government is recognized as legitimate by most citizens and has increasingly brought stability to all regions of the country. In August 2006, the government signed, a peace agreement with the Cabinda Forum for Dialogue, an umbrella group of civil society organizations and pro-independence factions, granting the oil rich enclave of Cabinda special status, but reaffirming Angola‘s territorial integrity. Efforts to clear landmines and rebuild roads and bridges after 2002 have opened up most of the country‘s main arteries to movement of people and goods. This has allowed nearly 3.7 million internally-displaced people and refugees to return home and restart their livelihoods.
5. Progress with demobilization and reintegration has been steady. Nearly 100,000 UNITA ex- combatants have been demobilized through programs managed and paid for by the government. The great majority has benefited from training and other types of assistance intended to help them reintegrate into civilian life. Surveys administered 3 to 6 months after demobilization found that
119 57 percent of former fighters are employed or self employed, 95 percent have access to land for agriculture, and 90 percent consider themselves socially integrated in their communities.
6. The legislative elections, the second elections during the independence of Angola, took place on September 2008. The ruling party - MPLA won the elections with 82 percent of the votes. According to the results of the September 5 legislative elections, the 220-seated Parliament is composed as follows: ruling MPLA (191), UNITA (16), PRS (8), FNLA (3) and ND (2). The voter turnout was estimated as high as 87%. The elections took place in a peaceful atmosphere and were generally considered as free by observers. The new government was appointed in October 2008 with 33 ministers and three new secretaries of state. There were changes in the governance structure, most notably with the creation of a new Ministry of Economy to lead the coordination among the economic ministries. Also new positions for secretaries of state were created for higher education, rural development and water. A new Constitution of the Republic of Angola was approved by the Parliament with constitutional powers on January 21, 2010, and after the Constitutional Court Judgement nº 111/2010 of January 30, 2010, on February 3, 2010.
7. The government has made progress with decentralization. The government approved its national strategy for decentralization in 2001, and is refining a decentralization program which will be implemented gradually. More recently, the Council of Ministers has revised the decree 17/99, which sets up the country‘s legal framework for decentralization. The government also approved Decree-Law nº 2/07 regarding the local governmental structures and Decree nº 9/08 related to the paradigm of the administrative structures at the level of province, municipality and communes. The government has expanded the coverage and outreach of a good governance system at the local level that effectively delivers services.
8. Governance. Between 2002 and 2006, Angola was perceived to be one of the most poorly governed countries in the world, according to indicators compiled annually by the World Bank Institute (see Figure 9).56 The lack of transparency and corruption were perceived to be high, but very recently the President of the Republic did initiate the implementation of a strong policy against corruption known as ―Zero Tolerance‖ which is expected to introduce significant changes in the governance‘s transparency. Angola‘s administrative capacity is very low by international standards, limiting the ability of the state to deliver essential public services. Institutional fragmentation and complexity also severely impede budget planning, particularly the translation of strategic policy objectives into budget allocation decisions. However, administrative and financial reforms are being implemented in order to strengthen the economic and budgetary policies and practices.
9. Angola‘s governance indicators are still below the African average on most indices. But, the trend is improving over time, albeit from a very low base. The 2008 Doing Business report ranked Angola 167 out of 178 countries, while the 2007 Global Competitiveness Report ranked Angola last (128th). The Worldwide Governance Indicators for 2008 show a slight decline on three indicators (i) Political Stability (ii) Rule of Law and (iii) Control of Corruption. It should be noted that these indicators are not designed to measure minute changes from year to year – but rather trends over time – and in this respect, Angola has been showing a general improvement on all indicators since 2002, while still remaining below the Sub-Saharan average (see Figure 10 below).
56 An interactive database of governance indicators for 213 countries is available at www.worlbank.org/wbi/governance/
120 Figure 9: Angola’s progress on governance, 2002 to 2006
Key: 2005 is the top bar, 2002 is the bottom bar. The thin black line indicates the margin of error.
10. Accountability is upward to the president, not toward public institutions, civil society or media. Angola is politically stable. The government party enjoys a significant majority in parliament, with no real challengers.. The public sector is very inefficient: execution rates for national budget are low. Basic social services are unavailable for a majority of the population with some of the worst social indicators in the world (HDI). Excessively bureaucratic and time- consuming regulations stifle private sector development. The supreme audit institution has just started its work, with significant delays. It was established in 2001 – and only started working on its first audits in 2006.
11. Despite these perceptions and very real challenges, progress is being made to improve governance since peace was achieved in 2002. Political stability, government effectiveness, and voice and accountability in particular have improved substantially (see Figure 10). The government‘s recent efforts to improve governance include: auditing oil companies, improving the management of oil revenues, regularly publishing oil company payments, strengthening oil tax administration, conducting petroleum revenue management workshops, encouraging transparency in the recent licensing round, adopting oil revenue savings, rolling out an integrated financial management system, and significantly strengthening the customs service.
12. The government has strengthened the capacity of the Ministry of Finance to control expenditures and ring-fence the operations of Sonangol on behalf of the treasury, but more needs to be done. However, due to institutional and technical limitations in the Ministry of Finance and in the Ministry of Petroleum, the government will need several years before significant changes in the institutional arrangements can be achieved. Despite some improvements in recent years,
121 transparency and accountability in the management of public resources remain low. As a result, Angola, in 2007, still ranked worse than the Sub-Saharan average on all governance indicators tracked by the World Bank Institute (Figure 10).
Figure 10: Angola’s governance in relation to the Sub-Saharan Africa average (2007)
Key: Angola is the top bar, Sub-Saharan Africa is the bottom bar. The thin black line indicates the margin of error.
13. Project’s Governance and Accountability Action Plan. The objective of this plan is to strengthen governance around the project and as a result eliminate corruptive practices, so that the full impact potential of the project is attained. The proposed plan has been designed specifically for the Angola Municipal Health Service Strengthening (MHSS) Project. The implementation of this plan by the Ministry of Health (MOH) would contribute greatly to the overall governance environment in the sector and would permeate to activities financed by other sources.
14. Action Plan Structure. The plan is essentially a tool to improve the impact of the project and to transfer a number of methods and practices that may be adopted by Ministry of Health to improve the efficiency of operations in the sector. The plan will be thus composed of preventive actions, deterrents, and detection mechanisms. It is organized around mutually agreed upon objectives and the key actions that are needed to achieve those objectives. The Governance and Accountability Action Plan was disclosed by the government on April 21, 2010.
15. The supervisory strategy will be the following: (i) the project unit in DNSP will monitor the activities in the project to determine if the MOH is implementing the plan, through direct supervision and follow-up of task completion; and (ii) the task team will monitor the plan on the basis of the periodic reports.
122 Table 28: Governance and Accountability Action Plan Objectives Key Actions to Achieve Objectives Responsible Target Party Start Date Enhanced public 1. Initiate a program to place posters in MOH/DNSP and September disclosure program health facilities informing the public that the Provincial and 2010 health services are free, and that no Municipal payment should be made to health Departments of workers. Health, with 2. Implement a program involving users‘ support from reference groups whose advice will be Central sought on strategic questions and quality Coordination Unit of care. (CCU) and 3. Issue a notice to the general public Regional through local media for all new Coordination Units procurement to invite any interested (RCUs) party to participate. 4. Make available to any member of the public promptly upon request all short- lists of consultants or pre-qualification of contractors.
Enhanced compliance 1. At the municipal level, the MOH/DNSP September mechanisms Revitalização program will include 2010 community committees who will work with the municipal health teams, giving a voice to the public, notably on community needs and quality of care. 2. Recruit qualified staff for all fiduciary positions in MOH and in the project unit. 2. Contract private sector professionals to staff the CCU – using private sector salaries to attract better qualified staff. 3. Design and implement regular training and capacity building programs for the fiduciary staff. 4. Prepare and use a FM manual and an appropriately sized accounting software package.
Mitigation of collusion 1. The project will contract a consultant MOH/DNSP Sept 2010 risks to perform procurement audits every two years. 2. The project unit will contract qualified procurement staff to support the MOH with all project procurement and to participate in the training and capacity building programs for the staff in the CCU..
123 Objectives Key Actions to Achieve Objectives Responsible Target Party Start Date Mitigation of forgery 1. Timely payment of interim payments MOH/DNSP November and fraud risks strictly following the terms and 2010 conditions in the contracts. 2. The use of independent consultants for both annual external audit and the internal audits. 3. The use of qualified staff paid competitive salaries. 4. Use of an accounting software package with appropriate controls built- in along with an acceptable Financial Management and Accounting Procedures Manual. 5. Regular training and capacity building programs for management and all project staff. 6. The attributions of community committees will include the oversight of project activities.
Strengthen human 1. A significant training programs will MOH/DNSP August resource capacity be implemented to strengthen the 2010 technical capacity of the staff in the sector. 2. Transfer of knowledge from the HAMSET project will be ensured by aiming at transferring some PIU staff to MHSS CCU.
Improve institutional 1. The capacity to manage projects will MOH/DNSP November capacity to manage the be addressed by strengthening the 2010 sector capacity of the CCU as well as that of provincial and municipal health departments. 2. Specific training in health system management will strengthen provinces and municipalities‘ capacity to manage the health system.
124 Annex 20: Availability of Health Workers in the Five Targeted Provinces ANGOLA: Municipal Health Service Strengthening Project (MHSS)
16. Availability of nurses. As a result of a significant training program during the years of the conflict, the MOH currently has a large number of nurses on its payroll, estimated at 36,000.
17. The ―Heath Facility Regulation‖ (REGUSAN) passed in 2003 defines the minimum staffing, package of services, organization and job descriptions for health facilities. The Regulation uses two criteria to define the minimum staff required in health facilities at each level: (i) the services that need to be provided; and (ii) ratios of staff per population. The following table shows the minimum number of staff per professional category and per Health Facility.
Table 29: Minimum number of professionals per category per health facility Health Health Staff category Facility Population Nurse General Auxiliary Medical Laboratory Radiology Type Covered Midwife Nurse Nurse Doctor Technician Technician Municipal 150.00 – 2 3 14 2+1* 2*** 2*** Hospital 500.00 Referral Health Center Health 75.000 2-3** 3-4** 8 2 2*** 2*** Center Health 20.000 1 2 5 - 1 1 Post type II Health 5.000 - - 4 - - - Post Type I *One of the doctors can be ObGyn or a doctor trained in surgery who can perform C-sections ** One nurse midwife can be substituted by a general nurse trained in EmONC *** One of them can be an auxiliary technician (basic level)
18. The actual number of staff per facility is available from the 2007 national survey of obstetric and neo-natal care in Angola. When these are compared to the needs under the regulation, it is clear that, although the total number of personnel is generally adequate, they are unevenly distributed, with an excess in provincial and municipal hospitals and a deficiency in more peripheral facilities. The MOH plans to reallocate the personnel by using non-monetary incentives such as training, provision of housing, and by providing a more rapid path for career progression for those who will accept reallocation.
19. A detailed analysis per province was undertaken. The analysis was made using the numbers of auxiliary nurses because the majority of the new nurse midwives and general nurses to be trained under the project will come from this category of nurses.
20. Bengo province. In the case of Bengo, the total number of doctors and general nurses are in line with the minimum requirements. However, the number of auxiliary nurses is more than twice the amount needed (48 auxiliary nurses in Catete and 32 in Ambriz when there is a need only for
125 14 in the municipal hospital. It is possible to reassign some of these nurses to fill posts in the health centers in the periphery. It is also possible to train them to specialize as midwifes, notably for the new delivery rooms to be built by the project. There will be no need for Bengo to recruit a significant number of new nurse graduates.
21. Uige province. In the case of Uíge, one of the municipal hospitals/referral health centers, in Negage has 105 auxiliary nurses which is almost 8 times the norm. Thus there is enough capacity in the municipality to train some of these auxiliary nurses as nurse midwives and in courses to train them to become general nurses and reassign them to the health centers that will receive the delivery rooms under the project, and also to fill the needs for general nurses for outreach teams. In the other municipalities the numbers of existing auxiliary nurses are 2-3 times the existing norm and as in Negage they can be trained and reallocated. It is even possible for the DPS to reallocate some of the nurses from Negage to the nearby municipality of Sanza Pombo that has fewer nurses, and even to staff the municipality of Maquela do Zombo that is more distant.
22. Malange province. When analyzing the situation in Malange, the municipality of Cacuso has almost 4 times the required number of auxiliary nurses (78), and in the municipality of Malange the number of auxiliary nurses in the city health centers is also 4 times (71) the minimum. The municipality of Kalandula has fewer nurses (34), but still has 2.5 times the minimum. Only the municipality of Caculama has a limited number of nurses. This is because it used to have only one smaller health facility. Now Caculama has a Municipal Hospital and it will need more staff. These can be transferred, after training, from the provincial capital, using a rotating scheme to encourage the nurses and doctors to stay in the municipality.
23. Moxico province. In Moxico, in the case of the 3 municipalities under the Revitalização program and supported by the project, only the municipality of Camanongue has an insufficient number of nurses (12), but in Luena, the municipality of the capital, excluding the provincial maternity, the number of auxiliary nurses (57) in three health centers is almost 3.5 times the minimum required. The number of general nurses (29) is also 3 times the required amount. The same is true for the municipality of Luau which has 40 auxiliary nurses and 34 general nurses. Here again the training of existing nurses and their relocation will help to cover the needs for nurse midwives and strengthen the new delivery rooms, without the need to contract new nurses.
24. Lunda Norte province. Finally in the Province of Lunda Norte, the picture is very similar. The municipality of Lucapa with 43 auxiliary nurses, and Cuango with 57, have enough nurses to be trained as nurse midwives and reallocated to the new delivery rooms. The provincial hospital with 25 nurse midwives and 203 general nurses can reallocate at least 20 percent of midwifes and 10 percent of general nurses to fill the needs for the health centres with delivery rooms in the periphery of the Chitato, the capital municipality.
25. Doctors. In the case of medical doctors, the arrival in each municipality of Cuban doctor teams will solve any existing gap. All the municipalities included in the project will receive or have already received a Cuban doctor team as well as some expatriate doctors from other nationalities to strengthen the capacity of municipalities. The movement of Cuban doctors to the municipalities is expected to continue during 2009, and they will be renewed every three years. The following table shows the availability of doctors and nurses in three selected municipalities of the project.
126 Table 30: Availability of doctors and nurses in three selected municipalities Province/Municipality Cuban Teams Other Teams 1 ObGyn doctor 1 Internal medicine 1 Surgeon (Korean) Uige/Negage Doctor 1 Nurse Midwife 1 Nurse Midwife ( still Uige/SanzaPombo waiting housing) 1 ObGyn Malange /Caculama 1 Paediatrician 1 Surgeon (Korean) 1 nurse midwife
26. Conclusion. Overall, there are sufficient health personnel for the project. Municipal hospitals are generally overstaffed either with nurses or doctors, which allows for the training of personnel to be redistributed to health centers and health posts in peripheral areas.
27. One must be cautious, however, when dealing with these numbers. For the next five years it makes sense to provide in-service training to the existing nurses and reallocate them within the provinces and municipalities. However, as the Angolan population grows and the health facility network expands, the need for nurses and doctors will also be larger. Furthermore, a number of nurses and doctors will begin to retire or to go to the private sector. Finally, as the health system stabilizes and the overall country develops, the paradigm will change. The country will be able to afford larger health staff/population ratios, thereby improving the population‘s access to services as well as the quality of care. The government will then need to train and contract new nurses and doctors.
127 Annex 21: Availability of Obstetric Care in the Five Targeted Provinces ANGOLA: Municipal Health Service Strengthening Project (MHSS)
28. The 2007 national survey of obstetric and neo-natal care in Angola provides data by provinces, which allowed reviewing the situation of obstetric care in the five targeted provinces. Table 32 below shows that although there is a reasonably high number of health units with at least one person who can perform selected procedures, most provinces fare poorly in terms of blood transfusion and evacuation of retained products. Bengo is the worst performer of the five provinces in this area.
29. Table 32 provides a good overview of the capacity of health facilities to provide the services that are the key interventions for EmONC. Malange, Moxico and Bengo lag in the number of health facilities able to provide blood transfusion, an essential service for comprehensive EmONC with C- sections. During project preparation visits to the five provinces, it was noted that the majority of the staff of provincial and municipal hospitals who were providing blood transfusion had received in- service training, with no quality control from the Luanda National Blood Institute, and were not specialists in blood transfusion.
30. An analysis of the data from the national obstetric survey shows the lack of skills of the staff. Less than 50% of basic and general mid-level nurses and only 52% of midwives know that pregnant women must have at least 4 ANC visits. For other crucial interventions in neo-natal care, knowledge is even lower: less than 30% of all obstetric care providers had promoted breast feeding. Also, less than 30% of nurse midwives and basic and mid-level nurses reassessed the physical status the newborn one hour after delivery or encouraged mothers to initiate breast feeding. Only 50% of midwifes and almost the same percentage of nurses in general provided eye prophylaxis to the new born.
31. An analysis of Table 33 shows that there is a serious lack of basic equipment in the five targeted provinces. This applies to normal delivery kits, C-section kits, and all key equipment except bi-auricular stethoscopes. Oxygen is strikingly inexistent and this is due to the fact that medicinal oxygen is only produced in Luanda, and logistical constraints limit the distribution of oxygen containers. The MOH is considering the production of medical oxygen in some provincial and municipal hospitals. This will reduce the dependence of the provinces from Luanda. An additional supply will be provided by the project.
32. Table 33 shows the low percentage of facilities with C-section kits, curettage and forceps kits, thus their limited capacity to provide quality obstetric care. They also have a limited capacity to forecast the needs for medical equipment and commodities. Less than 30% of facilities in Bengo and Moxico and only 50% of those in Malange have normal delivery kits limiting their capacity to perform quality normal deliveries The project will address this situation by providing delivery kits. These include magnesium sulfate and oxytocin, two commodities in scarce supply.
33. Table 34 shows that the availability of drugs was usually low, including magnesium sulfate, oxytocin, hydralazine hydrochloride and antiretrovirals. The lack of magnesium sulfate in more than 50% of the EmONC facilities is a concern because it is the first-line drug to control eclampsia and convulsions and is easy to use. The same is true for oxytocin, very useful in the late stage of labor. It can be administered by trained nurses and provides support to pregnant women in maintaining contractions.
128 34. This analysis shows the importance for the project to finance equipment for obstetric care, including normal delivery kits and C-section kits, as well as drugs.
129
Table 31: Percentage of health units with at least one person who can perform selected procedures Location Antibiotics Oxytocin Anticonvulsants Removal of Evacuation of Neonatal Blood Placenta Retained Resuscitation Transfusion Products National level 92 82 85 92 48 95 18 Bengo 94 50 78 94 33 100 6 Lunda Norte 100 100 100 100 73 91 36 Malange 100 77 100 92 46 92 8 Moxico 100 100 100 100 86 100 5 Uige 100 88 96 100 96 100 32
Table 32: Percentage of health units with selected equipment Location Biauricular Oxygen tank Delivery Kit Foley Curettage C-Section Forceps Kit Suction Kit Stethoscope (full) (complete) Catheter Kit Kit Bengo 56 16 28 33 17 6 6 6 Lunda Norte 93 9 73 27 45 27 9 18 Malange 82 0 54 23 46 8 8 8 Moxico 85 5 20 25 20 20 10 10 Uige 83 0 92 44 32 32 12 32
Table 33: Percentage of health units with selected drugs Location Magnesium Oxytocin58 Hydralazine Lactated Antiretrovirals Sulfate57 Hydrochloride59 Ringer's Solution60 Bengo 28 39 17 89 6 Lunda Norte 45 36 0 64 18 Malange 31 23 0 100 6 Moxico 30 25 10 60 5 Uige 24 20 20 96 28
57 A first-line anti-arrhythmic agent 58 Used to induce labor 59 Used to treat hypertension 60 Used for fluid resuscitation after blood loss
131 Annex 22: Supervision Plan ANGOLA: Municipal Health Service Strengthening Project (MHSS)
35. The project will need intensive supervision given the geographic spread of the proposed operation (18 municipalities in 5 provinces plus two pilot municipalities in two different provinces), and given implementation capacity weaknesses at the country and project level. The project will be implemented at three levels: the central MOH, Provincial departments of Health, and municipalities. A budget of US$150,000, is needed for the Bank team to supervise the project during the first 12 months of implementation.
36. The supervision by the Bank will be leveraged by the supervision carried out by the Central Coordinating Unit (CCU) on a regular basis. The MOH will have teams visiting each district four times a year for a period of about 8 days each and will prepare action-oriented supervision reports that will be reviewed by the Bank and donors during their bi-annual supervision missions, and through desk reviews. This system has been used successfully under the HAMSET project. It has allowed the MOH to distinguish between the better and lesser-performing provinces and provide more assistance to the latter. Sufficient funds to that effect have been included in the project design with a total of about US$3.5 million allocated for fuel and per diem over a five-year period (Annex 5).
37. As has been the case for the HAMSET project, some of the skills required by the Bank team for supervision will be needed on a regular basis while others will be required on an ad hoc basis. It is therefore proposed to establish a core supervision group, that will emphasize financial, procurement and operational basic needs, complemented by technical specialists, in particular those covering monitoring and evaluation, and maternal and child care.
38. While regular Bank (and donors) supervision will take place twice a year, this will be leveraged by about four visits each per year by the Bank procurement and financial management specialists who take advantage of their participation in the full supervision of the Bank portfolio (6 projects) to verify progress in the others and provide assistance to the client.
39. A much more intensive than normal supervision program should be carried out during the first year of the project to put in place a sound institutional base and properly begin interventions to be undertaken by this complex operation.
40. While the CCU will benefit from the experience of staff recruited from HAMSET, there will be an incubation period during which they will plan and organize the work with provinces and municipalities. There may also be some new CCU staff without knowledge of Bank procedures and standards and there will be a learning curve for the development of a smooth-working team and to get the supervision program under way. The priority technical specialists will provide support periodically, as required. The emphasis of the supervision missions will be in getting the MHSS project up and running, with particular stress on capacity development of provinces and municipalities.
41. Project supervision will also benefit from the Bank‘s Angola-based operational staff as well as from Bank specialists form the health, education, and social protection sectors. In addition there will be (i) a monitoring and evaluation specialist; (ii) an implementation specialist to provide longer-term support and to troubleshoot implementation issues at an early stage; and (iii) a maternal and child health specialist.
42. The supervision team therefore includes the following members: (i) the Task Team Leader with experience in health systems; (ii) a reproductive health specialist; (iii) a senior implementation specialist, to help in the critical first half year of project implementation; (iv) a financial management specialist who will review adherence to Bank procedures with regard to fiduciary responsibilities; and (v) procurement and implementation specialists, responsible for procurement, implementation, and institutional issues; and (vi) an environmental specialist.
43. The supervision team will be complemented by representatives of Total E&P Angola, the Bank‘s financing partner in this operation. As during the preparation process, technical partners, including UNICEF, WHO, and UNFPA, will be invited to participate in supervision missions to ensure the good quality of health interventions and project implementation, build strong partnerships, and facilitate a cross-fertilization of experiences. Areas of technical consultant support to highlight are monitoring and evaluation (including KAP surveys), and IEC and BCC, and coordination of returning refugees.
133