Document of The World Bank
FOR OFFICIAL USE ONLY
Public Disclosure Authorized Report No: 72281-MG
EMERGENCY PROJECT PAPER
ON A
Public Disclosure Authorized PROPOSED CREDIT
IN THE AMOUNT OF SDR 42.2 MILLION (US$65 MILLION EQUIVALENT)
TO THE
REPUBLIC OF MADAGASCAR
FOR AN
Public Disclosure Authorized EMERGENCY SUPPORT TO CRITICAL EDUCATION, HEALTH AND NUTRITION SERVICES PROJECT
November 13, 2012
Human Development Africa Region
Public Disclosure Authorized This document is being made publicly available prior to Board consideration. This does not imply a presumed outcome. This document may be updated following Board consideration and the updated document will be made publicly available in accordance with the Bank’s policy on Access to Information. CURRENCY EQUIVALENTS
(Exchange Rate Effective September 30, 2012) Currency unit = Madagascar Ariary (MGA) MGA 0.64843 = US$1 US$1 = SDR 0.64843
FISCAL YEAR January 1 – December 31
ABBREVIATIONS AND ACRONYMS
AAA Analytical and Advisory Activities AFD Agence Française de Développement (French Development Agency) AfDB African Development Bank AIDS Acquired Immunodeficiency Syndrome BCC Behavior Change Communication BCG Bacillus Calmette–Guérin (vaccine against TB) BIANCO Bureau indépendant de lutte contre la corruption (Independent Office for the Fight against Corruption) CISCO Circonscription Scolaire (School District) CL Letter of Credit CNA Community nutrition agent CNaPS Caisse Nationale de Prévoyance Sociale (National Social Security Administration) CRESANII Second Health Sector Support Project CRESED Crédit de Renforcement du Secteur de l’Education (Education Sector Reinforcement Credit) DA Designated Account DHS Demographic and Health Survey DL Disbursement Letter DPT Diphtheria, Pertussis, and Tetanus DREN Direction Régional de l’Education Nationale (Regional Directorate of National Education) EFA-FTI Education For All Fast Track Initiative ESSAF Environmental and Social Screening Assessment Framework EU European Union FAF Fiaraha-miombon’Antoka ho amin’ny Fampandrosoana ny Sekoly (Association for School Development or Partenariat pour le Développement des Ecoles) FM Financial Management FRAM Fikambanan’ny Ray Aman-drenin’ny Mpianatra (Parents’ Association or Association des Parents d’Elèves) GDP Gross domestic product GPE Global Partnership for Education Hep B3 Hepatitis B3 Doses HIV Human Immunodeficiency Virus HNP Health, Nutrition, and Population IBRD International Bank for Reconstruction and Development IDA International Development Association IEC Information, Education, Communication IFRs Interim Unaudited Financial Reports
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IMCI Integrated management of childhood illness IMF International Monetary Fund INSTAT National Statistics Office (Institut National de la Statistique) ISN Interim Strategy Note JHSSP Joint Health Sector Support Project LLINs Long-lasting insecticidal nets M&E Monitoring and Evaluation MAP Madagascar Action Plan MDGs Millennium Development Goals MEN Ministère de l'Education Nationale (National MEN) METF Medium-Term Expenditure Framework MICS Multiple Indicator Cluster Survey MSPPII Second Multisectoral STI/HIV/AIDS Prevention Project MWMP Medical Waste Management Plan NER Net Enrolment Ratio NGOs Non-governmental Organizations NMWMP National Medical Waste Management Policy PCC Project Coordination Cell PDO Project Development Objective PEMFAR Public Expenditure Management and Financial Accountability Review PIU Project Implementation Unit PNNC Programme National de Nutrition Communautaire (National Community Nutrition Program) PRS Poverty Reduction Strategy SADC Southern African Development Community SAGS Service Assainissement et Génie Sanitaire (Sanitation and Sanitation Engineering Service) SALAMA National Drug Procurement Agency SOE Statement of Expenditures STI Sexually Transmitted Infection TSC Technical Steering Committee UAT-EPT Education Technical Support Unit (Unité d’Appui Technique-Education pour Tous) UGP-Santé Health Programme Management Unit (Unité de Gestion des Projets d'Appui au Secteur Santé) UNICEF United Nations Children’s Fund US United States USD United States dollar WDR World Development Report WHO World Health Organization ZAP Zone Administrative et Pédagogique (Sub-District Office)
Vice President: Makhtar Diop Country Director: Haleh Z. Bridi Sector Director: Ritva Reinikka Sector Managers: Sajitha Bashir/Olusoji Adeyi Task Team Leaders: Andreas Blom/Jumana Qamruddin
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REPUBLIC OF MADAGASCAR
EMERGENCY SUPPORT TO CRITICAL EDUCATION, HEALTH AND NUTRITION SERVICES PROJECT
CONTENTS Page A. Introduction ...... 1 B. Emergency Challenge: Country Context and Rationale for Proposed Project ...... 2 C. Bank Response: The Project ...... 7 D. Appraisal of Project Activities ...... 14 E. Implementation Arrangements and Financing Plan ...... 21 F. Key Risks and Mitigating Measures ...... 24 G. Terms and Conditions for Project Financing ...... 25
Annex 1: Detailed Description of Project Components ...... 27
Annex 2: Results Framework and Monitoring ...... 35
Annex 3: Summary of Estimated Project Costs ...... 39
Annex 4: Operational Risk Assessment Framework ...... 40
Annex 5: Financial Management and Disbursement Arrangements ...... 47
Annex 6: Procurement Arrangements ...... 53
Annex 7: Implementation and Monitoring Arrangements ...... 65
Annex 8: Project Preparation and Appraisal Team Members ...... 77
Annex 9: Environmental and Social Safeguards Assessment Framework ...... 78
Annex 10: Economic and Financial Analysis ...... 111
Annex 11: Lessons Learned and Reflected in the Project Design ...... 129
Annex 12: Other Major Donor Interventions ...... 133
Annex 13: Documents in Project Files ...... 134
Annex 14: Statement of Loans and Credits ...... 135
Annex 15: Country at a Glance ...... 136
Annex 16: Maps...... 139 iv
REPUBLIC OF MADAGASCAR
EMERGENCY SUPPORT TO CRITICAL EDUCATION, HEALTH AND NUTRITION SERVICES PROJECT
PROJECT PAPER
AFRICA REGION
Basic Information Country Director: Haleh Z. Bridi Sectors: Primary education (40%), Sector Manager/Director: Sajitha Health (60%) Bashir/Olusoji Adeyi/Ritva Reinikka Themes: Education for all (40%), Team Leader: Andreas Blom/Jumana Health system performance (45%), Qamruddin Nutrition and food security (15%) Project ID: P131945 Environmental category: B-Partial Expected Effectiveness Date: January Assessment 31, 2013 Expected Closing Date: July 31, 2016 Lending Instrument: Emergency Joint IFC: Recovery Credit Joint Level: Project Financing Data [ ] Loan [ X ] Credit [ ] Grant [ ] Guarantee [ ] Other: Proposed terms: The credit would be an IDA Credit repayable in forty years, including a grace period of ten years. Financing Plan (US$m) Source Total Amount (US $m) Total Project Cost: 65.00 Cofinancing: Borrower: Total Bank Financing: 65.00 IBRD IDA 65.00 New 65.00 Recommitted Client Information Recipient: Republic of Madagascar Responsible Agency: Ministry of Finance and Budget B.P. 61 Antananarivo 101, Madagascar
Implementing Agencies: UAT-EPT (Unité d’Appui Technique-Education pour Tous ; Education Technical Support Unit-Education For All)
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Contact Person: Mrs. Josiane Rabetokotany Telephone No.: +261-202228295 Email: [email protected]
UGP (Unité de Gestion de Projet; Health Program Management Unit) Contact Person: Dr. Rémi Rakotomalala Telephone No.: +261-202255323 Email: [email protected]
PNNC (Programme National de Nutrition Communautaire ; National Program for Community Nutrition) Contact Person: Mr. Jean Rakotosalama Telephone No.: + 261-34 02 111 83 Email: [email protected]
FY 13 14 15 16 17 Annual 8.00 22.00 30.00 4.50 .50 Cumulative 8.00 30.00 60.00 64.50 65.00 Project Development Objective and Description Project Development Objective: The Project Development Objective (PDO) is to preserve critical education, health and nutrition service delivery in targeted vulnerable areas in the recipient’s territory.
Project description: The project will finance a package of essential interventions for preserving critical education, health and nutrition service delivery in vulnerable communities in response to the negative effects of the persistent political and economic crisis on human development. It constitutes an integrated, multi-sector approach, building on experiences and lessons learned of Bank and other donor activities; and will support the following activities: Component 1: Preserving Critical Education Services through subsidies for community teachers, support to school grants, and basic school health interventions; Component 2: Preserving Critical Health Services through the delivery of a comprehensive basic health package with a focus on pregnant women and children; and Component 3: Preserving Critical Nutrition Services by providing support to community nutrition sites to deliver essential interventions to pregnant women and children less than five years of age.
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Safeguard and Exception to Policies Safeguard policies triggered: Environmental Assessment (OP/BP 4.01) [X]Yes [ ] No Natural Habitats (OP/BP 4.04) [ ]Yes [X] No Forests (OP/BP 4.36) [ ]Yes [X] No Pest Management (OP 4.09) [ ]Yes [X] No Physical Cultural Resources (OP/BP 4.11) [ ]Yes [X] No Indigenous Peoples (OP/BP 4.10) [ ]Yes [X] No Involuntary Resettlement (OP/BP 4.12) [ ]Yes [X] No Safety of Dams (OP/BP 4.37) [ ]Yes [X] No Projects on International Waterways (OP/BP 7.50) [ ]Yes [X] No Projects in Disputed Areas (OP/BP 7.60) [ ]Yes [X] No Does the project require any exceptions from Bank policies? [ ]Yes [X] No Have these been approved by Bank management? [ ]Yes [ ] No Conditions and Legal Covenants: Financing Agreement Description of Condition/Covenant Date Due Reference Section 5.01 of the Establishment of the Technical Effectiveness Financing Agreement Steering Committee
Section I.A.2 (a) of Establishment of the Project Two weeks after Schedule 2 of the Financing Coordination Cell effectiveness Agreement
Section I.A.3 (c) of Each of the PIUs shall maintain the Two weeks after Schedule 2 of the Financing following staff from a date no later effectiveness Agreement than two (2) weeks after the Effective Date (i) a national coordinator or, in the case of the Nutrition PIU, a national director; (ii) an internal auditor; (iii) a procurement specialist; (iv) a financial management specialist; (v) an accountant; (vi) a monitoring and evaluation specialist (but only in the Health PIU and the Nutrition PIU); and (vii) a safeguard specialist (but only in the Health PIU)
Section I.B.4 of Schedule 2 Adoption of a regulation on school Three months after of the Financing Agreement grants (the “School Grant Regulation”) effectiveness
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Section I.D.2 (a) of Publication of a revised Medical February 28, 2013 Schedule 2 of the Financing Waste Management Plan Agreement
Section I.F.1 of Schedule 2 Updated Education, Health and Three months after of the Financing Agreement Nutrition Manuals effectiveness
Section I.F.2 of Schedule 2 Adoption of Project Implementation Three months after of the Financing Agreement Manual effectiveness
Section II.B.4 of Schedule 2 Engagement of independent auditors December 31, 2013 of the Financing Agreement for the carrying out of audits of the Recipient’s financial statement
Section IV.B.1 (b) of Payment Agreements signed and First Disbursement for Schedule 2 of the Financing Payment Account opened Teacher Subsidies Agreement
Section IV.B.1 (c) of Payment Agreements signed and First Disbursement for Schedule 2 of the Financing Payment Account opened; School School Grants Agreement Grant Regulation adopted
Retroactive financing: Withdrawals of up to an aggregate amount not to exceed SDR 4.6 million (US$7 million equivalent) may be made for payments made on or after December 1, 2012 to cover Eligible Expenditures. (In case the Board date is postponed, the Recipient has authorized IDA to change this date and reset it to one business day after the Board date).
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A. Introduction
1. This Project Paper seeks the approval of the Executive Directors to provide an Emergency Recovery Credit in the amount of SDR 42.2 million (US$65 million equivalent) to the Republic of Madagascar for the Emergency Support to Critical Education, Health and Nutrition Services Project. Following an unconstitutional regime change in early 2009, Madagascar has experienced a prolonged and deep political crisis. After almost a decade of steady progress on the Millennium Development Goals (MDGs), Madagascar’s social sectors have seen a severe decline in key indicators and an escalating risk of serious damage to the country’s social fabric and human capital base. The dramatic economic and social impacts from the crisis have been exacerbated by a series of external shocks and the withdrawal of most external funding due to the events of 2009.
2. This Rapid Response Emergency operation under OP/BP 8.00 will provide much- needed financial assistance for human development—basic education, health and nutrition service delivery—in vulnerable communities in five regions. The multi-sectoral approach proposed for this operation will help preserve basic social service delivery by increasing access to and utilization of services. More specifically, the project will finance critical interventions such as: (i) subsidies for community teachers, school grants, and basic school health interventions; (ii) a comprehensive basic health package, with a focus on pregnant women and children; and (iii) support to community nutrition sites to deliver essential interventions to pregnant women and children less than five years of age.
3. This project is proposed concurrently with the Emergency Infrastructure Preservation and Vulnerability Reduction Project, constituting a coordinated response to address the worst effects of the crisis and promote synergies to maximize impact. Together, these projects seek to address the emergency needs created by the combined impacts of the prolonged political crisis, a series of external financial shocks, and recent natural disasters such as cyclones, droughts, and floods. These developments have dramatically increased the incidence of poverty, have had devastating effects on infrastructure, and led to a sharp decline in basic social service delivery. This response will provide urgently needed support to the most vulnerable populations whose already difficult socio-economic situation would otherwise continue to deteriorate. It will also contribute to preserving key institutional structures and systems, which would otherwise be in danger of collapsing, making re-engagement much more challenging and costly once the crisis has been resolved. While there is no direct co-financing, the response to the crisis has been closely coordinated with other external partners.
4. This operation targets regions where the negative impacts of the crisis on human development indicators have been the most severe, whereas the Emergency Infrastructure Preservation and Vulnerability Reduction Project has a primary focus on regions where key infrastructure was damaged by cyclones. It consists of a coordinated, multi-sector approach and will contribute to maintaining basic social service delivery systems and restore lifeline infrastructure to help to ensure efficient distribution channels for social sector commodities such as medicines and bednets to different parts of the country. In addition, some of the priority activities of the physical infrastructure project will be implemented in the same regions as this proposed operation, most notably the rehabilitation of health and education infrastructure affected by cyclones and the renovation of rural roads to connect vulnerable populations to basic
1 social services. Both projects will utilize existing and well-performing mechanisms, with demonstrated experience in protecting programs against political interference, to ensure speedy implementation and minimize risk.
5. The focus and approach of the proposed project are consistent with the Interim Strategy Note (ISN) for Madagascar, the recommendations of the 2011 World Development Report (WDR) on Conflict and Security1, and the World Bank’s Africa Strategy. Following the political events in January 2009, preparation and approval of new lending was put on hold under the Madagascar portfolio in March 2009 in accordance with OP/BP 7.30, Dealing with De Facto Governments. At the end of 2009, disbursements for the existing portfolio resumed progressively to preserve human, physical and institutional assets. The full resumption of disbursements in April 2011 allowed for a major portfolio restructuring, which is now complete. The main objective of the restructuring was to enhance the projects’ impact through selectivity of activities while exiting from activities that have become unviable in the present context or that are at risk of political interference. Other development partners have since started to re-engage under their existing portfolios. Few have lifted sanctions on new aid, but some—including the European Union (EU) and African Development Bank (AfDB)—are developing operations complementary to the proposed project for delivery in 2013.
B. Emergency Challenge: Country Context and Rationale for Proposed Project Country Context
6. Madagascar’s economic potential has been hindered by periods of political fragility. Over the past 15 years, the country has experienced 5 years of political crisis on two distinct occasions. This most recent crisis has persisted since the unconstitutional regime change in March 2009, with devastating effects on the economy, poverty, and social outcomes. Socio- economic development has suffered from growing insecurity, stalled progress on already weak governance2, a reduced ability to deal with exogenous shocks, and deteriorating infrastructure. Recent progress has been made in resolving the political stalemate, mediated by the Southern African Development Community (SADC), most notably the independent electoral commission’s announcement of presidential and parliamentary elections in mid-2013. This important step forward in implementing the SADC-brokered roadmap has garnered the support of international organizations. Despite these positive developments, the political climate remains fragile.
7. The effects of the crisis have been exacerbated by exogenous shocks at the household level. More than half of Malagasy households experienced a catastrophic event—a cyclone, flood, drought, locust infestation, or plant disease—that adversely affected their economic well- being, and the majority have not recovered. While households vary in their probability of recovering from a shock, poor households that lack the necessary physical and human capital are less likely to recover. In 2010, 6 out of 10 extremely poor households suffered a catastrophic
1 World Bank (2011), “World Development Report 2011: Conflict, Security and Development,” Washington, DC. 2 Efforts to improve public sector governance have stagnated since the beginning of the crisis in 2009. Anti- corruption legislation and institutions were created prior to the crisis, but the institutional and regulatory reforms required to support their operation have yet to take place.
2 event. Households in the southern Madagascar are disproportionally affected by such events. In the regions of Vatovavy Fitovinany and Androy, for example, more than 9 out of 10 households reported having suffered a shock that adversely affected their economic well-being.
8. The economic cost of the crisis has been substantial, and the fiscal policy response has resulted in drastic cuts in the national budget for the social sectors and public infrastructure. Overall economic growth has been flat over 2009–12, and with high population growth (2.9 percent), income per capita in 2012 has returned to its 2003 level. The economic and social effects of the crisis have been intensified by the suspension of many donor activities, which, in a country where international aid represents at least 50 percent of the government budget, led to significant cuts in investments and a sharp decline in the delivery of services. Public expenditures on the social sectors have been cut sharply, as detailed in the next section. The share of social protection expenditure of total government expenditure fell from 13.4 percent in 2007 to 2.9 percent in 2010. Investment in transport infrastructure, two-thirds of which was financed by donors prior to the crisis, has fallen to near zero, and the very existence of some of the institutions responsible for operating and maintaining the national road and rail networks is now threatened by the lack of financing. As a result, many critically needed roads, bridges, and irrigation works have deteriorated noticeably during the last three years, further threatening the livelihoods of the large segment of the population that has suffered losses of lives, houses, assets, and tools. Because resources are lacking, large numbers of damaged schools and health centers have not yet been repaired, disrupting the delivery of basic social services.
9. Poverty in Madagascar, already pervasive prior to the crisis, has risen and is now among the highest in the world. Madagascar ranks 151 in the world in human development, according to the 2011 United Nations’ Human Development Index. Income per capita barely reached US$ 400 in 20113 and, reverted to its 2003 level in 2012. Preliminary estimates suggest that from 2008 to 2012, the proportion of the population living under the poverty line, already high before the crisis, may have increased by 10 percentage points, with the larger effects occurring over 2011–12 as the crisis deepened. About 77 percent of households are currently below the poverty line, the highest rate in Africa.4 Factoring in population growth, it is estimated that in 2012 Madagascar has some 4 million additional people in poverty as compared to 2008.
Sector and Institutional Context: Adverse Economic and Social Impacts of the Crisis on Human Development
10. In merely three years, the crisis is reversing a decade of progress in the education, health and nutrition sectors. From 2002 to 2008, Madagascar made considerable progress on the social MDGs. For example, Madagascar seemed likely to achieve the fourth MDG: Under- five mortality had declined from 94 in 2002 to 71 in 2008.5 The country was starting to tackle some persistent challenges, such as improving maternal health and reducing stunting among children caused by chronic malnutrition. Significant progress was also achieved in expanding universal access to primary education and reaching gender parity. Enrolment in primary
3 Based on the World Bank Atlas methodology. 4 Development Indicators, 2011. 5 Number of deaths of children less than 5 years old per 1000 live births.
3 education steadily grew by 500,000 annually, and the primary completion rate increased substantially, from only 37 percent in 2001 to 69 percent in 2008.
11. Since the start of the crisis, however, key social indicators have declined dramatically:6
• Immunization coverage with DPT, Hep B3, BCG, and measles rapidly decreased from an average of 90 percent in 2006 to 70 percent in 2011. • Acute malnutrition grew from 4.7 percent in 2008 to 7.4 percent in 2011 in some of the poorest districts. • Infant mortality increased by up to 23 percent and child mortality increased by 30 percent in some regions. • Prescription satisfaction rate, a key indicator for drug availability, declined from 69 percent in 2008 to 58 percent in 2010/11 at the facility level. • The utilization of basic health centers and prenatal consultations decreased by 20 percent from 2008 to 2011. • Enrolment growth in primary education halted abruptly in 2009 with only 0.1 percent (compared to 5 percent annual growth on average over almost a decade) and actually declined in 2010, for the first time in a decade, despite a 2.8 percent growth in the primary school age population. • Drop-out in the first year of education increased from 19 percent in 2007 to 25 percent in 2009. • The number of out-of-school children rose from an estimated 590,000 in 2005 to over 800,000 children in 2010.
12. The rapid deterioration of critical social service delivery results primarily from decreasing public resources. Relatively good macroeconomic performance has come at the expense of the social sectors, with drastic cuts in the national budget for education and health. Public expenditures on education as a share of gross domestic product (GDP) decreased from 3.6 percent in 2008 to 2.6 percent in 2010 (a 30 percent reduction in 2010 constant prices). Per capita, i.e. per primary student spending, decreased by MGA 10,000 (about US$5), i.e. by 15 percent from 2008 to 2011 alone. Similarly, per capita government expenditure on health decreased by more than 30 percent between 2008 and 2010.7 With the available budget for education, health and nutrition, the government largely pays only salaries.
13. Sharp cuts in public spending substantially decreased service delivery, reduced the availability of supplies, and increased the burden of payment on families. In education, for example, the relatively low recurrent spending on pedagogical materials, about 11 percent, negatively impacts the availability of basic learning materials in schools In addition, grants provided to school management committees for pedagogical materials declined by two-thirds from US$1.50 per pupil per year before the crisis to US$0.45 in 2011. This situation therefore necessitates household contributions to meet this gap in public spending. Furthermore, as many
6 Sources of information are: (i) for health: Ministry of Health 2011; UNICEF SMART Survey 2011; regional information is preliminary results from the Multiple Indicator Cluster Survey (MICS) 2012, and (ii) for education, administrative data from the Ministry of Education as well as the 2005 and 2010 household surveys. 7 Per capita government expenditure on health, average exchange rate US$-MGA in 2008 was 15, which decreased to 10 by 2010. Source: Global Health Observatory Data Repository, WHO, accessed September 8, 2012.
4 as two-thirds of primary school teachers are hired by communities, and a share of their salaries comes from parental contributions. In health, about 340 of 2,500 primary health care facilities (15 percent) were closed between 2008 and 201l, curtailing access to services. Outpatient visits decreased by nearly 20 percent in the same years. Health service delivery is now also constrained by a critical shortage of basic drugs and technical equipment and human resources. Similar to education, communities are now bearing greater costs. For example, the 5,500 community nutrition sites nationwide are now funded primarily through community efforts.
14. Access to social services is affected by families’ growing inability to pay these out-of- pocket costs and by weakened management and governance at all levels. As out-of pocket costs for service delivery have risen, greater numbers of households have suffered declining incomes, have become more vulnerable, and are increasingly unable to pay for services. Notably, 47 percent of households cite financial problems as the reason for not seeking medical care when stricken with an important illness.8 Services are delivered free of charge, yet in practice, the use of health services entails out-of-pocket prescription costs and other costs, such as for supplies and transportation. Similarly, public primary education is free of charge; however most families have to pay contributions to community teacher salaries and school maintenance. That same community involvement, however, explains why the capacity to deliver services at the facility and school levels has proven relatively resilient. But, as the crisis persists, an increasing number of families cannot afford these contributions, so their children either drop out of school or are excluded from education in the first place and individuals do not seek medical care because they cannot afford the associated costs. As the crisis has weakened strategic leadership and management of public service delivery systems at the central level, accountability has diminished and the quality of service provision has been compromised.
15. The need to preserve access to critical social services is urgent. The challenge is to preserve the availability of public services on the supply side (notably the availability of health, nutrition, and school supplies) as well as the presence of health workers and teachers at the facility level, in a way that builds upon the capacity of communities. In addition, demand-side obstacles such as financial and geographic barriers to accessing social services need to be addressed. The support should be coordinated among development partners and targeted to the neediest regions. Finally, a support program will be most effective if the investment in human capital “software” (specifically, in health, nutrition, and education services, along with increased earning opportunities for vulnerable households) can be complemented by investments in physical capital “hardware” (the rehabilitation of school and health facilities).
Rationale for Bank Financing
16. A strong case can be made for emergency support to the social sectors to avoid a significant, negative impact on poverty over the long term, and the Bank is well placed to provide such support. In the current country context, the cost of inaction in the health, nutrition, and education sectors is high and already disproportionately affects the poorest and most vulnerable quintiles of the population. This temporary crisis will, in fact, permanently affect the potential of the country’s human capital and will limit the impact of future poverty reduction interventions.
8 Household Survey, 2010
5 17. The rationale for Bank financing of this operation is strong for the following reasons: (i) it is in line with the ISN, the Africa Strategy, and the WDR 2011 on Conflict and Security; (ii) the Bank has extensive experience in supporting the social sectors in the country and can therefore rapidly make financing available to meet local emergency needs though modes of service delivery that have proven effective in Madagascar; (iii) the Bank can finance coordinated and complementary services across multiple sectors (health, nutrition, education, transport, agriculture, and so on); and (iv) the Bank will be filling critical gaps in the funding provided by other donors. Equally important, Bank financing, in partnership with other key donors in the sectors, protects valuable and well-established implementation and program management capacity, which is critical for both current and future implementation of sectoral programs. The preservation of institutional structures and systems that work is essential to maintain these capacities built over several years. This incremental investment will likely be significantly less than building systems from the ground up if these institutions and systems are allowed to collapse.
Institutional Context
Government Development Strategy
18. A five-year development plan, the Madagascar Action Plan (MAP), was put in place by the government in 2006 and broadly endorsed by the international donor community. The MAP focused on several key areas: building and maintaining infrastructure, increasing agricultural production, enhancing social protection, and mitigating and responding to the impacts of natural disasters. It outlined a strategy to reach the MDGs and support the poorest and most vulnerable segments of the population. The crisis placed implementation of the MAP on hold. The High Transitional Authority (Haute Autorité de la Transition) currently in power has neither formally refuted nor endorsed the MAP. As a result, there is currently no formal overall government strategy. The High Transitional Authority focuses on day-to-day management of the country and has to date refrained from committing to long-term policy changes.
19. Interim sectoral strategies for education, health and nutrition have been, or are being developed. These strategies focus on the short-term aim of preserving critical service delivery and protecting access to and utilization of education and health services. In education, the government, with support from its partners, is preparing a interim education sector plan for the next three years for submission to the multi-donor Global Partnership for Education (GPE) in 2013. The plan focuses on improving access to education and enhancing the learning environment for better results. In health, the government is finalizing the Transition Sustainable Health Strategic Development Plan (2012–2015), in which the primary focus remains on maternal and child health outcomes. The nutrition sector has finalized a National Nutrition Strategy, centered on ensuring adequate nutrition services for children between the ages of zero to two years old and for pregnant women, given both the short- and long-term implications of poor nutrition among these target populations.
6 Donor Programs and Coordination Mechanism
20. In Madagascar, external financing has traditionally accounted for almost half of the government’s budget and has been the main source of investment funding in the social sectors and infrastructure. As a consequence of the crisis, most donors stopped new commitments while continuing humanitarian and poverty programs through specialized agencies or nongovernmental organizations (NGOs). In 2010, total disbursements amounted to US$447 million, representing an overall reduction of 30 percent. Since 2012, donors have cautiously resumed policy dialogue and analytical activities to the social sectors and have been providing limited financial support. For example, in health, the EU will be channeling resources through United Nations Children’s Fund (UNICEF) for support to NGOs for service delivery, and the French Development Agency (Agence Française de Développement, AFD) will be providing US$10 million per year for 2012–2013 for the sector. In education, several donors have been or are planning to provide financing, such as the EU (which provides about US$10 million per year until 2015 for teacher training and local institutional development in five regions, in addition to funding for priority activities for 2013), Norway, the UNICEF, and AFD (which is developing a new project of about € 10 million) (for more detailed information, see Annex 12).
21. The sectoral donor groups meet regularly and remain an effective mechanism in the country for coordinating technical and financial support. The World Bank very actively coordinates its ongoing and proposed interventions with other development partners, notably the EU, AFD, UNICEF, and the World Food Programme (WFP), among others. This coordination implies that the development partners predominantly use the same implementation agencies, share implementation costs, provide financing to similar activities, and coordinate the supported regions to cover all regions as comprehensively as possible.
C. Bank Response: The Project
Consistency with Country and Bank Strategies for the Social Sectors
22. The focus and approach of the proposed project is consistent with the ISN for Madagascar, the recommendations of the 2011 WDR on Conflict and Security, and the World Bank’s Africa Strategy. Following the political events in January 2009, preparation and approval of new lending was put on hold under the Madagascar portfolio in March 2009 in accordance with OP/BP 7.30, Dealing with De Facto Governments, except on the basis of case- by-case exceptions to the Bank’s overall decision not to extend new financing to the country. Given the continued application of OP/BP 7.30 to Madagascar, a two-year ISN (2012–14) was discussed by the Board in February 2012. The ISN proposes a cautious, strategic, and selective approach to new operations to mitigate the heavy impact of the crisis on the most vulnerable populations and identifies the health, nutrition, and education sectors as the priority areas. The proposed project is thus well aligned with the ISN. It also integrates lessons from the 2011 WDR, which highlights the critical role of strengthening community-based social services in a fragile environment by producing tangible benefits for communities relatively quickly and thus promoting social cohesion. The proposed project also reflects a core area of the World Bank’s Africa Strategy, notably, by addressing vulnerability and strengthening resilience.
7 23. Complementarity with other International Development Association (IDA) activities. The proposed operation has substantial complementarities with other Bank activities in the Madagascar portfolio:
(i) Emergency Infrastructure Preservation and Vulnerability Reduction Project. This operation will prioritize the restoration of health centers and schools in the same five regions supported by the proposed project. This essential coordination will contribute to ensuring that all critical facilities, supplies, teachers, and health workers are present in the project areas. It will also prioritize the rehabilitation of rural roads that connect the population to health and education facilities in the project areas. (ii) Second Multisectoral STI/HIV/AIDS Prevention Project (MSPPII). The design of the operation dovetails with the Second Multisectoral STI/HIV/AIDS Project (MSPPII) Additional Financing approved in June 2012. It has the same regional focus and largely scales up the package of critical services financed under the health and nutrition components of the proposed operation. (iii) Global Partnership for Education grant (under preparation). This multi-donor financed grant, for which the Bank will be the supervising entity, is intended to provide sustainability to the critical education interventions supported in this project. The GPE will be national in scope but ensure complementary with ongoing support, and will focus on improving access to education, improving the learning environment, and enhancing governance and management of service delivery. (iv) Second Governance and Institutional Development Project. This operation includes a focus on enhancing social accountability, access to information, and knowledge sharing among state and non-state actors. The proposed emergency project will work towards these aims for the social sectors by: (i) enhancing civil society’s capacity to monitor budgets and (ii) increasing the administration’s transparency through community scorecards and school report cards.
Project Development Objectives
24. The Project Development Objective (PDO) is to preserve critical education, health and nutrition service delivery in targeted vulnerable areas in the recipient’s territory.
25. The proposed operation prioritizes activities that will facilitate access to basic education and health services through a reduction of private (out-of-pocket) costs of services and the easing of supply-side constraints. In addition, the activities aim to maintain the resilience of service delivery systems through a focus on providers at the community and primary care level and on targeted activities to strengthen governance and accountability in the delivery of services.
26. The project will take a “continuum of care” or “life cycle” approach to mitigating the negative impacts of the crisis on the most vulnerable populations by supporting a sequence of interventions to promote human development from early pregnancy through infancy through primary school age to maximize impact (Figure 3). This support to a sequence of interventions would promote maternal and reproductive health, management of childhood illness, and
8 childhood care and development,9 focusing on pregnant women and children through primary school age. The provision of a package of basic services builds on a vast body of global evidence that health, nutrition, and education outcomes are inextricably linked and critical for the socioeconomic well-being of populations over the long term.
Figure 3: Continuum of Care and Human Development Approach
Children 6 years and above
Pregnant women and children Schools: Teachers, Learning supplies, 0–5 years Health and Nutrition Interventions Component 1 Priority Focus: Health Facilities: - School age children (six Pregnant women Component 2 years and above) Priority Focus: and children 0-2 - Children under five years - Pregnant women - Referral from community nutriton sites for severly malnourished children Community Nutrition Sites: - Training for community Component 3 nutrition workers Priority Focus: - Children under five with critical interventions for children under two - Education and nutrition supplements for mothers and pregnant/lactating women
27. A targeted approach focused on five of the most vulnerable regions will allow reaching out to the poorest people, while maximizing results, and monitoring implementation adequately. The proposed activities will be implemented in 5 out of Madagascar’s 22 regions (Androy, Atsimo Atsinanana, Vatovavy Fitovinany, Haute Matsiatra, and Amoron‘i Mania). These regions are home to 4.9 million people (24 percent of the population). They have been selected based on several objective criteria, notably: (i) poverty and social indicators to ensure that the proposed project’s activities reach the most vulnerable. The five regions have the highest poverty rates; about 85–94 percent of the population fell below the poverty line in 2010; (ii) complementarity with other donor interventions, and (iii) the current IDA health operation (MSPPII) to optimize synergies between its health and nutrition activities and those under the proposed emergency project. Intervening in a limited number of regions will also intensify the
9 Donald A. P. Bundy, Sheldon Shaeffer, Matthew Jukes, and others, 2006, in Disease Control Priorities in Developing Countries, edited by D.T. Jamison et al., World Bank and Oxford University Press, Washington, DC.
9 pace of implementation and facilitate supervision and oversight by the Project Implementation Units (PIUs) and the Bank.
28. The primary schools, health facilities, and nutrition centers covered under the project are located in the same communities and in many cases, are close to each other. By implication, the activities supported by the education, health and nutrition components will benefit the same communities and in some instances even the same families.
Summary of Project Components
Component 1: Preserving Critical Education Services (US$23.5 million)
29. This component will preserve critical education services in the targeted vulnerable regions and benefit approximately 974,300 primary school aged children and 10,000 community teachers in the public primary schools in the five targeted regions—currently about 6,050 schools. This objective will be achieved through the following activities:
(a) Subsidies to community teacher salaries. This activity will contribute to the payment of salaries for community, non-civil-servant teachers—those supported through the Parent Association (Fikambanan’ny Ray Aman-drenin’ny Mpianatra, FRAM)10—for a limited number of months of the year.11 The government has been subsidizing the salaries of these teachers since 2002 to reduce the direct costs of education to families. Since the crisis, it has been a challenge for the government to continue paying the subsidy on a timely and regular basis, and the gaps had to be filled by parents’ contributions. To ensure the continued functioning of the system, while at the same time protecting future sustainability and government commitment for teacher salaries, donors have been contributing to the payment of these salaries for a limited number of months during the year, while the government assured the payment for the remaining months.12 The support under the proposed project will maintain this principle. The activity will be implemented through well-established mechanisms and structures (that is, through financial service providers and in close coordination with the regional and local education administrative structures, which will also supervise this process).
(b) Support to school grants (also called Local Catalytic Funds, Fonds Catalytiques Locaux, FCL). This subcomponent will provide a top-up to the grants provided to public primary schools by the government (called caisse école) since 2002. Specifically, these grants will: (i) provide schools with small annual funds for operational expenses for the maintenance of facilities and acquisition of basic learning supplies (chalk, notebooks, and so forth); (ii) fund activities of the school annual expenditure program and annual school action plan; and (iii) cover other eligible expenditures. The school grants will be given to school-based management committees (called FAF Fiaraha-miombon’Antoka ho
10 These locally recruited teachers constituted about 67 percent of all public primary school teachers in 2010 and are crucial to ensuring primary education for a large share of children. 11 It is planned to finance four months of teacher salaries annually under the project. 12 For example, the UNICEF-managed multi-donor grant of the GPE (expected to close in December 2012) has been paying part of the FRAM teacher salaries, as will the planned EU support for 2013.
10 amin’ny Fampandrosoana ny sekoly), consisting of parents, teachers, the school director and representatives from the local community. Well-functioning, existing mechanisms will be used to channel these resources directly to the committees. Training, financed under subcomponent (d), will also be provided to these school committees to strengthen their capacity to manage the grants. Third-party verification through unannounced spot checks will be performed in a sample of schools.
(c) School health and nutrition package. This subcomponent will deliver a package of basic treatment and preventative health and nutrition interventions, including deworming treatment, iron folate, and treatment of neglected tropical diseases in schools in selected areas. The school health activities will be implemented at the school level several times a year by the Ministry of Education (MEN, Ministère de l'Education Nationale), with supervision and training supported by the local health and nutrition structures (specifically trained health workers and community nutrition volunteers). These structures have a successful history of implementing school health and nutrition interventions. Supervision costs for this component will also be included in the health and nutrition components, respectively.
(d) Capacity strengthening, project management, and monitoring and evaluation (M&E). This subcomponent will finance: (i) operational and supervision costs for the already functioning education PIU; (ii) capacity strengthening of local communities for managing their schools; (iii) capacity building of local, regional, and central structures for the effective implementation and supervision of the activities; (vi) strengthening of sector policy dialogue; and (v) M&E activities, including beneficiary surveys. The subcomponent will also contribute to the financing of the Project Coordination Cell (PCC).
Component 2: Preserving Critical Health Services (US$25.0 million)
30. The main objective of this component will be to preserve the provision of critical health services—to pregnant women and children under five. Building on the MSPPII, the proposed operation will expand support to 60 percent of health facilities in targeted areas in delivering services and will address key supply- and demand-side barriers to access. This objective will be achieved through the following subcomponents:
(a) Critical package for pregnant women and children under five at the health facility level. For pregnant women, an existing cost-effective package of essential services13 will be financed from the first trimester of the pregnancy to the postnatal consultation. This subcomponent will finance training for health providers in obstetric and neonatal emergency care, as well as an existing integrated package for children under five at the health facility level. This package includes Information, Education, and Communication (IEC) activities to promote good practices and breastfeeding and nutrition for mothers
13 In line with national policy, the basic package of services includes: prevention of mother-to-child transmission, tracking, and treatment of syphilis, HIV/AIDS prevention, treatment and prevention activities, supplementation with iron and folic acid, tetanus vaccination, intermittent preventive medication against malaria, and distribution of safe delivery kits.
11 and children, Vitamin A supplementation, vaccinations, distribution of long-lasting insecticidal nets (LLINs), treatment of diarrhea with oral rehydration salts and zinc, prevention and treatment of malaria, and support to integrated management of childhood illness (IMCI). The subcomponent will finance periodic mass treatment campaigns against neglected tropical diseases (helminthiasis, bilharzia, and filariasis). Health facilities will receive funding to support outreach activities that will deliver services directly to the community by qualified health personnel, increasing coverage by health personnel from 5 kilometers to 15 kilometers from the health facility. This subcomponent will also finance contracts with NGOs for the delivery of key interventions to target groups in hard-to-reach areas.
(b) Project management and monitoring and evaluation. Operational costs will be financed for the already-functioning health PIU as well as supervision costs to effectively support implementation and monitor activities. This includes supervision costs for the school health subcomponent under component 1. The subcomponent will also contribute to the financing of the PCC. It will also finance a range of M&E activities, including a system for rapid data collection via mobile phone, periodic surveys and assessments, and third-party verification of support provided by NGOs to deliver services as well as activities to strengthen policy dialogue.
Component 3: Preserving Critical Nutrition Services (US$10.5 million)
31. The main objective of this component is to increase access to nutrition services in the community by expanding support to community nutrition sites, community nutrition agents (CNAs), with the aim of reaching 50 percent of the beneficiary population. This objective will be achieved through the following activities:
(a) Support basic community nutrition services. Nutrition inputs, recruitment of NGOs to support community nutrition sites, and capacity building activities for the CNAs will be financed. The CNAs will implement the community-based activities to improve nutrition. Activities will include a suite of cost-effective nutrition interventions (Annex 1) including growth monitoring for children under five (with a critical focus on children under two), nutrition awareness and education through culinary demonstrations, school health outreach activities, and referral to health facilities for severely malnourished children.
(b) Support project management and monitoring and evaluation. This subcomponent will finance the operational costs of the Nutrition PIU. It will also finance a range of M&E activities to monitor progress and assess impact including surveys and evaluations such as the biannual community assessments of local malnutrition issues to encourage community involvement in ensuring effective delivery of services. The subcomponent will also contribute to the financing of the PCC. Similar to the health component, the nutrition component will finance supervision costs and relevant nutrition inputs for the school health subcomponent under the component 1, the use of mobile phones for data collection and activities to strengthen policy dialogue.
12 32. Combined, components 2 and 3 will expand access to approximately 182,000 women and 750,000 children for critical health and nutrition services through support to approximately 350 health facilities and 2,000 community nutrition sites.
33. Unallocated Category (US$6 million). Approximately ten percent of project financing is in the unallocated category. The unallocated amount will be used to facilitate a quick response to unforeseen events, requiring fast assistance to affected populations. The amount can be used to cover cost overruns or as a contingency for unforeseen costs related to the project activities necessary to reach the PDO.
34. Monitoring and Evaluation. The project will support M&E activities under all components to ensure regular supervision, along with timely, regular data collection to measure progress and results and to inform sector policy dialogue. This information will support the integration of lessons learned during project implementation. In summary, the project could include (but is not limited to) the following types of M&E activities: (i) supervision of activities through several types of regular monitoring by the internal auditors of the PIUs, external auditors, and third-party verification agencies, such as NGOs, to verify delivery of services; (ii) evaluation of the impact of project activities; (iii) use of available administrative data (for example, from existing management information systems) for decision making; (iv) beneficiary surveys as a feedback mechanism; (v) scaling up of innovations around data collection (such as mobile phone data collection) to enhance the current information systems for baseline and endline evaluation of activities; and (vi) joint data collection with other donors.
Eligibility for Processing under OP/BP 8.0
35. The proposed instrument will be an Emergency Recovery Credit, the Bank’s instrument to provide rapid support for addressing major adverse economic and social impacts resulting from an actual or imminent natural or man-made crisis or disaster. Dramatic budget reductions in the social sectors have led to a significant deterioration in basic service delivery; increasing the vulnerability of already very poor communities (see also country context section). If emergency assistance is not provided, this alarming situation in the social sectors is expected to worsen, with severe consequences for the most vulnerable communities, posing a further danger to social cohesion. Expected Outcomes
36. There are six Project Development Objective (PDO) indicators. Given the emergency nature, short-term focus, and fragile context, the PDO indicators were selected based on a principle of being simple, realistically achievable, and measurable using existing credible sources. The health and nutrition indicators build on the M&E Framework for MSPPII (see Annex 2 for the results framework and a full list of indicators, including baselines and targets):
13
Project Development PDO Indicators Responsible PIU Use of data Objective
Education: - Students enrolled in primary schools in project areas Education PIU - Total number of schools receiving school grants funded by the project
Health and Nutrition
- People with access to a basic Monitor project Health and Nutrition progress on an annual To preserve critical package of health, nutrition, or PIUs basis to assess education, health and reproductive health services whether the project is nutrition service (number) on track to achieve delivery in the targets. Slow progress recipient’s territory Health will result in changes - Birth (deliveries) attended by in implementation. skilled health personnel in project Health PIU areas (number) - Children immunized (number)
Nutrition - Children under the age of 24 Nutrition PIU months benefiting from improved infant and young child feeding practices
D. Appraisal of Project Activities Technical
37. The key operational features of the proposed operation include: (i) a multi-sectoral approach to ensure availability of the critical required inputs; (ii) a focus on a few selected but critical interventions at the primary health, nutrition and education levels to have a direct impact on beneficiaries’ access to services; and (iii) the use of existing programs and mechanisms as a means of speeding implementation and delivering results quickly.
38. The “continuum of care” or “life cycle” approach is critical to preserve human development outcomes. Poor health outcomes and malnutrition within the first two years of life lead to proven cognitive impairments that significantly and negatively affect an individual’s learning potential and overall productivity over the longer term. The period from conception to a child’s second birthday is a critical window of opportunity to improve the child’s survival, growth, and development; after the age of two, malnutrition will have caused irreversible damage. Results from the multi-round anthropometric survey in Madagascar found that children ages 0–3 who were stunted had nonverbal test scores that were significantly lower than scores of
14 children who were not stunted. This same group of children had not “caught up” with their peers as they grew older (between ages 7 and 10). Recent findings suggest that school health and nutrition interventions (such as deworming) for children positively influence school attendance and participation. These interventions, combined with critical supply-side inputs, such as basic equipment for health facilities and teachers’ salaries, ensure that services are available and can be used by these vulnerable populations to maximize returns on human development investments in the short and long term.
39. The approach for the proposed project builds on experience and evidence. The project design is based on the analysis and recommendations of several pieces of Economic and Sector Work jointly undertaken by IDA and the government, as well as other sector studies prepared by development partners and local and international researchers and operations, such as the ongoing World Bank study on the impact of the crisis on the education sector, a health country status report, and joint financing of both sectors together with UNICEF for the planned Multiple Indicator Cluster Survey (MICS), among others (see Annex 12). The project’s design and implementation approach also integrates best practices from relevant IDA projects in the region and other donor projects (see Annex 11 for lessons learned and integrated into the project design).
Fiduciary
40. Financial Management: The financial management residual risk rating for the project is moderate. A financial management assessment of the three implementing agencies was conducted, namely the Education Technical Support Unit–Education for All (Unité d’Appui Technique-Education pour Tous, UAT-EPT), the Health Program Management Unit (Unité de Gestion des Projets d'Appui au Secteur Santé, UGP-Santé) and the National Community Nutrition Program (Programme National de Nutrition Communautaire, PNNC). The three implementing agencies will be responsible for the financial management of their respective components. All the implementing entities have the requisite experience in the management of World Bank–funded projects. The PIUs all have financial management staff with the relevant qualifications and the appropriate experience with regard to Bank Financial Management (FM) procedures and requirements. Details on the FM arrangements for this project are included in Annex 5.
41. Procurement: The overall project risk for procurement is moderate. Similar to FM, the procurement functions will be implemented by each of the three PIUs. The procurement capacity assessments for the PIUs have been carried out, and capacity is found satisfactory. Apart from identifying the minimum required staffing and equipment needed for the procurement units satisfactory to IDA, no other mitigation measures have been identified at this time. Close supervision and support will be undertaken to propose any additional mitigation measures, if and when they are needed. Details on the procurement arrangements for this project are included in Annex 6.
15 Summary of Economic and Financial Analysis
Education and Health Financing
42. In the social sectors, government budget constraints arising from the decrease in external aid and domestic revenues since the start of the crisis severely impacted service delivery. Recurrent expenditures in education consist predominantly of salaries (89 percent in 2011). Goods such as learning supplies and services account only for a small share of recurrent expenditures (11 percent). The relatively low recurrent spending on pedagogical supplies limits the availability of basic learning materials in schools and requires household contributions to close this gap in public spending. In 2010, parents financed about 19 percent of total primary education expenditures,14 and families spent 3.1 percent of their total expenditures on education in 2010, compared to only 2.1 percent in 2005. The largest share of those parental contributions went to school fees (42 percent), which to a large extent finance community teachers in public schools, followed by pedagogical materials (35 percent). In health, Madagascar spent little on the sector prior to the crisis compared to other countries in sub-Saharan Africa, and in the current context, with greatly diminished donor financing, the situation is worse. Since 2009, the share of out-of-pocket expenditures in the total expenditure on health has been increasing. Household expenditures, which constitute about 70 percent of private financing, are out-of-pocket expenditures in both public and private facilities, as pre-payment mechanisms cover only a small proportion of the formal sector workers. Prior to the crisis, in 2008, out-of-pocket expenditures accounted for 21 percent of expenditures on health, but their share had increased to 27 percent by 2010.
43. The proposed project interventions are aimed at reducing the burden on households and thus making education, health and nutrition services more affordable for the most vulnerable segments of the population. Greater affordability will have a positive impact on demand for education and health services, which will translate into increased school retention and attendance and public health and nutrition gains.
Economic Analysis of Main Education, Health and Nutrition Features of the Project
44. The proposed project interventions under Component 1 (support to community teacher salaries, school grants and a school health and nutrition package) are cost efficient. The unit cost of a community teacher (MGA 110,000, or about US$55) is considerably lower than that of a civil-servant teacher, which is on average MGA 380,000 (about US$175). School grants are to a large extent used to fund basic learning inputs. Qualitative analysis from several countries shows that local acquisition of these types of supplies is more cost efficient than centralized acquisition at the ministry or district level for the following reasons: (i) the direct costs associated with transporting and stocking materials at the central and subsequent levels; (ii) the indirect costs (time and effort) for the various decentralized levels involved to organize the distribution of centrally purchased supplies through the administrative chain to schools (which, based on experience, can be substantial); and (iii) better alignment with actual local needs of schools. With regard to the proposed school health and nutrition interventions, studies have shown that school-based deworming is far cheaper than alternative methods of boosting school
14 2010 household survey.
16 participation.15 An investment of US$4 in deworming led to a gain of one additional year of primary schooling—a significantly lower cost than other interventions (such as school feeding or the provision of uniforms) for the same effect.16
45. In addition to their cost-efficiency, the proposed investment in basic education services also has a considerable cost-benefit in terms of future earnings and social outcomes, in particular health outcomes such as antenatal and child health. Results from the 2010 Madagascar household survey indicate that annual salaries increase with the level of schooling. International evidence indicates that primary education provides the highest benefit in terms of social outcomes per dollar spent on education, compared to lower and upper secondary education. Each year of basic education contributes 8.0 percent to the total impact,17 compared to 8.5 percent for each year of lower secondary schooling and 9.2 percent for an additional year of upper secondary schooling. The benefit-to-cost ratio, defined as the ratio of the contribution to total social outcome of each year of schooling to per student cost per year of schooling, is 69 for basic education.
46. Given that the education component of the operation to a large extent finances recurrent expenditures such as subsidies to community teachers and school grants, it is essential to ensure continued government commitment and a strategy for sustainable financing of these activities over the medium to long term. Regarding the subsidies to community teacher salaries, the government will continue to pay the largest share of these expenditures, covering 8 of 12 months each year; this commitment is already inscribed in the national budget for 2013. In the medium to long term, with a normalization of the political and economic situation, it is expected that the government will be able to resume most of these recurrent expenditures. In the meantime, a financially sustainable interim education sector plan is being prepared, which will lay the foundations for medium-term sector development and include analytical work on teachers to inform policy dialogue and decision making on these issues. The main donors have been coordinating closely to provide financial assistance for priority expenditures. The situation is similar for support to school grants, which the government continues to fund with a reduced amount, albeit with difficulty. Nevertheless, this funding shows that there is considerable government commitment for these expenditures.
47. The proposed project interventions under the health and nutrition components are cost efficient. The project, will focus on delivering integrated packages of globally endorsed cost- effective health and nutrition interventions: (i) a maternal and reproductive health package which includes assisted delivery, antenatal care, malaria prevention, and antenatal care and syphilis testing and treatment at an estimated cost of US$14.00, (ii) a child health package that includes routine immunization, malaria prevention and treatment, iron, Vitamin A and deworming, diarrhea treatment and acute respiratory treatment estimated at US$3.30 per child and (iii) a suite of cost-effective direct nutrition interventions with an approximate US$6.00 per capita cost
15E. Miguel and M. Kremer (2004), “Worms: Identifying Impacts on Health and Education in the Presence of Treatment Externalities,” Econometrica 72(1): 159–217. 16 E. Miguel and M. Kremer (2004). 17 Majgaard and Mingat (2011); defined as the average across the social outcomes of child bearing, antenatal health, child health and development and poverty, HIV/AIDS, and the use of media.
17 for children under two years of age which is slightly below the average estimated cost of US$10.00-US$15.00 per child.
48. In addition to their cost-efficiency, the proposed investments in basic health and nutrition services have a considerable cost-benefit in terms of short and long term health benefits as well as on education and productivity outcomes. As with the other MDGs, 4 and 5 are interdependent: saving a pregnant woman’s life often means saving her newborn baby. Saving a mother’s life helps her other children as well, because without her they would be between three and ten times more likely to die before the age of five. The benefits of good health also generate huge economic returns and conversely, poor health can seriously hinder economic growth. Some estimates indicate that maternal and newborn mortality leads to US$15 billion in lost potential productivity globally every year.18 With low cost and high efficacy, many of the interventions have a significant cost benefit — the up-front expenditure is entirely offset by costs averted through prevention.19 For example, it is estimated that the basic childhood vaccine program costs $14-20 per year of healthy life gained in low-income countries.20 The focus on cost effective nutrition interventions for the first 1,000 days (pregnancy to under two years of age) will have life-long and life-changing impacts on educational attainment, labor capacity, reproductive health and adult earnings. Investing in good infant and child nutrition leads to an estimated 2-3 per cent growth in the economic wealth of developing countries. Further, costs of recommended nutrition-specific interventions have been compared with the economic value of their benefits (in terms of reduced mortality and morbidity) and the basic benefit to cost ratio is a very high 15.8 to 1. Even the low case, with extremely conservative estimates, yields a benefit to cost ratio of 4.8 to 1, and the high case value is 40 to 1. This is consistent with the findings of the Copenhagen Consensus 2008, which ranked nutrition interventions as providing some of the most effective returns of all development interventions. Research has also indicated that height- for-age at 2 years was the best predictor of future productivity. The results from a rigorous longitudinal study, for example, found that boys receiving fortified complementary food prior to age 3 grew up to have wages 46 percent higher than those in the control group.
Safeguards
49. The proposed project is classified as Category B, Partial Assessment. Activities to be supported by the project are expected to have some relatively minimal and site-specific adverse environmental and social impacts that are easily manageable and do not involve land acquisition, leading to involuntary resettlement and/or loss of access to resources or livelihoods. Therefore, only the environmental assessment policy (OP/BP 4.01) is triggered, and a medical waste management plan (MWMP) is required.
18 Campbell O, Graham J. 2006. Strategies for Reducing Maternal Mortality: Getting on With What Works. Lancet, 368: 1284-99. 19 Kim, J.J. The Role of Cost-Effectiveness in U.S. Vaccination Policy N Engl J Med 2011; 365:1760-1761, November 10, 2011, DOI: 10.1056/NEJMp1110539 20 Jamison, D. T., Mosley, W. H., Measham, A. R., Bobadilla, J. L. (1993): Disease Control Priorities in Developing countries. Oxford University Press.
18 50. As permitted under OP/BP 8.00, Rapid Response to Crises and Emergencies, an Environmental and Social Screening Assessment Framework (ESSAF) has been developed. In the context described here, the ESSAF addresses the potential repairs and rehabilitation of facilities with a focus on ensuring due diligence and effective treatment and elimination of both medical waste and expired pharmaceutical drugs in the health sector by the Government of Madagascar and its service providers. Interdepartmental Decree No. 2006-680 (September 12, 2006), adopted by the Ministry of Health and approved by the Ministry of the Environment, promulgates a National Medical Waste Management Policy that includes a Medical Waste Management Plan (MWMP). The MWMP publicly disclosed both in-country (March 20, 2007) and at the World Bank InfoShop (March 23, 2007). In September 2011, as part of the National Medical Waste Management Policy, the Ministry of Health prepared a guideline to dispose of expired medicines. The Ministry of Health is updating the MWMP building on the results achieved and lessons learned during five years of implementation; the indicators are being updated as well. They have adopted an extensive participatory approach for this revision, and the MWMP is expected for the Bank’s approval and subsequent disclosure (in-country and at the InfoShop) before the end of February 2013 (see Annex 9 for details).
51. Under the proposed operation, the main issues related to safeguards occur with the health component. The project will draw upon successful experience with the ongoing health project (MSPPII). In this context, for continuing timely management of safeguards, all of the project’s safeguard aspects will be led under the existing Sanitation and Sanitation Engineering Service (Service Assainissement et Génie Sanitaire, SAGS) which has a Social and Environmental Focal Point to ensure that the MWMP is properly addressed throughout project implementation. SAGS is fully operational and has the institutional capacity to manage the safeguard aspects of the proposed operation.
52. Although the project does not expect to undertake civil works, the ESSAF includes measures for addressing environmental and social impacts of the repair and rehabilitation of existing facilities, should it become necessary to undertake them during project implementation. Environmental and Social Management Plans (ESMPs) will be prepared as and when necessary during implementation. The primary environmental issue is the management of medical waste. It is therefore expected that with improvements in delivering health services, the production of both medical and pharmaceutical waste in the various care centers and pharmacies in the country will increase. The risks primarily affect personnel in medical facilities in charge of handling the proper disposal of medical waste, families whose basic income derives from the triage of waste, notwithstanding the general public, to the extent that waste is not disposed of on-site nor safely contained in protected areas. All of these activities may have environmental and human impacts that need to be managed appropriately.
Social Accountability and Governance
53. Governance continues to be a challenge in Madagascar, with the political crisis deepening existing issues. Therefore, several measures related to governance and social accountability at the community level are embedded into the proposed operation and additional social accountability activities will be further explored during the first phase of implementation to ensure that services reach their intended beneficiaries. Notably, this includes the following
19 project approach and activities, among others: (i) a focus on direct support to the community level, i.e. ultimate beneficiaries, e.g. school grants to community-managed school committees, and to community nutrition agents providing nutrition services to mothers and children; (ii) capacity strengthening activities of key local and community structures, e.g. training of school management committees for management of school grants, and (iii) contracting of an external verification firm to verify reported results/outputs on a periodic basis; (iv) contracting of NGOs to support service delivery; (v) strengthening of existing remedial and grievance mechanisms through better communications; and (vi) collaboration with the Bank-financed Governance and Institutional Development Project on implementing social accountability mechanisms at the community, health facility and school levels, including mechanisms for budget transparency.
Institutional
54. In view of the emergency nature of the project, the project’s multi-sectoral design, and the fragile country context, it was considered the most effective approach to base the proposed implementation arrangements on existing, well-performing structures and mechanisms to ensure speedy implementation, provide tangible benefits quickly to communities, and minimize risk. All Project Implementation Units (PIUs) currently successfully manage projects funded by IDA and/or other donors (AFD, UNICEF, and others). Furthermore, the project’s implementation arrangements focused on supporting communities as directly as possible and on reinforcing community capacity, an approach based on best practice (for example, as recommended in the 2011 WDR).
Readiness for Implementation
55. The project will be ready for implementation upon effectiveness. Each of the PIUs is already fully staffed and operational, with a project coordinator as well as fiduciary, technical, and M&E staff in place and supporting projects financed either by the World Bank or other donors. The contractual requirements of all PIU consultants are being reviewed, and new contracts will be issued or current contracts amended to ensure eligibility for working on the proposed operation. The PIUs already have Project Implementation Manuals, which are being reviewed and updated. In addition, a short overall Project Implementation Manual is being developed to describe the roles and responsibilities of the Technical Steering Committee (TSC) and the PCC. Draft terms of reference for the TSC and PCC have already been prepared and will be finalized shortly. The government is preparing a decree to set up the TSC, which is the only effectiveness condition, expected to be available by the end of December 2012. A Memorandum of Understanding for the procurement of drugs for school health activities is being prepared and will be signed shortly between the health and education PIUs. It is expected that these activities will be completed before effectiveness, and dated legal covenants are included to ensure their completion by three months after project effectiveness at the latest. In addition, the following activities are already underway: (i) bidding documents, for example for health and nutrition commodities, are being prepared to permit the implementation of critical interventions on the ground as soon as possible; (ii) for some activities the existing arrangements are acceptable, such as the transfer of school grants and holding of school accounts by the current, well-performing financial service providers; (iii) programs to strengthen the capacity of school committees are
20 also available; and (iv) the terms of reference to recruit NGOs for health and nutrition services and supervision are being finalized to initiate the recruitment process.
E. Implementation Arrangements and Financing Plan
Implementation Arrangements
56. The implementation of each of the three project components will be coordinated and supervised by the existing and well-function PIUs, in close collaboration with the respective national and regional structures of the MEN, Ministry of Health, and the National Office of Nutrition, and with oversight by a Technical Steering Committee (TSC) and consolidated project reporting ensured by a small Project Coordination Cell (PCC). The three PIUs will be responsible for day-to-day project implementation and monitoring of the respective components under their responsibility, including all fiduciary aspects. They consist of: (i) the education PIU (Technical Support Unit for Education for All, UAT-EPT) for Component 1; (ii) the Health Program Management Unit (UGP-Santé) for Component 2; and (iii) the National Community Nutrition Program Unit (Unité Programme National de Nutrition Communautaire, PNNC) for Component 3. The following responsibilities will be managed jointly by the three PIUs (with one PIU being responsible for executing the specific task of contracting, based on fiduciary assessments and practical considerations):21 (i) recruitment of an external auditor for the project; (ii) recruitment of consultants for the PCC; and (iii) support to the establishment of the TSC (among other tasks).
57. The TSC will be chaired by the Minister of Finance and include representation by the relevant line ministries and entities, notably the MEN, Ministry of Health, and the National Office of Nutrition/Prime Minister’s Office. The TSC’s role will consist of: (i) providing overall guidance for effective project implementation (such as the approval of annual work plans and budgets); (ii) ensuring cross-sectoral coordination and consistency of project activities with sector policies and strategies; and (iii) addressing issues that affect overall project implementation (such as restructuring, reallocation, and others).
58. The proposed project will have a light coordinating structure, the Project Coordination Cell. The PCC is essentially a project secretariat and will be responsible for consolidating overall project reporting, including financial reports, the annual work plan, the budget, the results framework, and the progress reports. The PCC will serve as single entry point for information on the project for the TSC and IDA. It will report to the Ministry of Finance. The PCC will organize regular meetings with the heads of the three PIUs to monitor overall implementation progress and facilitate the organization of supervision missions.
21 UGP was assessed by fiduciary specialists to be the best placed to handle contracting for these activities.
21 Project Financing by Component
Amount of the Credit Category Allocated (in US$ m)
Component 1: 23.50 Preserving Critical Education Services
Component 2: 25.00 Preserving Critical Health Services
Component 3: 10.50 Preserving Critical Nutrition Services Unallocated 6.00 Total Amount 65.00
Fiduciary Arrangements
59. Financial Management functions will continue to be undertaken by the current PIUs. The PIUs will prepare the annual budgets for their respective components, which will subsequently be consolidated by the PCC prior to approval by the TSC. The existing accounting software will be used as a basis for maintaining accounting records and generating financial reports. The PIUs will also amend their existing FM procedure manuals to meet the requirements of this multi- sectoral project. The respective internal audit departments will prepare quarterly reports for submission to the TSC. An independent external audit firm will be retained to carry out the annual external audit of the project.
60. Procurement will be carried out in accordance with the World Bank’s “Guidelines: Procurement of Goods, Works and Non-consulting Services under IBRD Loans and IDA Credits and Grants by World bank Borrowers,” published by the Bank in January 2011 and “Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits and Grants by World Bank Borrowers,” published by the Bank in January 2011, and in accordance with provisions stipulated in the Legal Agreement. The provision for a Procurement Agent to obtain medical goods will be included to reflect the use of the independent procurement agency, SALAMA, for the purchase of standard drugs and medical supplies. Competitive selection of NGOs will continue to be based on quality and cost selection, and contracts will be signed with the selected NGOs. In consideration of the application of OP7.30, procurement thresholds for the Bank’s prior review will be maintained as under the previous Bank financing. The procurement section of the Project Implementation Manual will be reviewed to ensure compliance with applicable Guidelines. "Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants”, dated October 15, 2006 and revised in January 2011" will apply. Simplified procurement plans for each component have been prepared and approved by the Bank (Annex 6). The plans will be updated at least annually to reflect the most current circumstances.
61. Disbursement Arrangements: Upon effectiveness of the proposed project, transaction- based disbursements will be used (as is the case for other Bank-financed projects under
22 implementation), as this disbursement method is considered to be the most stringent approach to facilitating the timely identification of potentially ineligible expenditures. New Designated Accounts denominated in US dollars on terms and conditions acceptable to IDA will be created for each implementing agency for the proposed project. The ceiling of the accounts will be: (i) US$5.0 million for Component 1; (ii) US$2.5 million for Component 2; and (iii) US$1.5 million for Component 3. These ceilings are set by component based on expected disbursements for key activities and will be included in the Disbursement Letter, to avoid issues related to payment delays. To expedite implementation, the proposed operation will have retroactive financing in the amount of US$7.0 million for project activities included in the project description and incurred on or after December 1, 2012 (that is, after Board approval). Payments will be for items procured in accordance with applicable Bank procurement procedures.
Implementation Support Plan
62. Given the current country context and multi-sectoral design of the project, intensified support will be essential to ensure that the project is implemented successfully. In addition to the respective task team leaders for each sector (20 staff weeks each), two experienced technical Bank staff for health, nutrition and education, are based in-country and would provide day-to- day implementation support for the project (25 staff weeks each). In addition, for the ongoing IDA projects, the health specialist has carried out bimonthly field visits with the health and nutrition PIUs to ensure implementation progress and troubleshoot any issues early on. This practice will be continued by both sectors during the implementation of the proposed operation. A strong fiduciary and safeguards team, both in headquarters and in the field, will also provide continuous support. During the first six months of implementation, the Project will benefit from the expertise of the consultants that worked on project preparation who have specialized in the implementation of Bank Projects in fragile states and challenging contexts. This will facilitate project effectiveness, timely compliance with dated legal covenants and allow for a quick launch of the project activities. In addition, focused M&E support will be provided. Formal supervision missions will be undertaken jointly to ensure maximum synergy and resource efficiency. A detailed and costed implementation support plan is being developed and will continue to be updated through start-up of the project and as needed during implementation.
Project Timeline
63. The project will be implemented over three years but will frontload resources in the first two years of the project. The project will close on July 31, 2016.
23 F. Key Risks and Mitigating Measures Risk Rating Summary
Risk Rating Risk Rating Project Stakeholder Risks Project Risk - Stakeholder Risk Substantial - Design Moderate - Social and Environmental Low Implementing Agency (IA) Risks (including - Program and Donor Substantial Fiduciary Risks) - Capacity Moderate - Delivery Monitoring and Sustainability Substantial - Governance Substantial - Political Interference Risk Substantial
64. The implementation risk of the proposed operation is substantial. The following risks are rated high or substantial.
65. The governance risk is substantial. Madagascar is undergoing a prolonged political and economic crisis. The likelihood of unrest or a major breakdown of law and order at election time is significant and could be protracted, especially if the outcome of the election is disputed. This situation could result in implementation delays and impact project performance considerably. The ability to mitigate this risk is limited, but close monitoring of the political, economic, and fiscal situation will be continued and will help with mitigation. Mitigation measures for country fiduciary risks consist of: (i) continued attention and dialogue of IDA and other donors on public financial management with technical representatives of the government on these issues; (ii) close supervision of fiduciary issues and strengthening of systems, controls, and audits; and (iii) the focus of the proposed policy-based operation on the improvement of fiduciary standards.
66. In the current political context, the overall risk of political interference in project approach, staff and implementation may be heightened. The following measures are in place to mitigate this risk, notably: (i) the regions of intervention and beneficiaries have been selected based on poverty levels according to the 2011 Poverty Map, complementarity with other donor support (including the ongoing Bank-financed health project), and the low level of social sector indicators; (ii) a very large percentage of all public education, health and nutrition facilities in the targeted regions are covered, which limits the risk of inequities in service delivery within regions; (iii) the project is implemented through three existing PIUs that maintain a high degree of independence and have good track records in implementing IDA-financed projects and other development partners’ projects, and (iv) IDA resources will flow directly to the PIUs into special accounts which are outside of the Government’s financial management system. At the activity level, the following measures will contribute to mitigating related risks: (i) strong involvement of direct beneficiaries in the project activities through existing social accountability structures at the community level, such as health facility committees and school management committees; (ii) existing grievance mechanisms through these structures, as well as the local and regional administrative structures, among others; (iii) beneficiary surveys; and (iv) capacity-strengthening activities in communities to enhance governance, such as training in the teacher accountability process.
24 67. Project stakeholder risk. Particular stakeholder risks consist of potentially weakened leadership and ownership due to the political crisis, as well as limited possibilities for active donor–government policy dialogue and donor funding. Proposed mitigation measures to address these issues include (i) continuation of the sector dialogue with the government and external partners; (ii) the inclusion of accountability and governance mechanisms at the local level on a sample basis during the implementation of the project (for example, third-party verification by NGOs); and (iii) the use of regional administrative structures for supervision and monitoring to strengthen ownership, enhance sustainability, and avoid parallel systems.
68. These substantial risks notwithstanding, inaction on protecting critical human services may pose an even greater risk by plunging people into greater vulnerability, potentially leading to a breakdown in the social fabric and creating social unrest. The technical design and proposed implementation arrangements will mitigate a number of these risks related to the country context (for more details on risks, see the Operational Risk Assessment Framework in Annex 4).
G. Terms and Conditions for Project Financing
69. The project is proposed for financing under an IDA Credit. The instrument will be an Emergency Recovery Credit. Substantial efforts by the government and Bank team are underway to ensure readiness for implementation by effectiveness (for more detail, see the earlier section on appraisal).
Project-specific Conditions of Effectiveness
70. Decree(s) issued establishing the Technical Steering Committee.
Withdrawal Conditions
71. Notwithstanding the provisions of Part A of Section IV of the Financing Agreement, “Withdrawal of the Proceeds of the Financing,” no withdrawal shall be made:
(a) for payments made prior to the date of the Financing Agreement, except that withdrawals up to an aggregate amount not to exceed SDR 4.6 million (US$ 7 million equivalent) may be on or after December 1, 2012 to cover eligible expenditures, for Eligible Expenditures (date to be one business day after Board date if Board is postponed);
(b) first disbursement of funds allocated to teachers’ subsidies under Category (2), until: (i) the Recipient has entered into a Payment Agreement; and (ii) the Payment Service Provider has opened a Payment Account;
(c) first disbursement of funds allocated to school grants under Category (3), until: (i) the Recipient has entered into a Payment Agreement; (ii) the Payment Service Provider has opened a Payment Account; and (iii) the Recipient has adopted the School Grant Regulation.
25 Dated Covenants
(a) Establishment of the Project Coordination Cell
(b) Each of the PIUs shall maintain the following staff from a date no later than two (2) weeks after the Effective Date (i) a national coordinator or, in the case of the Nutrition PIU, a national director; (ii) an internal auditor; (iii) a procurement specialist; (iv) a financial management specialist; (v) an accountant; (vi) a monitoring and evaluation specialist (but only in the Health PIU and the Nutrition PIU); and (vii) a safeguard specialist (but only in the Health PIU). (c) Adoption of a regulation on school grant: three months after effectiveness.
(d) Publication of a revised Medical Waste Management Plan: February 28, 2013.
(e) Updating of the Education, Health and Nutrition Manuals.
(f) Adoption of Project Implementation Manual: three months after effectiveness.
(g) Engagement of independent auditors for the carrying out of audits of the Recipient’s financial statement: December 31, 2013.
FM Standard Covenants
(a) Interim Unaudited Financial Reports (IFRs) will be prepared on a quarterly basis and submitted to the World Bank 45 days after each quarter.
(b) An annual detailed work program and budget, including disbursement forecasts, will be prepared each year by November 30.
(c) The overall FM system will be maintained operational during the project’s entire life in accordance with sound accounting practices.
26 Annex 1: Detailed Description of Project Components
MG–Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
Component 1: Preserving Critical Education Services (US$23.5 million)
1. This component builds on and complements interventions by other donors to mitigate some of the negative effects of the crisis on education service delivery to vulnerable populations by addressing supply- and demand-side constraints in access to schooling. About 974,300 primary aged children and approximately 10,000 community teachers in all public primary schools in the five targeted regions (currently about 6,050 schools) will benefit from this component’s support of the following four activities: (i) subsidies to community teacher salaries; (ii) support to school grants; (iii) a basic school health package (jointly funded and implemented with health and nutrition); and (iv) capacity strengthening, M&E, and project management. More specifically, the project will support:
(a) Subsidies to community teacher salaries (US$10.2 million): To cope with rapidly increasing enrolment in primary education, which grew from 2.4 million in 2001 to 4.31 million in 2010, the government decided in 2002 to subsidize the payment of community (non-civil-servant) teachers hired locally (and originally financed by) parents’ associations on a large scale. Since then, the number of community teachers has grown rapidly, e.g. from 31,512 in 2006 to 55,686 in 2010. This massive recruitment of community teachers and the financial support of their salaries by the government enabled a significant expansion of the total primary teaching force at a lower cost, from a primary teaching force of 49,410 in 2000 to 81,791 in 2010; enabled the effective implementation of the national policy for free primary education, i.e. elimination of school fees; and thus constituted a reduction in the direct costs of education to families. This expansion of the teaching force was a critical success factor in improving access to education over the past decade, from a NER of 70 percent in 2001 to 89 percent in 2008. By 2010, about 67 percent of all public primary school teachers were community teachers. The subsidy has been financed through two sources of funding: (i) the domestic education budget; and (ii) external donor e.g. the ongoing multi-donor GPE and in 2013, the EU. Since the crisis, due to financing gaps, it has been a challenge for the government to continue paying community teacher salaries on a timely and regular basis and parents have increasingly been covering this gap in public resources. To ensure continued service delivery at the school level, while at the same time protecting future sustainability and government commitment for community teacher salaries, donors have been contributing to the payment of these salaries for a limited number of months during the year, while the government assured the payment for the remaining months.
In line with this approach, agreed upon by the external partners and government, the project will fund: (i) payment of four months of the salaries of about 10,000 community (non-civil-servant) teachers currently subsidized by the government in the five targeted
27 regions (the government will pay the remaining eight months of the calendar year);22 (ii) social security contributions (to the national social security administration, Caisse Nationale de Prévoyance Sociale, CNaPS) for those teachers for the period of funding; (iii) associated financial transfer costs and banking charges of the service providers used (post office, microfinance institutions, and regular commercial banks); and (iv) supervision and data collection by regional and local administrative structures (including small equipment such as office supplies, communication costs, and other items). In addition, parents’ associations will be trained to manage the grants and ensure accountability of the teacher verification process. In addition, third-party verification by NGOs in a sample of schools will also be done (to be financed under subcomponent 4).
(b) Support to school grants (US$7.8 million): To reduce the costs of education incurred by households through voluntary (although de facto almost obligatory) parental contributions to schools for classroom supplies and small maintenance works, the Ministry of Education has been providing annual school grants to public primary school- based management committees since 2002.23 Since the crisis, the government has been struggling to continue paying the school grants regularly and on time. Moreover, it was forced to cut the amount of the school grant by more than two-thirds, from MGA 3,000 (approximately US$ 1.50) per student in 2008 to MGA 800 (about US$ 0.40) in 2010 and MGA 900 (about US$ 0.45) in 2011. In 2009, no school grants were paid at all. This subcomponent will contribute to the payment of grants to all public primary schools in the five targeted regions. The Ministry of Education will continue to pay the current, severely reduced, school grant amount, which will be supplemented by a top up by the project directly to the about 6,076 school management committees in the five regions. The purpose of these grants is to (i) provide schools with small annual funds for operational expenses for the maintenance of facilities, acquisition of basic learning supplies (such as chalk, notebooks etc.), which otherwise would have to be provided by parents, and (ii) fund activities of the annual school action plan. The grant amount is allocated to schools based on school size, number of pupils. The average supplemental grant amount funded by the sub-component is US$ 200 per school for small schools, US$ 250 per school for medium-sized schools, and US$ 300 per school for large schools.
This sub-component will finance: (i) payment of grants for all primary public schools through financial institutions; and (ii) fund transfer and banking charges for financial service providers; and (iii) supervision and data collection by regional and local administrative structures. In addition, training will be provided to school based management committees for management of the grants as well as third party verification by NGOs in a sample of schools (to be financed under sub-component 4).
(c) School health and nutrition package (US$1.5 million): This subcomponent will enhance student health by promoting preventative care. Until 2010, the Ministry of Education, in collaboration with the World Health Organization (WHO), the Ministry of
22 Disbursement during the first quarter is always difficult for the government owing to limited fiscal revenue. 23 In the first year, 2002, school grants were funded equally by the Bank-financed education project (CRESED) and resources from Heavily Indebted Poor Countries debt relief. Since 2004, the capitation grants primarily have been funded as part of the government’s recurrent budget, supplemented by the multi-donor GPE fund (since 2009).
28 Health, and National Nutrition Office (Office National de Nutrition, ONN), provided deworming treatment and distributed iron folate for all children enrolled in primary schools. This subcomponent will finance a package of basic preventative health and nutrition interventions to be delivered in schools in selected areas, with the aim of increasing attendance and enhancing learning capacities. This basic package will consist of a deworming treatment, iron folate, and drugs to prevent widespread tropical diseases (filhariasis and bilharzia). The activity will target most of the public primary schools in four of the five regions24 and cover about 600,000 or more public primary school students in areas where nutrition centers and health centers are located to supervise effective administration of the drugs and supplements. Deworming will be accompanied by a one- day nutrition activity, i.e. culinary demonstrations, performed by community nutrition agents (CNAs) at the school level. The demonstration ensures that children eat before the deworming treatment, since there is a risk of negative side effects otherwise. The demonstration has the added benefit of teaching students about nutrition.
(d) Capacity strengthening, project management, and monitoring and evaluation (M&E) (US$ 4 million): This subcomponent will finance (i) operational and supervision costs for the UAT-EPT and other relevant entities related to project activities, including support to the PCC; (ii) capacity strengthening of local communities for managing their schools; (iii) capacity reinforcement of local and regional ministry structures—the Regional Directorate of National Education (Direction Régional de l’Education Nationale, DREN); the School District (Circonscription Scolaire, CISCO); and Subdistrict Office (Zone Administrative et Pédagogique, ZAP)— for the effective implementation and supervision of the activities; (iv) strengthening of sector policy dialogue; and (v) M&E activities, including beneficiary surveys. Financing for M&E will strengthen the system that is already in place to collect timely data from all levels and use it for decision making and for monitoring the impact of project activities. Periodic evaluations of activities under sub-components (i)–(v) will also be included, reinforced by third-party verification of service delivery to target populations by an external agency, similar to the mechanism that will be implemented under the health and nutrition components.
2. The total number of beneficiaries for Component 1 is approximately 984,300, which includes the about 10,000 community teachers whose salaries will be subsidized and the 974,300 children currently enrolled in the public primary schools in the five regions.
24 The World Food Programme already provides a school health package in one of the five project regions.
29 Component 2: Preserving Critical Health Services (US$ 25.0 million)
3. Building on the MSPPII, this component will scale up critical activities to mitigate some of the negative impacts of the crisis on health service delivery to vulnerable populations by addressing supply- and demand-side constraints to accessing services. Resources from the proposed operation will expand geographic coverage from 20 percent of primary health care centers (MSPPII) to 58 percent of all health centers in the targeted regions, and it will enable targeted health centers to expand their coverage to 15 kilometers from the health facility (from 5 kilometers). This component will also protect implementation capacity in the health sector. Specifically, the project will support:
(a) Integrated package for pregnant women and children under five at the health facility level (US$ 20.0 million): For pregnant women, the essential package of services from the first trimester of the pregnancy to the postnatal consultation includes: testing, treatment, and prevention of mother-to-child transmission of HIV/AIDS and syphilis, supplementation with iron and folic acid, tetanus vaccination, intermittent preventative medication against malaria, and distribution of LLINs. The integrated package for children under five will include the promotion of good practices and breastfeeding and nutrition for mothers and children, vitamin A supplementation, vaccinations, distribution of LLINs, treatment of diarrhea with oral rehydration salts and zinc, integrated treatment of childhood diseases (IMCI), and mass treatment against neglected tropical diseases (helminthiasis, bilharzia and filhariasis). In addition, as part of the Ministry of Health’s Stratégie Avancée, health facilities will receive funding to support outreach activities by trained health workers. Financing will support transportation, operational costs, and medical equipment; for example, each health facility will receive a package of the minimum equipment25 required to function. For districts not covered by MSPPII, this subcomponent will finance technical focal points at district level to provide support and supervision to health facilities to ensure effective delivery of maternal and child health services. Finally, as with the ongoing health project, NGOs will be contracted to complement the public health system’s delivery of key interventions to vulnerable populations. The basic package of maternal and child health services can be found in Table 1.
(b) Project management and monitoring and evaluation (US$ 5.0 million): This subcomponent will continue to finance operational costs for the Health PIU as well as supervision costs related to project activities by the PIU and other relevant entities (including supervision costs for the school health and nutrition interventions under the education component). This subcomponent will also contribute to the overall management of the project, including support to the joint technical coordination unit, the PCC. In addition to project management, this subcomponent will support the M&E system to collect timely data from all levels for decision making and monitoring the impact of project activities. In particular, it will scale up the system of rapid data collection via mobile phone that was initiated under the ongoing health project. Periodic surveys to assess program and project implementation will be supported as needed.
25 Includes necessary medical equipment (obstetrical stethoscope, weight balances, blood pressure monitor, neonatal resuscitation equipment, delivery table) and safe delivery kits.
30 Continuing support will be provided for third-party verification of service delivery to target populations. The project will also continue to support the updating of the national MWMP.
Table 1: Minimum package of high-impact, low-cost maternal and child health and nutrition interventions
Children 0–28 days Pregnant women . Exclusive breastfeeding . Insecticide-treated mosquito net . Vaccination . At least 3 antenatal consultations . Management of neonatal infections . Vaccination (tetanus toxoid) . Integrated management of childhood illnesses . Treatment of syphilis in pregnancy . Comprehensive emergency obstetrical care for . Deworming in pregnancy newborns (including intensive care for newborns) . Folic acid Children 1–5 months . Prevention of mother-to-child transmission of . Exclusive breastfeeding HIV/AIDS . Vaccination . Information, Education, Communication (IEC) for . Oral rehydration solution hand washing . Zinc for diarrhoea management At birth . Management of acute respiratory infections . Assisted delivery: Basic emergency obstetric care . Integrated management of childhood illnesses . Clean delivery and cord care Children 6–12 months . IEC for hand washing . Vaccination Lactating women . Vitamin A supplementation . Family planning . Complementary feeding . Vitamin A supplementation . Oral rehydration solution . IEC for hand washing . Zinc for diarrhea management . Management of acute respiratory infections . Management of malaria . Integrated management of childhood illnesses . Insecticide-treated mosquito net Children 12–59 months . Vitamin A supplementation . Management of acute respiratory infections . Management of malaria . Integrated management of childhood illnesses
Component 3: Preserving Critical Nutrition Services (US$10.5 million)
4. Despite significant progress in reducing acute malnutrition prior to the crisis, Madagascar continues to have some of the highest rates of chronic and severe malnutrition in Africa, and the ongoing crisis is reversing over a decade of progress. Seven nutrition interventions26 will be prioritized in the proposed project. The interventions were selected based on evidence from the multi-round impact evaluation in the country, as well as other key studies in nutrition. The activities are consistent with the suite of direct nutrition interventions under the Scaling-Up for Nutrition Initiative supported by the National Action Plan for Nutrition II (Plan National d'Action pour la Nutrition II). These interventions will be delivered largely through
26 They are: (i) growth and development monitoring and promotion; (ii) promotion of nutrition for pregnant women using the life cycle approach; (iii) promotion of vegetable gardens and rich micronutrient products; (iv) support for providing food to vulnerable groups; (v) food fortification; (vi) micronutrient supplementation (iron, folic acid, multi-micronutrient); and (vii) deworming for children 0–5 and pregnant women.
31 community nutrition sites to protect pregnant women and children under five (with intensive focus on children under two) in line with the “continuum of care” approach adopted for the project. In Madagascar, where both malnutrition and stunting affect almost half of children under five, the community-based nutrition approach has proven very effective in reducing the prevalence of underweight in malnourished children. This component will scale up coverage for sites in the targeted regions, which have some of the highest rates of malnutrition in the country. Figure 1 illustrates how the proposed operation will scale up support over MSPPII. In total, Bank resources will support 2,000 community nutrition sites in the targeted regions.
Figure 1: Scaling up support for nutrition under the proposed project and MSPPII
•Support to 1,175 community nutrition sites (58% of all sites) •Add 516 new community Proposed nutriton sites Emergency •Expand geographic coverage from 16% to 50% of project Project areas •Enhance support to 659 sites under Additional Financing
•Support to 659 sites of 1,484 original sites in project areas (44%) MSPPII •Provided geographic coverage of 16% of project areas
5. Specifically, this component will finance:
(a) Basic community nutrition services (US$8.0 million): This component will protect the functioning of the community nutrition sites. It will train community nutrition workers (CNAs); provide nutrition inputs; build capacity for community nutrition workers in community education, counseling services, referrals, regular weighing, and culinary demonstrations; and recruit NGOs to support capacity building for CNAs. The CNAs are responsible for the following in their respective sites:
(a) Monitoring the nutritional status of pregnant women, of children 0–2 years old (First Thousand Days), as well as children between the ages of 2 and 5 years at the community nutrition sites through monthly weigh sessions. Table 2 outlines the specific activities for these age groups.
32 (b) Provide nutrition education sessions on prenatal and antenatal consultations, vaccinations, deworming, malaria, STI prevention and treatment, diet, breastfeeding and other relevant topics. CNAs are also responsible for vitamin A supplementation and more frequent monitoring of high-risk pregnancies through home visits. (c) Keeping records of various activities (weighing, nutrition education, cooking demonstrations, home visits, social mobilization). (d) Supporting household food security through gardening and promoting local product processing and conservation during cooking demonstrations.
Table 2: Activities to monitor nutritional status of children aged 0–2 and 2–5
Support to Children 0–2 Years of Age Support to Children 2–5 Years of Age (First Thousand Days) • Home visits for children 0–2 years • Quarterly monitoring of the nutritional status of children 2–5 years at community nutrition sites through mid-upper arm circumference measurements (MUAC) • Monthly weighing of every child followed by • Monitoring the integral (psychomotor) development counseling for the mother; monitoring the integral of young children (psychomotor) development of young children • Biannual deworming for children 12–23 months • Biannual deworming for all children between 2 and 5 years • Fortified food supplementation for children 6–23 months • Vitamin A supplementation for lactating women and children 6–23 months • Measuring the height of each child (bimonthly)
• Refer sick and/or severely malnourished children to health centers for treatment • Sensitization activities and cooking demonstrations, menu tasting sessions for mothers by the support group during the provision of services to all the children by the community nutrition agents
(b) Project management and monitoring and evaluation (US$2.5 million): This subcomponent will continue to finance operational costs for the community nutrition PIU as well as supervision costs by the PIU and other relevant entities related to project activities, including the ONN and each Regional Nutrition Office (Office Régional de Nutrition, ORN) in the targeted areas. These costs include supervision costs for the school health and nutrition interventions under the education component. The component will also contribute to the overall management of the project, including support to the joint technical coordination unit (PCC) This subcomponent will support project management as well as surveys and evaluations of overall project and program progress to evaluate impact. Similar to the health component, the nutrition component will scale up the use of mobile phones to CNAs not covered under the MSPPII for efficient data collection and real-time resolution of bottlenecks.
6. To ensure sufficient capacity to implement the interventions envisioned Under Components 2 and 3, two selection criteria were used: (i) availability of a functioning health facility and (ii) community nutrition sites referring up to the facility. The total number of key
33 beneficiaries (pregnant/lactating women and children under five) for these two components is approximately 932,900. In addition, the project will support 347 health facilities and 2,000 community nutrition sites, representing nearly 60 percent of all health facilities and 100 percent of community nutrition sites in the intervention areas. This is a 90 percent increase in support to health facilities and nutrition sites over MSPPII (Table 3).
Table 3: Summary of population with access to health and nutrition services
Total population with access to Total population with Total services under the Second access to services under Multisectoral STI/HIV/AIDS the proposed operation Prevention Project Pregnant women 92,323 182,161 274,484 Children under 5 years 328,261 750, 265 1,078,526 Total number of beneficiaries 420,584 932,916 1,353,500
7. Monitoring and Evaluation (M&E) under the Project: The project will support M&E under each component to ensure regular supervision. Timely and regular data collection will be done to measure progress and results, facilitate the integration of lessons learned during implementation, and obtain beneficiary feedback on service delivery. Efforts will include but are not limited to: (i) several types of regular monitoring by the internal auditors of the PIUs; external auditors; and third-party verification agencies, such as NGOs to verify delivery of services; (ii) evaluation of the impact of project activities; (iii) use of available administrative data (for example, from existing management information systems) for decision making; (iv) beneficiary surveys as a feedback mechanism; (v) scaling up of innovations around data collection (such as mobile phone data collection) to enhance the current information systems for baseline and endline evaluation of activities; and (vi) joint data collection with other donors.
34 Annex 2: Results Framework and Monitoring MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
Sector-specific PIUs will undertake M&E for the project. The PIUs will be responsible for the collection, analysis, presentation, and dissemination of progress on their respective indicators. The PCC will be supporting the collation of data from all three PIUs to report (on an annual basis) on overall project progress to the TSC and World Bank and IDA.
The project development objective (PDO) is to preserve critical education, health and nutrition service delivery in targeted vulnerable areas in the recipient’s territory. Cumulative Target Values Unit of Responsib Description PDO Level Results Indicators Core Baseline Data ility for (indicator Measure Year 1 Year 2 Year 3 Frequency Source/Methodology Data definition Collection etc.) Project Development Indicators Cumulative 1. Number of direct project 1,832,592 1,866,624 1,916,726 Project progress (difference Number 0 Annual PIUs beneficiaries27 (of which % 54% 55% 55% Reports increase Y1 female) to Y3) Education
2. Students enrolled in MEN annual school primary schools in Number, 974,300 974,300 974,300 974,300 census (EMIS), Non- Annual DPE/MEN targeted regions28 Percentage 49% 49% 49% 49% Project progress cumulative (of which % female) report
MEN annual school DPE/MEN 3. Total number of schools census (EMIS), Non- 29 Number 0 6,050 6,050 6,050 Annual , PIU receiving school grants Project progress cumulative Education funded by the project report
27 Direct project beneficiaries for education, health and nutrition 28 Students enrolled in primary public schools which receive school grants and payment of teacher salaries funded by the project. 29 The number of public primary schools can vary slightly from year to year due to school closures and openings.
35 Health and Nutrition 4. People with access to a Yearly basic package of health, Number of Number, PIU nutrition, or reproductive pregnant/lactating 0 172,373 177,199 182,161 Annual Project reports cumulative health Health (difference women services(number)30 increase Y1 to Y3) Yearly Number, Number of PIU cumulative 0 709,951 729, 830 750, 265 Annual Project reports children under 5 Health (difference increase Y1 to Y3) Health cumulative 5. Birth (deliveries) attended (difference by skilled health Project progress PIU Number 0 3,000 6,900 12,600 Bi-annual increase Y1 personnel in project report Health to Y3) areas (number)31 Absolute number 6. Children immunized Project progress PIU increase to 32 Number 0 3,600 11,600 18,300 Bi-annual (number) report Health baseline, cumulative Nutrition 7. Children under the age cumulative Number of 24 months benefiting (difference Children PIU from improved infant 70,160 107,100 135,660 164,220 Bi-annual Project reports increase Y1 Between 0 and Nutrition and young child feeding to Y3) 24 months (IYCF) practices
30The project will be providing a standardized basic package of services as defined in Annex 1 of the document which are currently not available comprehensively at health facility and community level. Therefore, the baseline is 0. 31 To evaluate access to quality delivery care at health facility level 32 To evaluate access to child health services; Full immunization package: children immunized to DTC3HepB3Hib3, children 0-11months.
36 Intermediate Results Indicators (Education) 8. Number of community Project progress PIU Non- teachers certified to be in Number 0 10,000 10,000 10,000 Annual service paid33 report Education cumulative Project progress PIU Non- of which % of female Percentage 49% 49% 49% 50% Annual report Education cumulative 9. School grants paid by the Project progress PIU Non- Percentage 0 80% 85% 95% Annual project on time34 report Education cumulative 10. Number of children cumulative receiving anti-helminth Project progress PIU (difference Number 0 429,000 663,960 667,944 Annual treatment (school age report Education increase Y1 children) to Y3) 11. Number of parents' associations / school management committees Project progress PIU Number 0 3,000 6,050 6,050 Annual Cumulative trained on teacher report Education accountability process and use of school grants year 12. Number of teachers trained cumulative in school health and Project progress PIU (difference Number 0 3,000 3,750 3,750 Annual nutrition activities report Education increase Y1 to Y3) Intermediate Results Indicators (Health) 13. Pregnant women receiving cumulative antenatal care during a visit Number PIU (difference 0 5,855 12,953 18,283 Annual Project reports to a health provider35 Health increase Y1 to Y3) 14. Health facilities Cumulative PIU constructed, renovated, Number 0 347 347 347 Annual Project reports Health and/or equipped36
33 Every two months, a certification of service for community teachers is issued and signed by the teacher, parents’ association and school director; and submitted to the subsequent levels of the administrative chain. 34 School grants paid on time is defined as the first quarter of the school year, i.e. October – December. 35 To evaluate access to maternal health services and by collecting the number of pregnant women receiving at least one antenatal care during a visit to a health provider. PIU will collect data on pregnant women receiving antenatal care before four months of pregnancy. This will illustrate the close collaboration between the health and nutrition sector with the referral process.
37 15. Number of syphilis cumulative treatments distributed to (difference PIU pregnant women in public Number 0 525 1,640 2,650 Annual Project reports increase Y1 Health health centers in project to Y3) areas (number) 16. Percentage of facilities Cumulative Project Progress PIU visited by the district Percentage 0 85% 90% 95% Quarterly report Health technical assistants Intermediate Results Indicators (Nutrition) 17. Number of children under Cumulative 2 years enrolled in the Project progress PIU (difference Number 140,319 153,000 193,800 234,600 Bi-annual growth monitoring report Nutrition increase Y1 program 37 to Y3). 18. Number of children Cumulative enrolled in the MUAC38 Project progress PIU (difference Number 207,368 263,500 302,200 341,000 Quarterly program between 2-5 report Nutrition increase Y1 Years of Age to Y3). 19. Number of Community Cumulative Nutrition Agents trained to Project progress PIU Number 1,484 1,800 2,000 2,000 Annual provide health and report Nutrition nutrition education 20. Percentage of Nutrition Cumulative sites Monthly Report Project progress PIU submitted within + 5 days Percentage 65 85 90 95 Bi-annual report Nutrition of the end of the month through mobile phones Cumulative 21. Number of schools Project progress PIU (difference supported by ACN during Number 0 2,000 2,500 2,500 Bi-annual report Nutrition increase Y1 de-worming sessions to Y3)
36 Health facilities will receive equipment needed to provide the essential package of basic health services. This will include necessary medical equipment (obstetrical stethoscope, weight balances, blood pressure monitor, neonatal resuscitation equipment, delivery table) and safe delivery kits. 37 To evaluate the coverage of the growth monitoring and the efficacy of project nutrition sites promotion activities 38 Quarterly monitoring of the nutritional status of children 2-5 years community nutrition sites by measuring the Mid-Upper Arm Circumference (MUAC)
38 Annex 3: Summary of Estimated Project Costs
MG–Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
Amount of the Credit Category Allocated (in US$ m)
Component 1: 23.50 Preserving Critical Education Services
Component 2: 25.00 Preserving Critical Health Services
Component 3: 10.50 Preserving Critical Nutrition Services
Unallocated 6.00 Total Amount 65.00
39 Annex 4: Operational Risk Assessment Framework MG–Emergency Support to Critical Education, Health and Nutrition Services Project (P131945) (BOARD)
1. Project Stakeholder Risks 1.1 Stakeholder Risk Rating Substantial Description: Risk Management: The focus on select geographical regions may • Five regions, namely Androy, Atsimo Atsinanana, Vatovavy Fitovinany, Haute Matsiatra, and Amoron‘i Mania, cause complaints in the non-selected regions have been selected on the basis of (i) poverty and social indicators (to ensure activities reach the most vulnerable, and prompt a backlash from civil society based on the 2011 poverty map); (ii) other donor interventions (to avoid overlap); and (iii) the existing health organizations. This would pose a reputational operation financed by the International Development Association (IDA) (to optimize synergies). risk. • Interventions by other donors in education, health and nutrition—(e.g. the European Union, United Nations Children’s Fund (UNICEF), and the French Development Agency (AFD)—have been centered on other regions and/or other interventions. • The design ensures interventions address the most urgent needs and avoid any duplication of future funding that may become available for the sector.
Low beneficiary capacity may pose a risk to • The project design includes activities to strengthen capacity and accountability mechanisms at school and health accountability and effective use of inputs facility levels. Activities will include, for example, training and school reports cards to reinforce the role of funded by the project, and to achievement of school-based management committees (which include parents, teachers, and directors) and community scorecards the (PDO). for health, among others.
Current persisting political crisis discourages • For the medium to long term, policy dialogue on these issues is planned as part of sector strategy development, donor participation and active dialogue with the based on extensive analytical work. This should contribute to alleviating the grievances expressed. government. • Updating of policy documents and strategies for reform is ongoing, namely the National Health Policy (PNS), Potential strikes across the health and education Health Sector Development Plan (PDSS), and Medium Term Expenditure Framework (MTEF). Pending the sectors may pose a considerable risk to project strategy and framework, the health sector has an Interim Operational Plan 2012–13, which includes partner performance and the implementation timeline. interventions. Prioritization of activities may be an issue in • The project design and objectives to be achieved are aligned with the existing strategic plan and with the national the health and nutrition sectors. Millennium Development Goal (MDG) targets, namely MDGs 1b, 4, and 5. Moreover, priority interventions being implemented under the Additional Financing (AF) will be expanded under this operation to increase coverage under the new project. Resp: Both Stage: Both Recurrent: Due Frequency: Status: In Date: Progress
40 3.Implementing Agency Risks (including fiduciary) 3.1 Capacity Rating Moderate Description: Risk Management:
• Keep project design, results framework, and M&E arrangements as simple as possible. Overall relatively weak accountability • The project design includes capacity strengthening at the local community level as well as the local and regional mechanisms and limited capacity for levels. implementation at the central and decentralized • Three PIUs are already staffed with the relevant experts. They have extensive experience with projects financed levels, especially for monitoring and evaluation by IDA and other donors and a good track record in fiduciary and M&E aspects as well as overall project (M&E). management.
Resp: Both Stage: Both Recurrent: Due Frequency: Status: Date:
Risk Management:
Procurement capacity:
Procurement capacity and potential delays in • Procurement for the education component is very limited and small scale. Procurement capacity will be recruiting nongovernmental organizations strengthened through training. The Health and Nutrition PIUs have extensive experience with procuring NGOs, (NGOs) may delay the delivery of critical and preparations for initiating the recruitment process for NGOs will start well in advance of effectiveness to education and health interventions. avoid delays.
Resp: Both Stage: Both Recurrent: Due Frequency: Status: Date: 3.2 Governance Rating Substantial Description: Risk Management:
• IDA will continue to support intensive technical dialogue. Resumption of governance activities will also The project will operate under a de facto contribute to addressing key issues on governance. It is expected that the existing PIUs, even though created by government lacking sound accountability the government under its authority, will in practice continue to remain relatively autonomous from the mechanisms and having weak institutional government. In addition, the PIUs are subject to the Bank’s oversight, given the obligation to follow Bank capacity at the central and local level. This procedures and guidelines. Funds will benefit target communities and the decentralized levels. The project environment could increase governance risks intends to use existing central government information systems (data collection) and contribute to capacity- for the project (for example, potential political building activities. Governance and social accountability activities and tools will be integrated in all components, interference in project management). including for instance the training of school-based management committees on the use of school grants and the
teacher accountability process, use of mobile phone technologies for data collection in health, third-party
verification, and so on.
41 Resp: Both Stage: Imple Recurrent: Due Frequency: Status: Not Yet mentat Date: Due ion
Risk Management: There is a considerable risk that the implementation of all components will be • Though the project implementation arrangements emphasize a light, multi-sectoral, overarching supervision and stalled if one PIU/component is encountering coordination structure across components and PIUs, each of the PIUs will be functioning independently of the implementation delays or governance issues. other PIUs—it will have its own Designated Account and funds for project management—which should Potential lack of coordination across the three contribute to alleviating this risk. different PIUs is a risk which could affect • The establishment of and supervision by a Technical Steering Committee (TSC) with representation from the project performance. three sectors as well as the Ministry of Finance will serve to mitigate this risk. A small Project Coordination Cell (PCC), consisting of 1–2 staff responsible for reporting and supporting the TSC across the three PIUs, will be contracted by the government. • Regular meetings between the coordinators of the PIUs to coordinate, share information, and prepare the meetings/reporting to the TSC will be part of the institutional arrangements. • The project design includes activities such as school health as well as cross-cutting program management functions (for example, external audits) on which the PIUs will work together, thus establishing a habit of collaboration and information sharing, which would translate into the project coordination overall. Moreover, the Ministry of Education, the Ministry of Health, and the National Office of Nutrition have collaborated on activities together. Thus overall links between the social sectors are already well established. Moreover, the design includes an unallocated category to facilitate the reallocation of resources among project components if necessary. Resp: Both Stage: Imple Recurrent: Due Frequency: Status: Not Yet mentat Date: Due ion Risk Management: • The Bank will continue to support the country through intensive dialogue at the technical level. The restructured Governance Project will also help address key issues on governance and public sector capacity. In addition, the availability of grievance mechanisms through structures at the community level, such as health and school committees, will help monitor potential governance issues. • Current PIUs have considerable experience and a good track record of IDA project implementation, and no major risks are foreseen in this regard. Well-qualified fiduciary staff members are already in place, as are the necessary procedures manuals and software. • Supervision and spot checks by local school inspectors, technical health coordinators at the regional level, and nutrition regional focal points will continue to be implemented at the decentralized levels. The internal audit departments of all the PIUs will be charged with conducting continuous reviews to enable timely detection and resolution of internal control weaknesses. • There will be third-party verification of results by an independent agency. Regional and district education,
42 health and nutrition focal points will continue their monitoring and supervision roles. Resp: Both Stage: Imple Recurrent: Due Frequency: Status: Not Yet mentat Date: Due ion 4. Project Risks 4.1 Design Rating Moderate Description: Risk Management:
• The project design is kept simple by: (i) only including a very limited number of priority activities for each The project is multi-sectoral and thus more sector; and (ii) providing support mostly to existing interventions (for example, school grants, community complex by nature, since it involves many nutrition sites, package of maternal and child health services) for which implementation mechanisms are well different activities and coordination among a established and functioning. multitude of stakeholders. • All relevant stakeholders were consulted at various stages during the design and there is a clear assignment of
roles and responsibilities for implementation.
• Capacity-building activities will be provided to regional and local education, health and nutrition personnel and to
communities to ensure effective delivery and use of services. The design of the project builds on experiences and
reflects lessons learned from past education, nutrition, and health programs.
If one project component is not performing well • Indicators were chosen to ensure that the overall rating is not dependent on just one aspect of the project. In on implementation, PDO achievement, and so addition, a coordination mechanism will be put in place between the various components and subsectors to ensure on, it would negatively affect the performance progress is made along the various dimensions of the project. and rating of the entire project, even if other Moreover, the design includes an unallocated category to facilitate the reallocation of resources among project components are performing well, given that the • components if necessary, success of the project depends on all three sectors being able to move forward in a parallel manner.
• Proposed target areas were confirmed during preparation to ensure that resource allocation would focus clearly on
high-risk areas. A clear set of criteria for identifying communities, schools, and health facilities was defined to The project focuses on geographical regions ensure adequate minimum capacity to implement activities. At the regional and district levels, implementation with high poverty and low nutrition, health, and capacity is adequate due to support from other donors in the form of operational costs that complement education outcomes to benefit the most government resources. The project will also cover additional incremental supervision costs for central and vulnerable populations. This fact could imply a regional offices to ensure adequate monitoring of activities. higher risk that these communities and local agents do not have adequate capacity to Resp: Both Stage: Both Recurrent: Due Frequency: Status: implement activities. Date:
Risk Management: The EU and UNICEF have been financing
43 similar activities in other regions in the • The project team will work closely with the EU and UNICEF to ensure coherence of approaches. education sector. Approaches might be Resp: Both Stage: Both Recurrent: Due Frequency: Status: different, resulting in possible confusion and Date: coordination issues among teachers/education officials at the local level. Risk Management:
• A cash on delivery arrangement will be introduced in contracting rather than commitment prior to delivery, with The public health sector uses SALAMA, the the aim of ensuring that drugs are delivered in a timely manner to the health facility level. National Drug Procurement Agency. This choice may hamper the efficient distribution of standard drugs and medical supplies in the short Resp: Both Stage: Both Recurrent: Due Frequency: Status: term. Date: 4.2 Social and Environmental Rating Low Description: Risk Management: The potential environmental risks associated • Resources will contribute to the implementation of the Medical Waste Management Plan (MWMP) of the with medical waste management apply, given ongoing Second Multisectoral HIV/AIDs Project. The implementation to date has been rated Satisfactory by the that the activities support the provision of Bank. The Integrated Safeguards Data Sheet has been updated based on implementation progress of the MWMP inputs such as medical equipment and and has been disclosed. materials. Therefore, OP/BP 4.01 for the Resp: Client Stage: Imple Recurrent: Due Frequency: Status: Not Yet management of medical waste is triggered. mentat Date: Due
ion
Risk Management: The task team developed an ESSAF that would • The Borrower has embarked on a peaceful reinstatement of democracy and safety in the country. Though the be further supported by the individual incidence and effects of disasters remain unpredictable, the project has chosen to ensure proper subproject safeguards instruments built upon handling/treatment of medical and pharmaceutical wastes. Additionally, it has developed, to the ESSAF, an the existing project safeguards documents. appropriate safeguard instrument (MWMP) for potential social and environmental impacts, including possible Given the political economy uncertainty in the repair/rehabilitation of facilities and medical waste management. country, along with the recurrent disaster- related impacts, the risk remains of not properly • Finally, to ensure both social accountability and sustainability of medical/pharmaceutical waste management, the implementing all the proposed Borrower will ensure that a systematic public consultation and participation process is implemented for adequate recommendations. decision making.
Resp: Gover Stage: Imple Recurrent: Due 06/30/2013 Frequency: Status: Ongoing nment mentat Date: ion 4.3 Program and Donor Rating Substantial
44 Description: Risk Management: Several external donors withdrew their support • Throughout the crisis, IDA continued to participate in the technical dialogue in each of the three sectors as part of as a result of the political situation, which had a the regularly occurring consultations with other donors. The dialogue helped ensure that IDA interventions would negative impact on the health, nutrition, and address the most urgent needs and complement interventions of other external partners, such as the EU, United schooling of the population, given that States Agency for International Development (USAID), Norway, UNICEF, AFD, and others. For example, in Madagascar largely depends on external education, IDA has been very engaged in the technical dialogue with the government as part of the dynamic resources for these sectors (for example, donors Local Education Group led by UNICEF. IDA has been leading technical support to the government for the financed 70 percent of health and 80 percent of preparation of its education sector plan, with a view to request funds from the Global Partnership for Education education spending). (GPE) in 2013. In health and nutrition, IDA conducted discussions with other donors to assess their degree of involvement in the short and medium term, ensure interventions address the utmost needs, and avoid any duplication of future funding. At the technical level, the PTF for health and nutrition remains in place, and coordination through this mechanism has started to be revitalized. The proposed project could become a catalyst for attracting other donors (AFD, EU) to support the social sectors in the short and medium term. Resp: Bank Stage: Both Recurrent: Due Frequency: Status: Date: 4.4 Political Interference Rating Substantial In the current political context, there is a Risk Management: heightened overall risk of political interference, which could impact the implementation and • At the project level, past positive experiences and the established relationship of trust between the Bank and the performance of the project overall. But more staff of the PIU will help defend the project against political interference. In addition, in the more recent past, the specifically, it could severely hinder the Bank was able to defend effectively against attempted interference at the project level. provision of services and inputs to direct beneficiaries. • At the activity level, the following measures will contribute to mitigating potential political interference: (i) strong involvement of direct beneficiaries in project activities through existing social accountability structures at the community level, such as health facility committees and school management committees: (ii) existing grievance mechanisms through these structures, as well as the local and regional administrative structures, among others; (iii) beneficiary surveys; and (iv) capacity-strengthening activities for communities to enhance governance, such as training in the teacher accountability process. Resp: Bank Stage: Both Recurrent: Due Frequency: Status: Date: 4.5 Delivery Monitoring and Sustainability Rating Substantial Description: Risk Management:
Delivery monitoring: Delivery monitoring: • The availability of data will be strengthened through: (i) planned MDG survey and Multiple Indicator Cluster Weak capacity for M&E at the local level. Data Survey (MICS); (ii) a series of studies on the impact of the crisis in health and education, among other analytical availability and quality still present a problem work by the World Bank and the other external partners; (iii) data collection by the project. The formulation of
45 in some instances. In health in particular, given the PDO and project performance indicators is also based on the availability of existing administrative data. the weak Health Management Information • Use of innovative data collection/verification methods, such as mobile phone applications; spot checks by NGOs Systems, reliability of data collected may or community-based organizations. become an issue.
With the ongoing political crisis, there is a lack • IDA will continue to support intensive technical dialogue. Resumption of governance activities will also of clear accountability and supervision contribute to address key issues on governance. Several governance and social accountability activities and tools mechanisms. will be integrated through the project. Examples include the training of school-based management committees on the use of school grants, and on teacher accountability processes, and ensuring the delivery of critical services directly to beneficiaries through NGOs.
Resp: Bank Stage: Recurrent: Due Frequency: Status:
Date: Sustainability: The government depends heavily on external Risk Management: resources, but funding needs are unmet due to Sustainability: unpredictability in funding. While the proposed • Over the short term, this project aims to protect as much as possible the delivery of basic social services to the project, in combination with other donor and most vulnerable people, but on its own it cannot address systemic sustainability issues. The question of IDA support (such as the GPE for education sustainability will be addressed in the dialogue with the government on longer-term priorities as the political and the IDA-supported AF in health) will help situation starts to normalize but should not be seen as one of the objectives for this period of financing. improve the situation for a small segment, sustainability cannot be guaranteed unless other Resp: Bank Stage: Recurrent: Due Frequency: Status: donors participate and operations resume. Date: 5. Overall Risk Implementation Risk Rating: Substantial Description: The decision meeting confirmed the proposed implementation risk as Substantial.
46 Annex 5: Financial Management and Disbursement Arrangements MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
Introduction
1. A financial management (FM) assessment was undertaken to evaluate the adequacy of the project arrangements in accordance with the Financial Management Practices Manual as issued by the Financial Management Sector Board on 1 March 2010. The assessment covered the three implementing agencies that comprise the Education Technical Support Unit (UAT-EPT), Health Program Management Unit (UGP-Santé), and the National Community Nutrition Program (PNNC). UAT-EPT is currently responsible for implementing the Education for All Initiative (Global Partnership for Education) funding, for which the Bank was the supervising entity prior to the 2009 crisis; UAT-EPT was also the implementing agency for the World Bank-financed CRESED (Education Sector Reinforcement Credit) project, closed in 2005. UGP-Santé has been managing Bank-funded projects for over 10 years and is currently the implementation unit for the Second Multisectoral HIV/AIDS Project financed by the World Bank in addition to several other donor resources, while PNNC implemented the Bank-funded Nutrition Project, a 12-year program that closed in July 2011.
2. All the PIUs have considerable experience in the management of Bank-funded projects, and their FM arrangements are assessed as acceptable to IDA. The overall FM risk rating is Moderate.
Financial Management Arrangements for the Project
(a) Budgeting and planning: The PIUs will prepare the annual budgets for their respective components, which will subsequently be consolidated by the PCC prior to approval by the TSC. The PIUs will be responsible for producing variance analysis reports comparing planned to actual expenditures on monthly and quarterly bases. The periodic variance analysis will enable the timely identification of deviations from the budget. These reports will be part of the IFRs that will be submitted to the Bank on a quarterly basis.
(b) Accounting software: The PIUs will use their existing TOMPRO and SIG accounting software as a basis for preparation and consolidation of the quarterly IFRs and the annual financial statements.
(c) Internal controls/FM Procedures Manual: The PIUs will amend their existing FM Procedures Manuals to meet the requirements of the multi-sectoral project. The implementing entities will periodically review the manual over the project’s life to ensure its continued adequacy and ensure compliance with the requirements set out therein.
(d) Internal audit: The PIUs all have internal audit departments, which will prepare quarterly reports for submission to the TSC. The internal audit department will perform an objective assurance function and will not be involved in carrying out operational tasks to ensure their independence in executing their work.
47 (e) Financial reporting: The PIUs will prepare quarterly unaudited IFRs for the project in form and content satisfactory to the Bank, which will be submitted to the Bank within 45 days after the end of the quarter to which they relate. The project will prepare and agree with the Bank on the format of the IFRs and the annual financial statements will be prepared using International Public Sector Accounting Standards. At the end of each fiscal year, the project will prepare annual financial statements using the format for the existing projects. (f) Staffing: The PIUs will retain the existing FM personnel who have experience in the management of Bank-funded projects and are conversant with Bank FM procedures and requirements.
Disbursement Arrangements and Flows of Funds
3. Flows of funds—Designated Account. Each PIU will open a Designated Account (DA) in a commercial bank acceptable to IDA denominated in US dollars to enable payment of eligible project expenditures. Interest income received on the DA will be deposited into the project account. Additional advances to the DA will be made on a monthly basis against withdrawal applications supported by Statements of Expenditures (SOE) or other documents as specified in the Disbursement Letter.
4. Disbursement arrangements. Disbursements for this project will be transaction based. Upon the effectiveness of the financing, and provided that no disbursement conditions need to be fulfilled, each implementing agencies will submit a withdrawal request for an initial advance up to ceiling amount specified in the Disbursement letter (DL). Subsequent disbursements will be made on a monthly basis against submission of the SOE and other additional documents as specified in the DL. All other disbursement methods are described in the DL which may be subject to periodic updates.
5. Retroactive Financing. For payments made prior to the date of this Agreement, except that withdrawals up to an aggregate amount not to exceed SDR 4,600,000 (approximately US$7,000,000 equivalent) may be made for payments made prior to this date but on or after December 1, 2012, for Eligible Expenditures.
6. The Credit will disburse 100 percent of eligible expenditures (inclusive of taxes). The proceeds of the Credit have been allocated as follows in Table 1.
48 Table 1: Allocation of Credit proceeds Amount of the Credit Percentage of Expenditures Category Allocated to be Financed (expressed in SDR) 1) Minor Works, goods, consultants services, non-consulting services, including Operating Costs and Training under 5,350,000 100% Component 1 of the Project, excluding Sub-Grants and Teacher Subsidies
2) Teacher Subsidies 5,850,000 100% of amounts disbursed
3) Sub-Grants to Schools 4,100,000 100% of amounts disbursed
4) Minor Works, goods, consultants services, non-consulting services, including 16,200,000 100% Operating Costs and Training under Component 2 of the Project 5) Minor Works, goods, consultants services, non-consulting services, including 6,800,000 100% Operating Costs and Training under Component 3 of the Project
6) Unallocated 3,900,000 100%
TOTAL AMOUNT 42,200,000
7. Disbursement of funds to service providers, contractors, and suppliers. The PIUs will make disbursements to service providers, contractors, and suppliers of goods and services for specified eligible activities under the Credit. Payments will be made on the basis of the terms and conditions of each contract.
Funds Flow Diagram
World Bank
UAT-EPT UGP-Santé U-PNNC
Designated Account Designated Account Designated Account
UAT-EPT UGP-Santé PNNC Project Account Project Account Project Account
Contractors and Suppliers of goods and services
49 8. External audit: The project accounts will be audited annually and a report submitted to the World Bank no later than six months after the end of each financial year. The terms of reference and recruitment of the project external auditor will be finalized no later than December 31, 2013. At the time of this appraisal, there is no overdue audit report for the sector. The project will comply with the Bank disclosure policy on audit reports; for example, promptly after receipt of all final financial audit reports (including qualified audit reports), it will make them publicly available and place the information provided on the official website within one month of the report being accepted as final by the Bank.
9. Supervision plan: Based on the current overall residual FM risk and the multi-sectoral approach to this operation, the project will be supervised at least twice a year, in addition to routine desk-based reviews, to ensure that the project’s FM arrangements operate as intended and that funds are used efficiently for the intended purposes.
10. FM risk assessment and mitigation. The Bank’s principal concern is to ensure that project funds are used economically and efficiently for the intended purpose. Assessment of the risks that the project funds will not be appropriately used is an important part of the FM assessment work. The risk comprises two elements: (i) the risk associated with the project as a whole (inherent risk) and (ii) the risk linked to a weak control environment with regard to project implementation (control risk). The content of these risks is described in Table 2.
Table 2: Risks, mitigating measures, and residual risk Conditions Risk Risk-mitigating Measures for Residual Risk Rating Incorporated into Project Design Effectiveness Risk (Y/N) Inherent risk S S Country level: The Public The implementation of public FM Expenditure and Financial reform has stalled owing to the limited Accountability reports donor engagement with the de facto identified critical public S government. The continued use of N S financial management (FM) standalone Project Implementation weaknesses at central and Units (PIUs) will mitigate these decentralized levels weaknesses. Entity level: The implementing The PIUs will retain the existing FM entity may not be able to meet M personnel that possess adequate N M the FM requirements due to experience and competence. lack of FM capacity The PIUs will comply with the internal control processes as set out in Project level: The resources of the respective FM Procedures the project may not be used for M Manuals. The internal audit units will N M the intended purposes. also continuously review the adequacy of internal controls and make improvement recommendations. Control risk M M Budgeting: Weak budgetary The FM Procedures Manuals will execution and control leading spell out the budgeting and budgetary to budgetary overruns or M N M control arrangements to ensure inappropriate use of project appropriate budgetary oversight. funds.
50 Conditions Risk Risk-mitigating Measures for Residual Risk Rating Incorporated into Project Design Effectiveness Risk (Y/N) The PIUs will retain suitably qualified Accounting: The accounting and experienced FM personnel to function might not be able to ensure appropriate performance of the execute its duties and to M accounting and FM functions. The N M generate financial information financial reporting processes will also in a timely manner. be facilitated by the existing information systems. Internal Control: Specific The FM Procedures Manuals will be aspects of the project activities reviewed to ensure continuing may not be appropriately M N M adequacy over the course of the addressed in the FM Procedures project’s life. Manuals. The rigorous review of all transactions prior to final payment will be performed by the Project Coordinator Funds Flow: Risk of misused M and the Finance Manager. Internal N M and inefficient use of funds. audit reviews will also mitigate the risk of the use of funds for unintended purposes. The existing FM staff are Financial Reporting: The appropriately experienced in financial project may not be able to reporting and are conversant with the produce the financial reports related Bank requirements. All the M N M required in a timely manner as PIUs have computerized accounting required for project monitoring systems that will enable the efficient and management and timely generation of financial information. An independent external audit firm will be hired by the project with Auditing: Delays in submission regard to the audit submission of audit reports or delays in timelines set out in the financing implementing the M N M agreement. The Bank will monitor recommendations of the audit submission compliance and management letter. ensure implementation of management letter recommendations. Governance and Robust FM arrangements (including a Accountability: Possibility of comprehensive annual audit of project corrupt practices including accounts, Bank FM supervision that bribes, abuse of administrative M includes a review of transactions and N M and political positions, asset verification) designed to mitigate misprocurement and misuse of the fiduciary risks in addition to the funds, among others, are a PIUs’ overall internal control systems. critical issue. OVERALL FM RISK M M
11. The overall FM risk rating, taking into account the mitigation measures, is deemed Moderate.
Financial Management Action Plan
12. The Financial Management Action Plan described in Table 3 has been developed to mitigate the overall FM risks.
51 Table 3: Financial Management Action Plan Responsible Completion Effectiveness Issue Remedial Action Recommended Entity Date Conditions Preparation of the Terms of Reference December 31, External auditing All PIUs No and recruitment of the external auditor 2013 3 months Procedures Amendment of the FM Procedures No All PIUs following Manuals Manuals effectiveness
List of conditionalities and covenants
(i) FM effectiveness conditions: • There is no FM condition of effectiveness
(ii) Financial covenants / Dated covenants • Engagement of independent auditors for the carrying out of the audits of the Recipient’s financial statement (by December 31, 2013)
(iii) Other FM standard covenants • IFRs will be prepared on a quarterly basis and submitted to the Bank 45 days after each quarter. • Annual detailed work program and budget, including disbursement forecasts, will be prepared and approved by the Steering Committee each year by November 30. • The overall FM system will be maintained operational during the project’s entire life in accordance with sound accounting practices.
52 Annex 6: Procurement Arrangements
MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
A. General
1. Madagascar is in the process of major procurement reforms. A new Procurement Code was passed by the Parliament and the Senate and became effective in July 2004. The main pillars of the code are transparency, efficiency, and economy; accountability; equal opportunity for all bidders; prevention of fraud and corruption; and promotion of local capacity. The Procurement Code was supplemented by regulations, procedures manuals, and standard bidding and other procurement documents. The Procurement Code defines methods of procurement and review procedures. The Code also created (i) the Public Procurement Oversight Authority (Autorité de Regulation des Marchés Publics, ARMP) in 2006, which includes oversight of the National Tender Board (Commission National des Marchés, CNM) for procurement reviews and the Regulatory and Appeals Committee (Commission de Regulation et de Recours, CRR) for the handling of complaints and norms. Finally the Code provides for the creation of procurement units (Unité de Gestion de la Passation de Marchés, UGPM), under the leadership of a Personne Responsible des Marchés Publics (PRMP), and a Tender Committee (Commission d’Appel d’Offres, CAO) in each ministry, and decentralized departments of national public institutions.
2. The Procurement Code is generally consistent with good public and international practices and includes provisions for: (i) effective and wide advertising of upcoming procurement opportunities (general procurement notice for each procuring entity and ARMP website); (ii) public bid opening; (iii) pre-disclosure of all relevant information, including transparent and clear bid evaluation and contract award procedures; (iv) clear accountabilities for decision making; and (v) an enforceable right of review for bidders when public entities breach the rules. The Country Procurement Assessment Report (CPAR) was submitted to government and adopted in June 2003. The action plan of the CPAR was agreed upon with government during the December 2003 CPAR mission and workshop. During the preparation of Poverty Reduction Support Credits 2 to 6, four key ministries (education, health, transport, and agriculture) were assessed on the application of the new procurement code provisions, with these assessments being used as triggers from one Poverty Reduction Support Credit to the next.
3. The government has proposed to delegate project management including procurement responsibilities to the respective Health, Nutrition, and Education PIUs, which have similar experience under the previous projects financed by the Bank. The agencies are very experienced with the Bank’s procurement procedures. Their existing Procurement Manuals were approved by the Bank and are being updated to specific project needs. The agencies will update the preliminary procurement plans that have already been submitted for the first six (6) months of project implementation. The PIUs will procure some drugs and nutrition supplements via SALAMA (the National Drug Procurement Agency), on the basis of an agreement that will be signed, with prior review of the Bank, between the PIUs and that Agency. The use of the United Nations Office for Project Services (UNOPS) on the basis of agreement with the United Nation would be envisaged for vehicle purchases, if any.
53 4. Guidelines. In general, Madagascar’s Procurement Code and regulations do not conflict with IDA guidelines.
5. The procurement for the proposed project will be carried out in accordance with: (i) the World Bank’s “Guidelines: Procurement of Goods, Works and Non-consulting Services under IBRD Loans and IDA Credits and Grants by World Bank Borrowers” published by the Bank in January 2011; (ii) “Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits and Grants by World Bank Borrowers” published by the Bank in January 2011; and (iii) the provisions of the Financial Agreement. Furthermore the Guidance Note to World Bank Staff, “Rapid Response to Crises and Emergencies— Streamlined Procurement Procedures” (June 2009) will also guide procurement.
6. Anti-corruption guidelines. The “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants,” dated October 15, 2006 and updated in January 2011, shall apply to this project.
7. Procurement Documents. Procurement transactions will be carried out using the Bank’s Standard Bidding Documents or Standard Request for Proposal, respectively for all International Competitive Bidding (ICB) and National Competitive Bidding (NCB), for goods and for selection of consultants. For NCB, the Borrower could submit a sample form of bidding documents to the Bank for prior review and will use this type of document throughout the project once agreed upon. The Sample Form of Evaluation Reports published by the Bank will be used. For certain procurement activities that need rapid responses, especially in emergency situations, the very simple sample documents in the annexes of the Note to World Bank Staff, “Rapid Response to Crises and Emergencies—Streamlined Procurement Procedures” (June 2009), will be used.
8. Retroactive Financing. The proposed amount of retroactive financing will be US$7 million. Only project activities incurred on or after December 1, 2012 (that is, after Board approval) will be eligible for reimbursement through retroactive financing. Payments will be for items procured in accordance with applicable Bank procurement. Disbursements will be subject to expenditures meeting the requirements of retroactive financing as outlined in OP 6.0, Bank Financing, and paragraph 2(e).
B. Advertising Procedure
9. General Procurement Notice (GPN), Specific Procurement Notices (SPN), Requests for Expression of Interest (EOI), and results of the evaluation and contracts award should be published in accordance with advertising provisions in the following guidelines: “Guidelines: Procurement under IBRD Loans and IDA Grants,” dated January 2011, and “Guidelines: Selection and Employment of Consultants by World Bank Borrowers,” dated January 2011. The borrower will keep a list of responses received from potential bidders interested in the contracts.
10. For ICB and request for proposals that involve international consultants, the contract awards shall be published in UNDP online and in dgMarket within two weeks of receiving IDA’s "no objection" to the recommendation of contract award. For Goods, the information to publish shall specify: (i) name of each bidder who submitted a bid; (ii) bid prices as read out at bid opening; (iii) name and evaluated prices of each bid that was evaluated; (iv) name of bidders whose bids were rejected and the reasons for their rejection; and (v) name of the
54 winning bidder and the price it offered, as well as the duration and summary scope of the contract awarded. For Consultants, the following information must be published: (i) names of all consultants who submitted proposals; (ii) technical points assigned to each consultant; (iii) evaluated prices of each consultant; (iv) final point ranking of the consultants; and (v) name of the winning consultant and the price, duration, and summary scope of the contract. The same information will be sent to all consultants who submitted proposals. The other contracts should be published in the national gazette periodically (at least quarterly) and in the format of a summarized table covering the previous period with the following information: (i) name of the consultant to whom the contract was awarded; (ii) the price; (iii) duration; and (iv) scope of the contract.
C. Procurement Methods
11. Procurement of Works. Though the project does not plan to finance any Works at this point, it will nevertheless include the option of financing minor Works as a provision for all components, to provide the necessary flexibility (for example, to respond rapidly to natural disasters such as a cyclones, which are common in some of the project areas).
12. Procurement of Goods. The Goods to be financed by IDA would include: drugs and nutrition supplements, medical equipment as well as office furniture and equipment, office supplies, and so on. Similar Goods that could be provided by the same vendor would be grouped in bid packages estimated to cost at least US$500,000 per contract and would be procured through ICB. Contracts estimated to cost less than US$500,000 equivalent may be procured through NCB. Goods estimated to cost less than US$50,000 equivalent per contract may be procured through shopping procedures. For shopping, contracts will be awarded following the evaluation of bids received in writing on the basis of written solicitation issued to several qualified suppliers (at least three) who have a physical shop of the concerned goods. The award would be made to the supplier with the lowest price, only after comparing a minimum of three quotations open at the same time, provided the supplier has the experience and resources to execute the contract successfully. For shopping, the project procurement officer will keep a register of suppliers updated at least every six months. With prior approval of the Bank, Goods may also be procured through Direct Contracting, United Nations agencies, and/or by the use of the services of Procurement Agents. The “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants”, dated October 15, 2006 and revised in January 2011, will apply to this project.
13. Selection of Consultants. The project will finance Consultant Services such as surveys, technical and financial audits, technical assistance, and supervision of service delivery, trainers, and workshop facilitators. Consultant firms will be selected through the following methods: (a) Quality and Cost Based Selection (QCBS); (b) selection based on the Consultant’s Qualification (CQS) for contracts that amount to less than US$200,000 equivalent and are relative to exceptional studies and research which require specific and very strong expertise; (c) Least Cost Selection (LCS) for standard tasks such as insurance and financial and technical audits costing less than US$200,000; (d) Single Source Selection (SSS), with prior agreement of IDA, for services in accordance with paragraphs 3.10–3.12 of the Consultant Guidelines. Individual Consultant (ICs) will be hired in accordance with paragraphs 5.1–5.4 of Bank Guidelines; Sole Source may be used only with prior approval of the Bank.
55 14. Short lists of consultants for services estimated to cost less than US$200,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines, if a sufficient number of qualified individuals or firms are available. However, if foreign firms express interest, they would not be excluded from consideration.
15. Procurement of consulting services other than consulting services covered by Consultant Guidelines. Least Cost Selection (LCS) or shopping will be used.
16. Training, Workshops, and Conferences. The training (including training material and support), workshops, and conference attendance will be carried out on the basis of an approved annual training and workshop/conference plan. A detailed plan giving the nature of training/workshop, number of trainees/participants, duration, staff months, timing, and estimated cost will be submitted to IDA for review and approval prior to initiating the process. The appropriate methods of selection will be derived from the detailed schedule. After the training, the beneficiaries will be requested to submit a brief report indicating which skills have been acquired and how these skills will contribute to enhance his/her performance and contribute to the attainment of the project objective.
17. Operational Costs. Operating costs financed by the project are incremental expenses, including office supplies, vehicle operation and maintenance, maintenance of equipment, communication costs, supervision costs (specifically transport, accommodation, and per diem), and salaries of locally contracted staff. They will be procured using the procurement procedures specified in the Project Financial and Accounting Manual.
D. Assessment of the Agency’s Capacity to Implement Procurement
18. The procurement capacity assessment for the PIUs has been carried out and found satisfactory with the following recommendations:
- EDUCATION (UAT-EPT): The Project Implementation Manual will be updated to reflect project specificity.
- NUTRITION: The new financing under the proposed project will continue to be implemented by contracting NGOs under the same arrangements as the preceding project. Accordingly, the new Terms of Reference and contracts will reflect new provisions.
- HEALTH (UGP): The procurement action plan agreed upon during the preparation of last health project is being and will continue to be fine-tuned quarterly, and the main procurement plan will be updated accordingly. The overall project risk for procurement is therefore average. Table 1 outlines the procurement risk assessment and corresponding risk mitigation measures.
56 Table 1: Procurement risk assessment and risk mitigation Designation Concerns Risk Mitigation Due Date Establishment of Terms Interpretation and Technical assistance with Before program of Reference and formatting of documents health expertise for the implementation technical specifications coming from technical Unités de Gestion de la units Passation de Marchés Program management Lack of clarity on roles Program implementation By effectiveness and responsibilities for manual to be updated and the new project training to be held at all levels
Other Mitigation Measures:
19. Apart from identifying the minimum required staffing and equipment needed for a procurement unit satisfactory to IDA, no other mitigation measures can be identified at this time. However, given that the Bank’s procurement specialist is based in Madagascar, close supervision and support will be undertaken to propose any additional mitigation measures if and when they are needed.
20. Frequency of procurement reviews and supervision. The Bank’s prior and post reviews will be carried out on the basis of thresholds indicated in the Table 2. The Bank will conduct six-monthly supervision missions and annual Post Procurement Reviews (PPRs), with the ratio of post review at least 1 to 5 contracts. The Bank may also conduct an Independent Procurement Review (IPR) at any time until two years after the closing date of the project.
Overall Procurement Risk Assessment: High Average X Low
Table 2: Procurement and selection review thresholds Expenditure Contract Value Procurement Contract Subject to Category (Threshold) Method Prior Review US$ 1. Works NA Prudent quotation First three contracts 2. Goods ≥500,000 ICB All <500,000 NCB The first two contracts <50,000 Shopping The first two contracts No threshold Direct contracting All 3. Consulting QCBS; QBS; LCS; Firms ≥200,000 FBS All contracts QCBS; QBS; LCS; <200,000 FBS, CQ The first two contracts Individuals ≥100,000 Comparison of 3 CVs All contracts <100,000 Comparison of 3 CVs The first two contracts Firms and No threshold Single Source All Individuals All terms of reference regardless of the value of the contract are subject to prior review
57 21. All trainings, terms of reference, and all amendments of contracts raising the initial contract value by more than 15 percent of the original amount or above the prior review thresholds will be subject to IDA’s prior review. For contracts with an estimated cost under US$ 200,000, the short list can be composed of national consultants.
22. All contracts not submitted for prior review will be submitted to IDA for post review in accordance with the provisions of paragraph 5 of Annex 1 of the Bank’s Consultant Selection Guidelines and Bank’s Procurement Guidelines. Anticipated procurement and retroactive financing are applicable to the project.
23. Procurement Plan. All procurement activities will be carried out in accordance with approved original or updated procurement plans. The procurement plans will be updated at least annually or as required to reflect the actual project implementation needs and capacity improvements. All procurement plans should be published at the national level and on the Bank website according to the Guidelines. Table 3 shows the 12-month Simplified Procurement Plan of all three components following the guidelines of OP 8.00:
24. Procurement Filing. Procurement documents must be maintained in the project files and archived in the safe place until at least two years after the closing date of the project. Staff recruited into the procurement unit within the PIU will be responsible for the filing of procurement documents.
Table 3: Simplified Procurement Plans
COMPONENT 1 - EDUCATION
GOODS
1 2 3 4 5 6 7 Ref. Contract Estimated Procurement Review Expected Expected No. Description Cost Selection by Bank Bid/Proposal Contract Method (Prior or Submission Completion Post) Deadline Date 1 Procurement and distribution of 305 ICB/NCB39 Prior November December school health pharmaceuticals 2012 2013 2 Printed materials 41 Shopping Post March June 2013 2013 3 Office supplies and 82 NCB Prior January 2013 October 2013 consumables 4 Development and printing of 3 Shopping Post January 2013 June 2013 manuals 5 Services in support of 27 Shopping Post March 2013 December communication strategy (e.g., 2013 radio broadcasting) 6 IT hardware and software for 202 NCB Prior December February UAT, DREN, CISCO 2012 2013 7 Office furniture 9 Shopping Prior November December 2012 2012
39 Through SALAMA–the National Drug Procurement Agency–as Procurement Agent.
58 8 Supply and installation of a 4 Shopping Post November December generator set 2012 2012 9 Vehicles 290 Through Prior November February UNOPS 2012 2013 TOTAL 963
The amounts shown in the table are in 1,000 US$.
CONSULTANTS
1 2 3 4 5 6 7 Ref. Contract Estimated Procure Review Expected Expected No. Description Cost ment by Bank Bid/Propos Contract Selection (Prior or al Completion Method Post) Submission Date Deadline 1 Evaluation of financial services 6 IC prior November November 2012 2012 2 Beneficiary ENF/FCL enquiry 20 IC post September November 2013 2013 3 Consulting firm or NGO for 185 CQS prior December December FAF/FRAM capacity building 2012 2013 4 Study ENF employment contracts 10 IC post November November 2012 2012 5 TA for development of 75 IC post December February management tools 2012 2013 6 Consulting firm or NGO for ENF 185 CQS prior December December capacity building 2012 2013 7 Communication strategy 32 IC post December February development 2012 2013 8 Development of procedures 16 IC prior November November manuals 2012 2012 9 Current PIU staff consultant 260 SSS prior January December contracts 2013 2013 10 Recruitment of additional PIU 70 IC prior January December staff 2013 2013 TOTAL 859
59 COMPONENT 2 - HEALTH
GOODS
1 2 3 4 5 6 7 Ref No. Contract Description Estimated Procurement Review Expected Expected Cost in Selection by Bid/Proposal Contract US$ 000s method Bank Submission Completion (Prior Deadline Date or Post)
1 2 3 4 5 6 7 213a111 Purchase of 347 kits for 3,320 ICB Prior March 2013 October delivery 2013
213a112 Purchase of 347 kits PEV 1,550 ICB Prior April 2013 November 2013
213a113 Purchase of 347 kits CPN 2,250 ICB Prior May 2013 December 2013
213a114 et Purchase medicines for 21c2a pregnant women and HIV tests: Purchase of approx. 1,000 215 ICB Prior November June 2013 kits of 100 tests of 2012 Détermine Purchase of approx. 200 kits 6 Direct Prior February June 2013 of 10 tests of Retrocheck contracting 2013 MAEXI40 Purchase of approx. 100 kits 11 Direct Prior February June 2013 of 20 tests Unigold contracting 2013 RLM41 Purchase of approx. 2,500 60 Direct Prior February June 2013 kits of 30 tests SD Bioline contracting 2013 VERIZON42 Purchase of supplies for 75 ICB Prior November June 2013 laboratories for HIV and 2012 Syphilis tests 213a115 Purchase of drugs and 950 ICB/NCB43 Prior December May 2013 213a211 medical supplies for 2012 22b211 pregnant women
213a116 Purchase of 21,301 kits for 540 ICB Prior February September newborns 2013 2013
213a117 Purchase of 21,301 kits for 600 ICB Prior February September mothers 2013 2013
40 MAEXI: Exclusive representative. 41 RLM: Exclusive representative. 42 VERIZON: Exclusive representative. 43 Through SALAMA.
60 1 2 3 4 5 6 7 Ref No. Contract Description Estimated Procurement Review Expected Expected Cost in Selection by Bid/Proposal Contract US$ 000s method Bank Submission Completion (Prior Deadline Date or Post)
213a211 Purchase of medicines PEC Palu: * Purchase of 3,702 45 Direct Prior November April 2013 packs/25 of ACT contracting 2012 SANOFI44 * Purchase of 30,847 tests 25 Shopping Post November April 2013 RDT 2012 213a211 Purchase of small equipment 25 Shopping Post February August for PCIME 2013 2013 22b11 Purchase of 365 motorcycles 950 ICB Prior January 2013 August and transport equipment for 2013 advanced strategies 22b211 Purchase of 150,000 LLINS 1,050 ICB Prior February September for advanced strategy 2013 2013
22b21 Purchase of drugs for mass 825 ICB/NCB45 Prior December May 2013 treatment of neglected 2012 tropical illnesses (excluding schools) 22b21 Management tools 150 NCB Prior November May 2013 2012
21c2a Purchase and distribution of 50 Shopping Post February August condoms for target groups 2013 2013
Subtotal A: 12,697
CONSULTANTS
2.2.b.1.1.1 Recruitment of NGOs to reinforce 1,600 QBS Prior October December the interventions targeting 2012 2015 vulnerable populations (youth/SW/military) 2.2.a.1.2.1 Recruitment of a research institute 150 Single Prior October December for monitoring the progress of the Source46 2012 2015 indicators related to NGOs’ activities 2.2.a.1.3.1 Recruitment of controllers to 25 IC Prior October December assist the UGP in monitoring 2012 2015 NGOs’ activities 2.2.a.1.4.1 Recruitment of a consulting firm 40 Single Prior March December to enlarge the rapid data collection Source47 2013 2015 system
44 SANOFI: Exclusive representative (under Combo Form). 45 Through SALAMA. 46 With the Institut National de la Santé Publique et Communautaire (INSPC). 47 With the Institut National des Statistiques (INSTAT).
61 4.3.3.1.1 Recruitment of a consulting firm 150 QCBS Prior March September to update of mapping 2013 2013
5.1.4 Recruitment of 18 technical 40 IC Prior December March assistants for support at the district 2012 2013 level 5.3.1.1 Recruitment of an auditing firm 200 QCBS Prior March June 2016 for the external financial audit of 2013 the project (for all 3 components for 3 years and the end of project) Subtotal B: 2,205
COMPONENT 3 - NUTRITION
GOODS
1 2 3 4 5 6 7 Ref. Contract Estimated Procurement Review Expected Bid Expected No. Description Cost in Selection by Bank Proposal Contract US$ 000s Method (Prior or Submission Completion Post) Deadline Date Purchase of Salter scales, MUAC (mid-upper arm circumference measurement) bracelets, Hammocks, Height gauge 01 2,000 Salter scales with trousers 143 NCB Prior March 2013 June 2013 02 25,000 MUAC bracelets 6 Through Prior March 2013 June 2013 UNICEF 03 1,400 height gauges 17 Shopping Post April 2013 June 2013
04 4,000 children’s hammocks 30 Shopping Post April 2013 June 2013 Supports for Behavior Change Communication (BCC) activities (displays, calendars, tee shirt, wrappers, blouses) 05 16,800 Displays /themes for 20 Shopping Post August 2013 October sites 2013 10,000 mural calendars 2013 06 5,000 T-shirts for participants, 95 NCB Prior July 2013 October supporting groups, model 2013 mothers 5,000 wrappers for participants, model mothers, 2,100 blouses CNAs
Purchase of kitchen utensils and 64 NCB Prior April 2013 June 2013 other materials for the sites
Printing of materials (periodic reports, cooking demonstration 50 NCB Prior April 2013 June 2013 fliers) for participants
62 Printing of health report cards 90 NCB Prior March 2013 May 2013 for children (WHO) and pregnant women Printing BCC materials for agents (CORAL guidebook, nutrition education guidebook, dietary guidebook, report cards, and others) 11 4,000 dietary guidebooks 140 NCB Prior April 2013 July 2013 2,000 nutrition education guidebooks 192,000 recipe books for CORAL document st 12 4,000 report cards (1 semester) 4 Shopping Post May 2013 June 2013 nd 13 4,000 report cards (2 semester) 4 Shopping Post October 2013 November 2013 Purchase of fortified food 15 9,600,000 fortified food rations 135 Through Prior April 2013 August 2013 KALINA including transport UNICEF Purchase of weighing scales 19 2,000 weighing scales, including 55 NCB Prior May 2013 August 2013 transport Purchase of jars for the sites and other equipment for food storage and processing 20 Purchase of jars, including 65 NCB Prior April 2013 June 2013 transport Purchase of small equipment 50 Shopping Post May 2013 July 2013 and tools for vegetable gardens Bonus for CNAs with 6 Shopping Post November 2013 December outstanding performance, 2013 “model mothers,” and “best sites” Allocation of equipment for 7 Shopping Post May 2013 July 2013 community evaluation Making props for BCC (such as 3 Shopping Post October 2013 November banners) 2013 Purchase of cars for Regional 450 NCB Prior March 2013 June 2013 Nutrition Offices (ORNs) (8 cars) Purchase of motorcycles (200) 600 NCB Prior March 2013 June 2013 for employees in charge of monitoring, and monitoring and supervision Purchase of equipment for ORN 50 NCB Prior April 2013 June 2013 for better project management (cameras, video recorders, megaphones) 27 35 metallic arbors 9 Shopping Post May 2013 June 2013 IT equipment (desktops, laptops, 135 NCB Prior March 2013 June 2013 scanner, printers, photocopiers) Implementation for the 50 NCB Prior July 2013 September monitoring, supervision, data 2013 collection system and the purchase of mobile phones 04 Purchase of monitoring, 30 Direct Prior May 2013 September
63 accounting and procurement contracting 2013 software with TOMPRO48 TOTAL 2,308
CONSULTING SERVICES
1 2 3 4 5 6 7 Ref. Contract Estimated Procurement Review Expected Bid Expected No. Description Cost in Selection by Bank Proposal Contract US$ 000s Method (Prior or Submission Completion Post) Deadline Date 01 Recruitment of NGOs for support 3,800 SBQ Prior February 2013 December to the CNAs (approx. 100 for 3 2015 years) 02 Data collection via SMS 45 Direct Prior February 2013 December contracting49 2013 03 Periodic project evaluation 15 CI Prior November 2013 February 2014 TOTAL 3,860
48 TOMPRO: Update of Integrated Financial Management Information System (IFMIS). 49 AIRTEL: Continuation of services.
64 Annex 7: Implementation and Monitoring Arrangements
MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
1. Given the emergency nature of the project, the project’s multi-sectoral design, and the country context, the government and IDA agreed that the best strategy for project implementation would be through existing project implementation units (PIUs), with oversight by a Technical Steering Committee (TSC). The TSC will be chaired by the Secretary General or designate of the Ministry of Finance and include representation by the relevant line ministries and entities. Its role will consist of providing overall guidance for effective project implementation and ensuring cross-sectoral coordination and consistency of project activities with sector policies and strategies. The TSC will be supported by a light reporting structure, the Project Coordination Cell (PCC), which functions as a secretariat and serves as a single point of entry for the TSC as well as IDA for the project. This proposed institutional set-up is considered the most appropriate for ensuring effective management and implementation of the proposed operation.
2. Figure 1 provides an overview of the implementation arrangements.
Figure 1: Implementation arrangements
- Ensure overall guidance and cross-sectoral coordination Technical - Chaired by the Ministry of Steering Finance with representation from the Ministries of Committee Education and Health and the Office of Nutrition
Project Coordination Cell (Secretariat) The role of the PCC will be to consolidate overall project reporting from the three respective PIUs. Education PIU Health PIU Nutrition PIU All three PIUs will: (UAT-EPT) (UGP) (i) Coordinate and monitor the (PNNC) day-to-day implementation of the project. (ii) Prepare consolidated technical and fiduciary reports for their respective components. Resources from IDA will flow directly to the PIUs.
Project Implementation Units
3. The implementation of each of the three project components will be coordinated and supervised by the existing and well-functioning PIUs, in close collaboration with the
65 respective national and regional structures of the Ministries of Education and Health and the National Office of Nutrition (ONN). All three PIUs will: (i) coordinate and monitor the day- to-day implementation of the project and (ii) manage all fiduciary, M&E, and safeguard aspects and prepare consolidated technical and fiduciary reports for their respective components.
4. The PCC will consolidate these reports into one report, which will provide an overview of the project’s performance and implementation progress. These reports will be the basis of annual budgeted action plans, which the PIUs will prepare for their respective components.
5. Cross-cutting PIU responsibilities: The following responsibilities will be managed jointly by the three PIUs (namely, development of terms of reference, interviews, and scope of work), with one PIU being responsible for executing the specific task of contracting, based on fiduciary assessments and practical considerations:50
• Recruitment of external auditor • Recruitment of consultants for PCC
6. Fiduciary responsibilities: IDA resources will flow directly to each PIU. Each PIU will open a Designated Account in a commercial bank acceptable to IDA. The financial management experts of each PIU will prepare quarterly and annual financial statements. The PCC will consolidate these financial statements into one statement for the project, which will be submitted to the TSC for validation. All quarterly financial statements (IFRs) will be sent to the Bank 45 days after the closing of each quarter. Annual financial audits will be conducted by an external auditor acceptable to IDA and in accordance with international auditing standards. Consolidated audit reports will be sent to IDA within six months after the end of the audit period. Financial arrangements will be detailed in the Project Implementation Manual. Each of the three PIUs will be responsible for procurement for the respective activities under their components, according to the World Bank Consultant Guidelines (More detailed information on the fiduciary arrangements can be found in Annexes 5 and 6).
7. The fiduciary assessments confirmed that all three PIUs already have the relevant qualified personnel to support the respective coordinators in the fiduciary management, M&E, budgeting, and planning activities. The core team of each of the PIUs will maintain the following staff (minimum): national coordinator, an internal auditor, a financial management specialist, a procurement officer, a monitoring specialist, an accounting assistant, and other suitably qualified and experienced staff in adequate numbers. These existing staff contracts are being reviewed, and contract extensions/new contracts for this new operation will be put in place as required in the next few weeks, in accordance with World Bank procurement guidelines.
8. The three PIUs are the following:
• The Education PIU (Unité d’Appui Technique-Education pour Tous, UAT-EPT) has been in place since 2002. It was responsible for implementing the IDA CRESED Project, closed in 2005, and more recently has been responsible for the implementation of the Multi-Donor Trust Fund for the Education For All Initiative
50 UGP was assessed by fiduciary specialists to be the best placed to handle contracting for these activities.
66 (EFA-FTI, now GPE), for which the Bank was the supervising entity prior to the crisis in 2009. The PIU will also be the implementing agency for a planned AFD project. The PIU is effectively implementing most of the activities proposed under Component 1 of this project (support to school grants and community teacher salaries) under the supervision of UNICEF.
• The Health PIU (Unité des Gestions de Programmes des Santé, UGP-Santé) has been operating since 1999 and started originally as a Bank PIU. Given its track record of management and implementation, as evidenced by its continuous timely and unqualified fiduciary audit, the PIU now manages several donor resources, including AFD, the Global Fund, and resources from the Government of Monaco. The UGP is also the implementing agency for the MSPPII and the Additional Financing (AF) recently approved by the Bank. Similar activities with extended scope are proposed under Component 2 of the project.
• The Nutrition PIU (Unité Programme National de Nutrition Communautaire, PNNC) has been operating since 1992 and is currently overseeing the implementation of the National Community Nutrition Program on behalf of the ONN. The PNNC is also implementing the activities under the MSPII and the AF. Similar activities with extended scope are proposed under Component 3 of the project.
Technical Steering Committee (TSC)
9. The TSC will ensure overall guidance and cross-sectoral coordination. It will be chaired by the Secretary General or designate of the Ministry of Finance and will include the key stakeholders, with representation by the Secretaries General or their designates of the Ministry of Education and Ministry of Health, and the National Coordinator from the ONN.
10. The role of the TSC will be to: (i) provide overall policy guidance and ensure consistency with sector strategies and priorities; (ii) oversee project implementation and approve the annual work plans, procurement plans, and budgets; and (iii) address issues that affect overall project implementation (such as restructuring, reallocation, and so on). The TSC will meet at least semi-annually to validate the consolidated quarterly reports and once a year to validate the consolidated annual report. All reports that have to be validated will be consolidated and presented by the PCC.
Project Coordination Cell (PCC)
11. In addition to the TSC, a light reporting structure, the Project Coordination Cell (PCC), will be established. The PCC will comprise 1–2 staff, a coordinator and an assistant, and will be located in a rented office space. The PCC, attached to the Ministry of Finance, will essentially fulfill a secretariat role and report to the TSC.
12. The role of the PCC will be to consolidate overall project reporting from the three respective PIUs, including financial reports, the annual work plan, the budget, the results framework, and the progress reports. The PCC will serve as a single entry point for information and reporting for IDA and the Ministry of Finance. The PCC will also organize a monthly meeting with the heads of the three PIUs to monitor overall implementation progress. It will also facilitate joint World Bank supervision missions.
67 Implementation of Project Components
13. Responsibility for the technical implementation of the three project components will be as follows:
Education (Component 1)
14. Overall coordination and management. The existing Education PIU, UAT-EPT, will coordinate and supervise the implementation of Component 1, in close collaboration with the respective national and regional structures of the Ministry of Education. The resources of the proposed project will flow directly to the PIU. More specifically, the PIU will: (i) manage day-to-day project implementation and (ii) manage all fiduciary, M&E, and any potential safeguards aspects of the activities under the component, and prepare consolidated technical and fiduciary reports related to the component.
15. Implementation. The implementation of the subcomponent will be based on tested and well-functioning existing transfer and verification mechanisms. These mechanisms have been carefully evaluated during project preparation, and improvements have been made where necessary to ensure effective delivery of critical interventions to beneficiary populations.
16. Supervision, monitoring, and evaluation. Regarding the subsidies to community teacher salaries and the support to school grants, the Education PIU (UAT-EPT) is responsible for transferring funds to financial institutions, monitoring payment, verifying reports made by the financial institutions, and reporting to the Ministry of Education. Unannounced spot checks of schools will also be carried out. The following supervision and monitoring mechanisms and operational audits will ensure that services are delivered effectively: (i) supervision and unannounced spot checks by the PIU (for example, by the internal auditor); (ii) third-party verification through NGOs (including interviews with beneficiaries and the school community); (iii) the parents' association (which will receive training in the procedures of and roles in the teacher certification process) and/or school management committees (which will receive training on the management of school grants); (iv) regional and local structures of the Ministry of Education; and (v) as part of the external audits for the project. Periodic evaluations will be conducted for each of the activities under the component.
(a) Subsidies to community teacher salaries
17. Recruitment and employment of community teachers at the school level. Community teachers are locally hired and employed by the parent association based on criteria recommended by the MEN and under the supervision of the school director, chef ZAP), and chef CISCO. However, teacher salaries are subsidized by the government (in some instances through donor funding, as in this instance with Bank funding). The contract between the parents' association and the community teacher is subject to approval and supervision by the various local/regional levels of the education administration (sub-district/district levels). The contract stipulates that the Ministry of Education will pay a monthly salary subsidy of MGA 110,000.
18. Verification of teacher lists. Based on this recruitment process, a list of teachers eligible for subsidies is drafted by the local and regional education administrative levels and submitted, cross-checked, and approved by the central level.
68 19. Payment of community teachers takes place bi-monthly based on a certification of teacher services rendered (attestation de service fait), approved by the parents’ association and the school director, and then sent to, reviewed by, and consolidated into a final list by the subsequent levels of the administration (ZAP, CISCO, and DREN), which is submitted to and verified by the central MEN, and lastly the PIU. This procedure is followed to ensure a regular, bimonthly updating of the beneficiary teacher list; ensure good governance (for instance, to make sure teachers are still teaching at a particular school for a given period); and prevent errors in the transfer of payments.
20. Transfer mechanism. The flow of funds for the community teacher subsidy is shown in Figure 2. The funds for the salaries and social security contributions are transferred from the PIU’s Designated Account into the DRENs’ special accounts, based on the consolidated and verified list of beneficiary teachers. The DREN then transmits the list for payment to the financial institutions contracted, with which each of the beneficiary teachers has an individual account. It also sends the list to the CISCO level for information. Several different financial service providers are used, based on criteria of accessibility/geographic coverage, performance, and cost. The financial institutions used as service providers consist of regular commercial banks, post offices, and microfinance agencies. Social security fees are directly paid to the CNaPS by the DREN.
21. Transparency and governance. The community teachers eligible for the salary subsidy are identified publicly at the school level every two months through the certification of teacher services rendered which each individual teacher, the school director, and representatives of the parent's association must sign.
22. The following improvements will be implemented or explored in the first phase of implementation to strengthen the transparency and management of the existing mechanisms:
(i) Include the beneficiary (the community teacher) in the certification process: The teacher certification process previously did not include any involvement of the teacher himself. However, signature/initialing of the certification of services rendered by the teacher will be an added feature of the implementation arrangements under the proposed project to strengthen the transparency of this process.
(ii) Include information on the teacher presence in the certificate of teacher services rendered—specifically, the number of days the teacher was present at the school and reason for any absences.
(iii)Publicly identify community teachers receiving the salary subsidy: A list of the teachers and/or a copy of the certificate of teacher service rendered will be posted in a publicly accessible space at the school.
(iv) Train parent associations in the teacher accountability process to ensure they understand their critical role in this process.
(v) Provide information to local stakeholders about the complaints hotline, that is, the Independent Anti-Corruption Office (Bureau Independent Anti-Corruption, BIANCO), so the PIU and the Bank can ensure that complaints can be logged, are collected for review by the project team, and can be integrated.
69 Figure 2: Flow of funds for community teacher subsidy
(b) Support to school grants
23. The project will fund a top-up to the school grants, which the MEN will continue to pay to all of the public primary schools in the five project regions (about 6,075). The implementation arrangements for the school grants are indicated in Figure 3.
70 24. The purpose of these grants is to: (i) provide schools with small annual funds for operational expenses for facility maintenance, acquisition of basic learning supplies (such as chalk, notebooks etc.), which otherwise would have to come from parents, and (ii) fund activities of the annual school action plan.
25. Allocation formula: The grant amount is allocated to schools based on school size (number of pupils). The average supplemental grant amount funded by the subcomponent is US$200 per school for small schools, US$250 per school for medium-sized schools, and US$ 300 per school for large schools.
26. Verification of schools: The MEN prepares the list of beneficiary schools based on its Education Management Information System and lists of closed and opened schools compiled by the DREN. The UAT makes a direct transfer of the grant amounts to the financial service providers (post offices, banks, and microfinance institutions) at the regional level. The grant is then transferred to each school management committee’s individual account.51
27. Eligible expenditures and financial reporting: The school-based management committee makes use of the funds based on a list of eligible and non-eligible expenditures. Each year, school management committees prepare expenditure plans, which have to be publicly endorsed by the General Assembly of the committee, approved by the ZAP, and submitted to the CISCO. At the end of the school year, schools prepare expenditure reports. Their conformity with their initial expenditure plans is reviewed by the heads of ZAP and CISCO.
28. Transparency and governance: The following improvements will be implemented or explored in the first phase of implementation to strengthen the transparency and management of the existing mechanisms:
(i) Posting the grant amount and list of eligible expenditures at each school in a publicly accessible space.
(ii) Training school-based management committees in the use/management of school grants to make sure they understand their responsibilities in this process and can perform simple financial management.
(iii)Providing information to local stakeholders about the complaints hotline (see the discussion under support to community teacher salaries).
51 The school management committee has representatives of the parent association and community and the school principal.
71 Figure 3: Implementation arrangements for school grants
72 (c) School health and nutrition package
29. The school health activities will be implemented jointly by the central, regional, and local structures of the Ministry of Health, the Ministry of Education, and ONN, which have a history of collaboration and considerable experience in the joint implementation of such activities (Figure 4). The school health activities funded by the project build on similar types of interventions that are already successfully carried out using similar mechanisms.
30. A Memorandum of Understanding will be established between the UAT-EPT and ONN for the acquisition of nutritional supplements and medicines. ONN will then procure the drugs for the Education PIU at SALAMA, the central drug procurement agency for the Government of Madagascar, since ONN has considerably more experience with purchases of this type. SALAMA will deliver the health package directly to the CISCOs. The CISCOs have sufficient storage space, because they also serve as distribution centers for education supplies and equipment (such as textbooks and school kits). From the CISCO level onward, the education administrative chain will dispatch the school health package via the head of ZAP to schools.
31. To ensure smooth implementation and effective administration of the medications and supplements in schools and the nutritional demonstrations, the MEN, in close collaboration with health agents, will implement training for DRENs, CISCOs, ZAPs, school directors, and teachers. The implementation of the school health activities will be coordinated to match the periodic advanced strategy52 organized by the Ministry of Health; the one-day nutrition activity at the school level will be carried out by the CNAs, who are already have knowledge about preparing nutritious and low-cost food.
32. Supervision, monitoring, and evaluation: The Education PIU (UAT-EPT) will be responsible for fund transfer to ONN, verification of reports made by ONN, and reports to the MEN. Spot checks will also be carried out.
52 SALAMA is the semiautonomous central drug procurement agency for the Government of Madagascar. It supplies District Pharmacies, based on their purchase orders; in turn, the District Pharmacies supply the health centers with drugs.
73 Figure 4: Implementation arrangements for school health and nutrition
(d) Capacity strengthening, monitoring and evaluation, and project management
33. The activities of this component will be implemented by the PIU and the respective technical staff of the Ministry of Education at the central, regional, and local levels, as well as NGOs for selected training activities.
74 Health (Component 2) and Nutrition (Component 3)
34. Coordination, management, monitoring, and verification. As noted, resources under the proposed project will flow directly to the Health PIU and Nutrition PIU, operating at technical levels of the government. In addition to participation from the Secretary General levels of line ministries, the TSC will also have a health, nutrition, and HIV/AIDS specialist to ensure expertise is present on the TSC for the planned activities. The external verification agency will continue to play an essential third-party verification role in ensuring that services are delivered efficiently through periodic operational audits.
35. Implementation. Implementation of health and nutrition activities will build on the MSPPII and use existing and well-functioning mechanisms. Implementation will be further enhanced to ensure effective delivery of key interventions to beneficiary populations (Figure 5):
a. Health: The Health PIU will deposit funds to a Special Account at the district health level for health facilities. These funds will contribute to the operational costs of the facilities, the basic package of health service delivery for fixed and outreach activities, and operational costs of outreach activities. District technical assistants recruited under the project will provide supervision support to the facilities and ensure data collection and timely reporting from health facilities to the Health PIU. The PIU will also directly contract NGOs to support delivery of maternal and child health and nutrition services at the facility and community levels based on well-defined terms of reference. To address gaps and scale up impact, they will be involved in the direct delivery of interventions as well as in providing support to health facilities and CNAs to ensure the quality of service delivery.
b. Nutrition: The Nutrition PIU will deposit funds into a Special Account at the Nutrition Regional Office (ORN) to support regional officers in carrying out M&E and supervision activities. The operational costs of community nutrition sites will also be included. Finally, project funds will also be transferred to finance the nutrition NGOs supervising the CNAs. NGOs will also serve as third-party fund holders for resources to the CNAs.
36. The health facilities and community nutrition sites will continue to collaborate closely to ensure service delivery through outreach activities and referral services. In addition, both the Health and Nutrition PIUs will support supervision for activities being implemented under the school health and nutrition subcomponent.
75 Fund flow or Contract . Figure 5: Implementation Arrangements-Components 2 and 3
Supervision/Verif/Accountability Collaborative Relationship Services Provision PROJECT IMPLEMENTING AGENCY – NATIONAL COMMUNITY-BASED HEALTH – UGP NUTRITION PROGRAM - PNNC
REGIONAL From PIU NUTRITION SPECIAL ACCOUNT to DISTRICT HEALTH OFFICE From PIU SPECIAL ORN BANK AUTHORITY ACCOUNT to DISTRICT ACCOUNT pay BANK ACCOUNT to finance NGOs primary care health facilities: financing Operational Costs; basic package of health. HEALTH TECHNICAL ASSISTANCE FOR DISTRICT: TA support to health − Community Nutrition center; data collection support. Program Manager − M&E Responsible
PRIMARY HEALTH HEALTH & NUTRITION NGOs FACILITY − Program Responsible Fixed strategy & − Animator Outreach strategy INDEPENDENT VERIFICATION COMMUNITY OUTREACH AGENT NGOs NUTRITION COMMUNITY SITES - Community Nutrition Agent
PRIMARY BENEFICIARIES - Pregnant and lactating women - Children under the age of 5
76 Annex 8: Project Preparation and Appraisal Team Members MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
Team Composition Bank Staff Name Title Specialization Unit UPI Andreas Blom Lead Education Economist Task Team Leader AFTEE 211617 Jumana N. Qamruddin Operations Officer Co-Task Team Leader AFTHE 230924 Cornelia Jesse Operations Officer Operations Officer AFTEE 268403 Harisoa Danielle Education Specialist Education Specialist AFTEE 365539 Rasolonjatovo Andriamihamina Norosoa V. Andrianaivo Language Program Assistant Language Program Assistant AFTEW 156788 Samia Benbouzid Program Assistant Program Assistant AFTHW 189466 Helene Bertaud Senior Counsel Senior Counsel LEGAM 231602 Joseph Byamugisha Financial Management Financial Management AFTMW 352814 Specialist Specialist Fadila Caillaud Education Economist Education Economist AFTEE 332097 Wolfgang Chadab Senior Finance Officer Senior Finance Officer CTRLA 15321 Papa Aynina Diop Finance Analyst Finance Analyst CTRLA 278272 Paul-Jean Feno Senior Environmental Senior Environmental AFTN1 279344 Specialist Specialist Rama Lakshminarayanan Senior Health Specialist Senior Health Specialist AFTHE 83907 Tawhid Nawaz Operations Adviser Operations Adviser AFTHD 10575 Voahirana Hanitriniala Health Specialist Health Specialist AFTHE 375305 Rajoela Ramahatra Andriamamy Senior Education Specialist Senior Education Specialist AFTEE 153516 Rakotomalala Sylvain Rambeloson Senior Procurement Senior Procurement AFTPE 181839 Specialist Specialist Lalaina Rasoloharison Program Assistant Program Assistant AFCS4 351140 Lova Ravaoarimino Procurement Specialist Procurement Specialist AFTPE 293987 Cheikh Sagna Senior Social Development Senior Social Development AFTCS 216532 Specialist Specialist Shilpa Challa Consultant Consultant AFTHE 243921 Jean Van Eenaeme Consultant Education AFTEE 248015 Ioana Kruse Consultant Health AFTHE 232769 Axelle Latortue Consultant Education AFTEE 155669 Nelly Rakoto-Tiana Consultant Education AFTEE 418223 Mark Zeydler Consultant Health AFTHE 211030
77 Annex 9: Environmental and Social Safeguards Assessment Framework MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
Introduction
1. As permitted under OP/BP 8.00, Rapid Response to Crises and Emergencies, an Environmental and Social Screening Assessment Framework (ESSAF) has been developed to support the Madagascar–Emergency Support to Critical Education, Health and Nutrition Services Project. The ESSAF describes the basic approach to be taken during project implementation for the selection and design of proposed investments as well as key principles to be followed throughout to ensure due diligence in managing the potential adverse environmental and social impacts and risks associated with the project, including consultation and disclosure requirements. More specifically, the ESSAF addresses the following issues: (i) minimization of environmental pollution risks; (ii) protection of human health; and (iii) enhancement of positive environmental and social outcomes.
Project context
2. The proposed IDA credit to the Republic of Madagascar for an amount of US$65.00 million aims to preserve basic services in education, health and nutrition in targeted vulnerable areas. As the sector analyses pointed out, key constraints to improving education, health and nutrition outcomes include the significant supply-side constraints in the public sector and a sharp increase in private costs of services, due to cuts in public financing since 2009, as well as a weak governance and management environment. The proposed operation therefore prioritizes activities that will facilitate access to basic education and health services by reducing their private cost and easing supply-side constraints.
3. The PDO is to preserve critical education, health, and nutrition service delivery in targeted vulnerable areas in the recipient’s territory. The project design will be kept simple and will build on activities that are implemented by ongoing projects and can either be continued or scaled up. The proposed operation will have the following three components:53
Component 1: Preserving Critical Education Services (US$23.5 million)
4. This component will preserve critical education services in the targeted vulnerable regions and benefit about 974,300 primary aged children and about 10,000 community teachers in the public primary schools in the five targeted regions—currently about 6,050 schools. This objective will be achieved through the following activities:
(a) Subsidies to community teacher salaries. This activity will contribute to the payment of salaries for community, non-civil-servant teachers—those supported through the Parent Association (Fikambanan’ny Ray Aman-drenin’ny Mpianatra, FRAM)54—for a limited
53 The project also has an unallocated category in the amount of US$ 6.0 million 54 These locally recruited teachers constituted about 67 percent of all public primary school teachers in 2010 and are crucial to ensuring primary education for a large share of children.
78 number of months of the year.55 The government has been subsidizing the salary of these teachers since 2002 to reduce the direct costs of education to families. Since the crisis, it has been a challenge for the government to continue paying the subsidy on a timely and regular basis, and the gaps had to be filled by parents’ contributions. To ensure the continued functioning of the system, while at the same time protecting future sustainability and government commitment for teachers’ salaries, donors have been contributing to the payment of these salaries for a limited number of months during the year, while the government assured the payment for the remaining months.56 The support under the proposed project will maintain this principle. The activity will be implemented through well-established mechanisms and structures (that is, through financial service providers and in close coordination with the regional and local education administrative structures, which will also supervise this process).
(b) Support to school grants (also called Local Catalytic Funds, Fonds Catalytiques Locaux, FCL). This subcomponent will provide a top-up to the grants provided to public primary schools by the government (called caisse école) since 2002. Specifically, these grants will: (i) provide schools with small annual funds for operational expenses for the maintenance of facilities and acquisition of basic learning supplies (chalk, notebooks, and so forth); (ii) fund activities of the school annual expenditure program and annual school action plan; and (iii) cover other eligible expenditures. The school grants will be given to school-based management committees (called FAF Fiaraha-miombon’Antoka ho amin’ny Fampandrosoana ny sekoly), consisting of parents, teachers, the school director and representatives from the local community. Well-functioning, existing mechanisms will be used to channel these resources directly to the committees. Training, financed under subcomponent (d), will also be provided to these school committees to strengthen their capacity to manage the grants. Third-party verification through unannounced spot checks will be performed in a sample of schools.
(c) School health and nutrition package. This subcomponent will deliver a package of basic treatment and preventative health and nutrition interventions, including deworming treatment, iron folate, and treatment of neglected tropical diseases in schools in selected areas. The school health activities will be implemented at the school level several times a year by the Ministry of Education (Ministère de l'Education Nationale, MEN), with supervision and training supported by the local health and nutrition structures (specifically trained health workers and community nutrition volunteers). These structures have a successful history of implementing school health and nutrition interventions. Supervision costs for this component will also be included in the health and nutrition components, respectively.
(d) Capacity strengthening, project management, and monitoring and evaluation (M&E). This subcomponent will finance: (i) operational and supervision costs for the already functioning education PIU; (ii) capacity strengthening of local communities for managing their schools; (iii) capacity building of local, regional, and central structures for
55 It is planned to finance four months of teacher salaries annually under the project. 56 For example, the UNICEF-managed multi-donor grant of the GPE (to be closed in December 2012) paid part of the FRAM teachers’ salaries, as will the planned EU support for 2013.
79 the effective implementation and supervision of the activities; (vi) strengthening of sector policy dialogue; and (v) M&E activities, including beneficiary surveys. The subcomponent will also contribute to the financing of the Project Coordination Cell (PCC).
Component 2: Preserving Critical Health Services (US$25.0 million)
5. The main objective of this component will be to preserve the provision of critical health services—to pregnant women and children under five. Building on the MSPPII, the proposed operation will expand support to 60 percent of health facilities in targeted areas in delivering services and will address key supply- and demand-side barriers to access. This objective will be achieved through the following subcomponents:
(a) Critical package for pregnant women and children under five at the health facility level. For pregnant women, an existing cost-effective package of essential services57 will be financed from the first trimester of the pregnancy to the postnatal consultation. This subcomponent will finance training for health providers in obstetric and neonatal emergency care, as well as an existing integrated package for children under five at the health facility level. This package includes Information, Education, and Communication (IEC) activities to promote good practices and breastfeeding and nutrition for mothers and children, Vitamin A supplementation, vaccinations, distribution of long-lasting insecticidal nets (LLINs), treatment of diarrhea with oral rehydration salts and zinc, prevention and treatment of malaria, and support to integrated management of childhood illness (IMCI). The subcomponent will finance periodic mass treatment campaigns against neglected tropical diseases (helminthiasis, bilharzia, and filariasis). Health facilities will receive funding to support outreach activities that will deliver services directly to the community by qualified health personnel, increasing coverage from 5 kilometers to 15 kilometers from the health facility. This subcomponent will also finance contracts with NGOs for the delivery of key interventions to target groups in hard-to-reach areas.
(b) Project management and monitoring and evaluation. Operational costs will be financed for the already-functioning health PIU as well as supervision costs. This support includes supervision costs for the school health and nutrition interventions under the education component. The subcomponent will also contribute to the financing of the PCC. It will also finance M&E activities, including a system for rapid data collection via mobile phone, periodic surveys and assessments, and third- party verification of support provided by NGOs to deliver services.
57 In line with national policy, the basic package of services includes: prevention of mother-to-child transmission, tracking, and treatment of syphilis, HIV/AIDS prevention, treatment and prevention activities, supplementation with iron and folic acid, tetanus vaccination, intermittent preventative medication against malaria, and distribution of safe delivery kits.
80 Component 3: Preserving Critical Nutrition Services (US$10.5 million)
6. The main objective of this component will be to increase access to nutrition services in the community by expanding support to community nutrition sites, community nutrition agents (CNAs), with the aim of reaching 50 percent of the beneficiary population. This objective will be achieved through the following activities:
(e) Support basic community nutrition services. Nutrition inputs, recruitment of NGOs to support community nutrition sites, and capacity building activities for the CNAs will be provided. The CNAs will implement the community-based activities to improve nutrition. Activities will include growth monitoring for children under five (with a critical focus on children under two), nutrition awareness and education through culinary demonstrations, school health outreach activities, and referral to health facilities for severely malnourished children.
(f) Support project management and monitoring and evaluation. This subcomponent will finance the operational costs of the Nutrition PIU. It will also support surveys and evaluations, including biannual community assessments of local malnutrition issues to encourage community involvement in ensuring effective delivery of services. The subcomponent will also contribute to the financing of the PCC. Similar to the health component, the nutrition component will support the use of mobile phones for data collection.
7. Combined, components 2 and 3 will reach approximately 182,000 women and 750,000 children with critical health and nutrition services through support to approximately 380 health facilities and 2,000 community nutrition sites.
Intervention areas
8. A more targeted approach focused on five of the most vulnerable regions will make it possible to reach out to the poorest and most vulnerable groups in the country, will help maximize the impact of the available resources and proposed activities, and will help to adequately monitor implementation. Specifically, the project will be implemented in 5 regions (out of 22): Androy, Atsimo Atsinanana, Vatovavy Fitovinany, Haute Matsiatra, and Amoron'i Mania (see Map). These regions have been/were selected on the basis of: (i) poverty and social indicators (to ensure that activities reach the poor and most vulnerable groups); (ii) the existence of other donor interventions (to avoid overlap); and (iii) the existing IDA health operation (to optimize synergies). Intervening in a limited number of regions will intensify the pace of implementation and facilitate supervision and oversight by the PIUs and the Bank.
Compliance with World Bank safeguards policies
9. The project, which for purposes of safeguards has been classified as Category B, is being prepared under OP/BP 8.00, Rapid Response to Crises and Emergencies, as an emergency
81 operation. For this reason, preparation needs to be expedited, even as appropriate environmental and social measures are taken into consideration.
10. Activities to be supported by the project are expected to have some relatively minimal and site-specific adverse environmental and social impacts that would be easily manageable. For this reason, only one safeguard policy is triggered: OP/BP 4.01, Environmental Assessment.
11. OP/BP 4.01, Environmental Assessment. The proposed operation will mainly support activities in targeted sectors: (i) in the Education sector, the project will (a) subsidize the payment of community teacher salaries, (b) provide support to school grants; and (c) support a basic package of preventative school health and nutrition interventions (medicines) to be delivered in schools in selected areas; and (ii) in the Health sector, the project will: (a) support the delivery of an essential package including immunizations, vitamin supplementation to pregnant women and children, and STI/HIV services to high-risk populations, with procurement and delivery of relevant health commodities (drugs) through SALAMA and (b) support the delivery of an essential package of equipment to health facilities to improve services to a minimum acceptable standard. While the project does not expect to undertake civil works, the ESSAF includes measures for addressing environmental and social impacts of the repair and rehabilitation of existing facilities, should it become necessary to undertake them during implementation. Since no major civil works will be undertaken, no significant negative environmental and social impacts are envisaged in the proposed operation.
12. Ultimately, any improvement in health services delivery would also improve the populations’ access to those health services. It is expected that the great improvements envisioned under the project will increase the production of both medical and pharmaceutical waste in the various care centers and pharmacies. Though there is a regulation on the management of expired pharmaceutical waste (expired medicines), the fact is that the risk of an increase in expired medicines in the country will continue to be elevated as long as the management and delivery system for pharmaceuticals remains weak. Such a situation could involve various kinds of risks associated with the inappropriate handling and disposal of HIV- and other STI-infected materials that could increase the environmental pollution from medical and pharmaceutical wastes. These risks primarily affect personnel in medical facilities in charge of properly disposing of medical waste, families whose basic income derives from the triage of waste, and even the general public, to the extent that waste is not disposed of on-site or safely contained in protected areas. If not properly dealt with and managed appropriately, preferably at early stages, all of these activities could have environmental and human impacts that could then hinder overall project outcomes. (Note however that the activities envisioned under the project extend activities carried out under the previous IDA financing in the health sector.)
13. The ESSAF describes the basic approach to be taken during project implementation for the selection and design of proposed subprojects as well as key principles to be followed throughout to ensure due diligence in managing the potential adverse environmental and social impacts and risks associated with the project, including consultation and disclosure requirement. In light of the above, only the environmental assessment policy (OP/BP 4.01) is triggered, and a Medical Waste Management Plan (MWMP) will be developed. The plan will build upon the 2007 national policy (guideline on disposing of pharmaceutical drugs), which is being updated to
82 set forth practical steps for properly handling the potential social and environmental impacts related to the expiration of pharmaceutical drugs.
14. Though the project is not expected have major negative or irreversible environmental and social impacts, it is possible that it could have ancillary impacts that are not foreseen at present. In that case, it may be necessary to put mitigation measures into place, drawing on existing strategies or relying on any national experience deemed satisfactory to maximize positive outcomes.
15. The following safeguards policies are not triggered:
• OP 4.04 (Natural Habitats): The project will not take place in or near natural habitats. • OP 4.09 (Pest Management): The project will not support procurement or use of pesticides. • OP 4.10 (Indigenous Peoples): There are no indigenous peoples in southeastern Madagascar, where targeted project activities will occur. • OP 4.11 (Physical Cultural Resources): The project is not expected to affect any physical cultural resources; • OP 4.12 (Involuntary Resettlement): As the project may involve repairs/rehabilitation of existing facilities within existing footprints and the management of medical waste from existing facilities, the project is not expected to lead to any land acquisition or loss of livelihood support assets that would result in the involuntary resettlement of persons affected by the project. • OP 4.36 (Forests): The project is not expected to involve deforestation or illegal logging of forest resources; • OP 4.37 (Safety of Dams): The project is not expected to support rehabilitation or construction of dams or intervene in irrigation perimeters. • OP 7.50 (Projects on International Waterways). Madagascar is an island, so the policy does not apply. • OP 7.60 (Projects in Disputed Areas): There are no disputed areas in the project area.
Safeguards screening, mitigation, and implementation support
16. The ESSAF developed specifically for this project is aimed at ensuring due diligence and effective treatment and elimination of both medical waste and expired pharmaceutical drugs in the heath sector by the Government of Madagascar and its service providers. To tangibly address these potential impacts on the overarching environment and general public health, the Ministry of Health adopted by interdepartmental decree No. 2006-680 of September 12, 2006, approved by the Ministry of the Environment, a National Medical Waste Management Policy that includes a Medical Waste Management Plan (MWMP) (Attachment 1). The MWMP was approved and publicly disclosed both in-country (March 20, 2007) and at the World Bank InfoShop (March 23, 2007). The MWMP includes proper disposal of hazardous biomedical wastes and a biosafety training program for the staff of all hospitals, health centers, and community-based programs, including traditional midwives and practitioners, who may be involved in HIV/AIDS and/or STI testing and treatment. At the national level, after 18 months of its implementation, the National Medical Waste Management Policy was updated to improve its results and its compliance with
83 the National Health Sector Development Plan, which covers 2007–11. The National Medical Waste Management Policy and its national action plans provide for five strategic objectives linked to 51 activities. Operational activities have mainly included dissemination of tools, development of medical waste management plans in the health facilities, training of health staff and patients, as well as the provision of incinerators to hospitals that meet national standards.
17. Under the Ministry of Health, the implementation of the National Medical Waste Management Policy shows the following results: 200 small-scale burners for medical wastes in all 200 health centers rehabilitated under Second Health Sector Support Project (CRESANII); 61 percent of public hospitals (77 health centers) have been sensitized to the National Medical Waste Management Policy ; 30 percent (or 37 health centers) have developed medical waste management plans, 10 percent of the Primary Health Faculties Centres de Santés de Base (120 health facilities) have been sensitized to develop their own medical waste management plans; 44 De Montfort incinerators have been built. Moreover, the National Medical Waste Management Policy and its tools and mechanisms have been circulated to the partners, the Regional Health Directorates (Direction Regional de Santé, DRS), and 120 public hospitals and health facilities. The training modules are available in CD format. Training of trainers has progressively moved from the inter-regional and regional level to the hospital and health centers: in 16 of the 22 regions, 1,044 Service de Santé de District and Centre Hopitalier de Districts trainers have been trained. In the health sector, a coordination unit (Service d’Appui aux Genies Sanitaires, SAGS), in charge of supervising and monitoring implementation of the National Medical Waste Management Policy, is operational. Under the current MSPPII health project, the Ministry of Health has received support to implement the National Medical Waste Management Policy through Component 2, including construction of 22 incinerators and health centers and training at the regional, district, and health center level. Supervision missions have noted the strong commitment of the Ministry of Health in the implementation of the National Medical Waste Management Policy.
18. To complete the National Medical Waste Management Policy, in September 2011 the Ministry of Health prepared a guideline to eliminate expired medicines (Attachment 2). As noted, expired medicines are hazardous waste that must be disposed of correctly to avoid any risks to the environment and local population. The guideline is very detailed and clear on the characterization of expired medicines and the disposal methods and steps to be adopted, depending on the type of medicine involved. The guideline provides criteria to select members of the disposal committee and presents models of the minutes and report to be provided and disclosed within a specific timeframe. Finally, the guideline describes the institutional arrangements for the implementation and M&E of the disposal of expired medicine in the health sector. The institutional arrangements for appropriate and timely management of expired medicines and their disposal includes the public sector and private agencies. The Ministry of Health has conducted many specific training events at different levels (national and regional) to ensure proper and wider dissemination of the guidelines.
19. As noted, the National Medical Waste Management Policy, after five years of implementation, is being updated by the Ministry of Health to capitalize on results obtained and lessons learned and update the indicators to be achieved in the next five years. The terms of reference for this revision have been reviewed by the different donors and development partners in the health sector, including the World Bank, and were found to be sufficient and coherent. The
84 Ministry of Health has adopted a participatory approach for this revision, and the updated National Medical Waste Management Policy is expected for Bank approval and disclosure in- country and at the InfoShop by the end of February 2013.
Responsibilities for safeguard screening and mitigation
20. Each of the components (education, health and nutrition) will be adequately coordinated and supervised by an existing implementation unit (PIU): Education (UAT-EPT); Health (UGP- Santé); and Nutrition (Unité de Gestion du Programme National de Nutrition Communautaire). The respective PIUs will be responsible for the usual day-to-day project management and implementation, including safeguards and fiduciary management, monitoring, and evaluation. As the main safeguard issues for this proposed operation are under the health component, the project will be able to draw upon successful previous experience with the ongoing health project (MSPPII). In this context, for continuing timely management of safeguards, leadership on all aspects of safeguards will be the responsibility of an existing agency (SAGS) under the Ministry of Health, which has a Social and Environmental Focal Point to ensure that the MWMP is properly addressed throughout project implementation. SAGS is fully operational and has the institutional capacity to manage the safeguards for the proposed operation.
Capacity building and monitoring of safeguards framework implementation
21. The Recipient is familiar with World Bank safeguard policies through the implementation of other World Bank-funded projects. In the health sector, the MWMP has been implemented in the country in a satisfactory manner under the current MSPPII health project. The proposed project therefore will be able to draw upon successful previous experience with the SAGS team. During and throughout the project supervision, the World Bank task team will assess the appropriate implementation of the MWMP and subsequently recommend additional strengthening measures whenever required. Public awareness will be part of the capacity- building plan, and will be accomplished with the help of local media and communication systems.
Consultation and disclosure
22. IDA funding will support a number of subprojects classified as Environment Category B, to which the public consultation and disclosure policy applies. During preparation of the current MSPPII health project, the National Medical Waste Management Policy was prepared through a consultative and participatory process involving all stakeholders at the regional and national levels in the health sector. The Ministry of Health includes the status of implementation of the National Medical Waste Management Policy in its annual technical report. As mentioned, the MWMP is being revised in a public, participatory, inclusive manner.
85 List of Attachments
Attachment 1 National Medical Waste Management Policy Attachment 2 Guideline to eliminate expired medicines in September 2011 Attachment 3 List of Negative Project Attributes Attachment 4 Steps for Screening Potential Environmental and Social Impacts, Mitigation Measures, and Implementation Procedures Attachment 5 Checklist of Possible Environmental and Social Impacts of Projects Attachment 6 Site Characteristics Attachment 7 Safeguards Procedures for Inclusion in the Technical Specifications of Contracts Attachment 8 Guidelines for Preparation of Environmental and Social Management Plans Attachment 9 General Guidelines for Preparation of Medical Waste Management Plan
86 Attachment 1: National Medical Waste Management Policy
The National Medical Waste Management Policy has been publicly disclosed as part of the ESSAF in country on October 10, 2012 and at the World Bank Info Shop on 10/16/2012. The document can be accessed at the following address:
http://documents.worldbank.org/curated/en/2012/09/16917298/madagascar-emergency-support- critical-education-health-nutrition-services-project-environmental-assessment-vol-1-3- madagascar-emergency-hd-multisector-operation-environmental-assessment
87 Attachment 2: Guideline to Eliminate Expired Medicines- September 2011
The Guideline to Eliminate Expired Medicines has been publicly disclosed as part of the ESSAF in country on October 10, 2012 and at the World Bank Info Shop on 10/16/2012. The document can be accessed at the following address:
http://documents.worldbank.org/curated/en/2012/09/16917298/madagascar-emergency-support- critical-education-health-nutrition-services-project-environmental-assessment-vol-1-3- madagascar-emergency-hd-multisector-operation-environmental-assessment
88 Attachment 3: List of Negative Project Attributes
Subprojects with any of the attributes listed below will be ineligible for support under the proposed MG–Emergency Support to Critical Education, Health and Nutrition Services Project:
Attributes of Ineligible Subprojects Subprojects concerning significant conversion or degradation of critical natural habitats, including, but not limited to, any activity within: 1. Wildlife reserves 2. Ecologically sensitive marine and terrestrial ecosystems 3. Parks or sanctuaries 4. Protected areas, natural habitat areas 5. Forests and forest reserves 6. Wetlands 7. National parks or game reserves 8. Any other environmentally sensitive areas Subprojects requiring any land acquisition and subprojects that can result in involuntary resettlement and/or permanent or temporary loss of access to assets or loss of assets for the project-affected populations. Subprojects requiring pesticides that fall in WHO classes IA, IB, or II.
89 Attachment 4: Steps for Screening Potential Environmental and Social Impacts, Mitigation Measures, and Implementation Procedures
The selection, design, contracting, monitoring, and evaluation of subprojects will be consistent with the guidelines and requirements listed below and included as attachments to this document. Screening of potential environmental and social safeguards impacts, mitigation and management measures, and implementation procedures will follow these steps:
Step 1: Screening of potential environmental and social safeguards impacts, and determination of the appropriate set of safeguard instruments
During the preparation of subprojects, the PIU will ensure that technical design can minimize or avoid environmental and social impacts, including land acquisition.
More detailed environmental and social screening criteria (specifically, a list of negative subproject attributes) are included as Attachment 3, and a proposed checklist of likely environmental and social impacts, to be filled out for each subproject, will be used to determine the type and scope of the environmental and social safeguards impacts (Attachment 5).
Step 2: Definition of the environmental and social safeguards instruments for the project and for each micro-project or subproject
The PIUs, with the assistance of specialized technical assistance, will determine and prepare appropriate instruments for mitigating environmental and social safeguards impacts identified in the screening.
Sample Environmental Safeguards enforcement procedures for inclusion in the technical specifications of construction contracts (Attachment 7).
The PIU will prepare a Safeguard Screening Summary, which includes: • a list of micro-projects and subprojects that are expected to have environmental and social safeguards impacts; • the extent of the expected impacts; • the instruments used to address the expected impacts; and • the timeline to prepare the instruments.
Step 3: Review of the Safeguards Screening Summary
The PIU will retain a copy of the Safeguards Screening Summary for possible review by the Implementing Agency and the World Bank. The review, which may be conducted on sample basis, will verify the proper application of the screening process, including the scoping of potential impacts and the choice and application of instruments.
90 Step 4: Preparation of safeguards instruments
The PIU will prepare the safeguards instruments, the Environmental and Social Management Plan (ESMP) / Medical Waste Management Plan (MWMP), as required. The ESMP and/or MWMP will be prepared in consultation with affected peoples and with relevant NGOs, as necessary. The ESMP and/or the MWMP will be submitted to the Implementing Agency, for review, prior to the submission to the World Bank for approval.
Step 5: Application of the safeguards instruments
Appropriate mitigation measures will be included in the bidding documents and contract documents to be prepared by the PCU. Compliance by the contractors will be monitored in the field by the project engineers, working under close supervision. The performance of the contractors will be documented and recorded for possible later review.
The PIU will supervise and monitor the overall safeguards implementation process and prepare a progress report on the application of safeguards policies during the planning, design, and construction phases of the project. The PCU will also develop the reporting requirements and procedures to ensure compliance of the contractors; conduct public consultation and public awareness programs; and carry out periodic training for field engineers and contractors as appropriate.
91 Attachment 5: Checklist of Possible Environmental and Social Impacts of Projects
This Form is to be used by the PCU in screening subproject proposals.
Note: One copy of this form and accompanying documentation will be kept in the PCU office, and one copy is to be sent to the World Bank Task Team Leader.
Name of Project: Number of subprojects: Proposing agency: Subproject location: Subproject objective: Estimated cost: Proposed date of commencement of work: Community to be included in the subproject location: Relevant details: Any environmental and social issues: Estimated costs: Proposed starting date of works: Designs / plans / specifications reviewed: Yes __ No __ Other comments: Completed by: Date: Reviewed by: Date:
92 Site-related Issues No. Issues Yes No Comments A. Zoning and Land Use Planning Will the subproject affect land use zoning and 1. planning or conflict with prevalent land use patterns? Will the subproject involve significant land 2. disturbance or site clearance? Will the subproject land be subject to potential encroachment by urban or industrial use or 3. located in an area intended for urban or industrial development? Is the subproject located in an area susceptible to 4. landslides or erosion? Is the subproject located on prime agricultural 5. land? B. Utilities and Facilities Will the subproject require the setting up of 6. ancillary production facilities? Will the subproject require significant levels of accommodation or service amenities to support 7. the workforce during construction (e.g., contractor will need more than 20 workers)? C. Water and Soil Contamination Will the subproject require large amounts of raw 8. materials or construction materials? Will the subproject generate large amounts of 9. residual wastes, construction material waste, or cause soil erosion? Will the subproject result in potential soil or 10. water contamination (e.g., from oil, grease, and fuel from equipment yards)? Will the subproject lead to contamination of ground and surface waters by herbicides for 11. vegetation control and chemicals (e.g., calcium chloride) for dust control? Will the subproject lead to an increase in suspended sediments in streams affected by road 12. cut erosion, decline in water quality, and increased sedimentation downstream? Will the subproject involve the use of chemicals 13. or solvents? Will the subproject lead to the destruction of 14. vegetation and soil in the right-of-way, borrow pits, waste dumps, and equipment yards?
93 No. Issues Yes No Comments Will the subproject lead to the creation of stagnant water bodies in borrow pits, quarries, 15. etc., encouraging mosquito breeding and other disease vectors? Is the subproject located in a polluted or 16. contaminated area? D. Noise and Air Pollution Hazardous Substances Will the subproject increase the levels of 17 harmful air emissions? Will the subproject increase ambient noise 18. levels? Will the subproject involve the storage, 19. handling, or transport of hazardous substances? E. Fauna and Flora Will the subproject involve the disturbance or modification of existing drainage channels 20. (rivers, canals) or surface water bodies (wetlands, marshes)? Will the subproject lead to the destruction or damage of terrestrial or aquatic ecosystems or 21. endangered species directly or by induced development? Will the subproject lead to the disruption/destruction of wildlife through 22. interruption of migratory routes, disturbance of wildlife habitats, and noise-related problems? F. Destruction/Disruption of Land and Vegetation Will the subproject lead to unplanned use of the 23. infrastructure being developed? Will the subproject lead to long-term or semi- 24. permanent destruction of soils in cleared areas not suited for agriculture? Will the subproject lead to the interruption of 25. subsoil and overland drainage patterns (in areas of cuts and fills)? Will the subproject lead to landslides, slumps, 26. slips, and other mass movements in road cuts? Will the subproject lead to erosion of lands 27. below the roadbed receiving concentrated outflow carried by covered or open drains? Will the subproject lead to long-term or semi- 28. permanent destruction of soils in cleared areas not suited for agriculture?
94 No. Issues Yes No Comments Will the subproject lead to health hazards and 29. interference of plant growth adjacent to roads by dust raised and blown by vehicles? G. Physical Cultural Resources Will the subproject have an impact on 30. archaeological or historical sites, including historic urban areas? Will the subproject have an impact on religious 31. monuments, structures, and/or cemeteries? Is the subproject located in an area with 32. designated physical cultural resources, such as archaeological, historical, and/or religious sites? H. Expropriation and Social Disturbance Will the subproject involve land expropriation or 34. demolition of existing structures? Will the subproject lead to induced settlements 35. by workers and others causing social and economic disruption? Will the subproject lead to environmental and 36. social disturbance by construction camps? Is the project or subproject located in an area 37. from which people have been displaced? Is the subproject located in an area where PAPs 38. are temporarily relocated? Is the subproject located in a densely populated 39. area? I. Natural Habitats Does the subproject require land acquisition? 40. [Note: If YES, the subproject cannot be financed] Will the subproject negatively impact 41. livelihoods? [Note: Describe separately if YES] Is the subproject located in an area with 42. designated natural reserves or protected areas? Is the project or subproject located in an area 43. with unique natural features? Is the subproject located in an area with 44. endangered or conservation-worthy ecosystems, fauna, or flora? Is the subproject located in an area falling within 500 m of natural forests, protected areas, 45. wilderness areas, wetland, biodiversity, critical habitats, or sites of historical or cultural importance?
95 No. Issues Yes No Comments Is the subproject located in an area which would 46. create a barrier for the movement of conservation-worthy wildlife? Is the subproject located close to groundwater 47. sources, surface water bodies, watercourses, or wetlands J. Pesticides and Agricultural Chemicals Involve the use of pesticides or other agricultural 48. chemicals, or increase existing use? Cause contamination of soil by agrochemicals 49. and pesticides?
96 Attachment 6: Site Characteristics
No. Issues Yes No Comments Is the subproject located in an area with designated 1. natural reserves? Is the subproject located in an area with unique 2. natural features? Is the project or subproject located in an area with 3. endangered or conservation-worthy ecosystems, fauna, or flora? Is the subproject located in an area falling within 500 m of national forests, protected areas, wilderness 4. areas, wetlands, biodiversity, critical habitats, or sites of historical or cultural importance? Is the subproject located in an area which would 5. create a barrier for the movement of conservation- worthy wildlife or livestock? Is the subproject located close to groundwater 6. sources, surface water bodies, water courses, or wetlands? Is the subproject located in an area with designated 7. cultural properties such as archaeological, historical, and/or religious sites? Is the subproject in an area with religious 8. monuments, structures, and/or cemeteries? 9. Is the subproject in a polluted or contaminated area? Is the subproject located in an area of high visual and 10. landscape quality? Is the subproject located in an area susceptible to 11. landslides or erosion? 12. Is the subproject located in an area of seismic faults? 13. Is the subproject located in a densely populated area? 14. Is the subproject located on prime agricultural land? Is the subproject located in an area of tourist 15. importance? 16. Is the subproject located near a waste dump? 17. Does the subproject have access to potable water? Is the subproject located far (1–2 km) from accessible 18. roads? Is the subproject located in an area with a wastewater 19. network? 20. Is the subproject located in the urban plan of the city? 21. Is the subproject located outside the land use plan?
97 Signed by Environment Specialist: Name: ______Title: ______Date: ______
Signed by Project Manager: Name: ______Title: ______Date: ______
98 Attachment 7: Safeguards Procedures for Inclusion in the Technical Specifications of Contracts (for rehabilitation/repairs activities)
I. General
1. The Contractor and his employees shall adhere to the mitigation measures set down and take all other measures required by the Engineer to prevent harm, and to minimize the impact of his operations on the environment.
2. Remedial actions which cannot be effectively carried out during construction should be carried out on completion of each subproject and before issuance of the “Taking over certificate”:
i. these subproject locations should be landscaped and any necessary remedial works should be undertaken without delay, including grassing and reforestation; ii. water courses should be cleared of debris and drains and culverts checked for clear flow paths; and iii. borrow pits should be dressed as fish ponds, or drained and made safe, as agreed with the land owner.
3. The Contractor shall limit construction works to between 6 am and 7 pm if it is to be carried out in or near residential areas.
4. The Contractor shall avoid the use of heavy or noisy equipment in specified areas at night, or in sensitive areas such as near a hospital.
5. To prevent dust pollution during dry periods, the Contractor shall carry out regular watering of earth and gravel haul roads and shall cover material haulage trucks with tarpaulins to prevent spillage.
6. To avoid disease caused by inadequate provision of water and sanitation services, environmentally appropriate site selection led by application of the environmental and social screening form provided in this ESSAF, design and construction guidance, and a procedure for ensuring that this guidance is followed before construction is approved. Ensure engineering designs include adequate sanitary latrines and access to safe water.
7. To prevent unsustainable use of timber and wood-firing of bricks, the Contractor should replace timber beams with concrete where structurally possible. In addition, the Contractor should ensure fired bricks are not wood-fired. Where technically and economically feasible, substitute fired bricks with alternatives, such as sun-dried mud bricks, compressed earth bricks, or rammed earth construction.
8. The Contractor shall conduct appropriate disposal of waste materials and the protection of the workforce in the event of asbestos removal or that of other toxic materials.
99 Prohibitions
9. The following activities are prohibited on or near the project site:
• Cutting of trees for any reason outside the approved construction area; • Hunting, fishing, wildlife capture, or plant collection; • Use of unapproved toxic materials, including lead-based paints, asbestos, etc.; • Disturbance to anything with architectural or historical value; • Building of fires; • Use of firearms (except authorized security guards).
II. Transport
10. The Contractor shall use selected routes to the project site, as agreed with the Engineer, and appropriately sized vehicles suitable to the class of road, and shall restrict loads to prevent damage to roads and bridges used for transportation purposes. The Contractor shall be held responsible for any damage caused to the roads and bridges due to the transportation of excessive loads, and shall be required to repair such damage to the approval of the Engineer.
11. The Contractor shall not use any vehicles, either on or off road, with grossly excessive exhaust or noise emissions. In any built up areas, noise mufflers shall be installed and maintained in good condition on all motorized equipment under the control of the Contractor.
12. Adequate traffic control measures shall be maintained by the Contractor throughout the duration of the Contract and such measures shall be subject to prior approval of the Engineer.
III. Workforce
13. The Contractor should whenever possible locally recruit the majority of the workforce and shall provide appropriate training as necessary.
14. The Contractor shall install and maintain a temporary septic tank system for any residential labor camp and without causing pollution of nearby watercourses.
15. The Contractor shall establish a method and system for storing and disposing of all solid wastes generated by the labor camp and/or base camp.
16. The Contractor shall not allow the use of fuel wood for cooking or heating in any labor camp or base camp and provide alternate facilities using other fuels.
17. The Contractor shall ensure that site offices, depots, asphalt plants, and workshops are located in appropriate areas as approved by the Engineer and not within 500 meters of existing residential settlements and not within 1,000 meters for asphalt plants.
18. The Contractor shall ensure that site offices, depots, and particularly storage areas for diesel fuel and bitumen and asphalt plants are not located within 500 meters of watercourses, and
100 are operated so that no pollutants enter watercourses, either overland or through groundwater seepage, especially during periods of rain. This will require lubricants to be recycled and a ditch to be constructed around the area with an approved settling pond/oil trap at the outlet.
19. The Contractor shall not use fuel wood as a means of heating during the processing or preparation of any materials forming part of the Works.
20. The Contractor shall conduct safety training for construction workers prior to beginning work. Material Safety Data Sheets should be posted for each chemical present on the worksite.
21. The Contractor shall provide personal protective equipment (PPE) and clothing (goggles, gloves, respirators, dust masks, hard hats, steel-toed and –shanked boots, etc.) for construction and pesticide handling work. Use of PPE should be enforced.
IV. Quarries and Borrow Pits
22. Operation of a new borrow pit area, on land, in a river, or in an existing area, shall be subject to prior approval of the Engineer, and the operation shall cease if so instructed by the Engineer. Borrow pits shall be prohibited where they might interfere with the natural or designed drainage patterns. River locations shall be prohibited if they might undermine or damage the river banks, or carry too much fine material downstream.
23. The Contractor shall ensure that all borrow pits used are left in a trim and tidy condition with stable side slopes, and are drained ensuring that no stagnant water bodies are created which could breed mosquitoes.
24. Rock or gravel taken from a river shall be far enough removed to limit the depth of material removed to one-tenth of the width of the river at any one location, and not to disrupt the river flow, or damage or undermine the river banks.
25. The location of crushing plants shall be subject to the approval of the Engineer, and not be close to environmentally sensitive areas or to existing residential settlements, and shall be operated with approved fitted dust control devices.
V. Earthworks
26. Earthworks shall be properly controlled, especially during the rainy season.
27. The Contractor shall maintain stable cut and fill slopes at all times and cause the least possible disturbance to areas outside the prescribed limits of the work.
28. The Contractor shall complete cut and fill operations to final cross-sections at any one location as soon as possible and preferably in one continuous operation to avoid partially completed earthworks, especially during the rainy season.
101 29. In order to protect any cut or fill slopes from erosion, in accordance with the drawings, cut off drains and toe-drains shall be provided at the top and bottom of slopes and be planted with grass or other plant cover. Cut off drains should be provided above high cuts to minimize water runoff and slope erosion.
30. Any excavated cut or unsuitable material shall be disposed of in designated tipping areas as agreed to by the Engineer.
31. Tips should not be located where they can cause future slides, interfere with agricultural land or any other properties, or cause soil from the dump to be washed into any watercourse. Drains may need to be dug within and around the tips, as directed by the Engineer.
VI. Historical and Archeological Sites
32. If the Contractor discovers archeological sites, historical sites, remains, and objects, including graveyards and/or individual graves during excavation or construction, the Contractor shall:
(i) Stop the construction activities in the area of the chance find; (ii) Delineate the discovered site or area; (iii) Secure the site to prevent any damage or loss of removable objects. In cases of removable antiquities or sensitive remains, a night guard shall be present until the responsible local authorities and the Ministry of Culture and Patrimony take over; (iv) Notify the supervisory Engineer who in turn will notify the responsible local authorities and the Ministry of Culture and Patrimony immediately (less than 24 hours); (v) Contact the responsible local authorities and the Ministry of Culture and Patrimony who would be in charge of protecting and preserving the site before deciding on the proper procedures to be carried out. This would require a preliminary evaluation of the findings to be performed by the archeologists of the relevant Ministry of Culture and Patrimony (within 72 hours). The significance and importance of the findings should be assessed according to the various criteria relevant to cultural heritage, including the aesthetic, historic, scientific or research, social and economic values; (vi) Ensure that decisions on how to handle the finding be taken by the responsible authorities and the Ministry of Culture and Patrimony. This could include changes in the layout (such as when the finding is an irremovable remain of cultural or archeological importance) conservation, preservation, restoration, and salvage; (vii) Implementation for the authority decision concerning the management of the finding shall be communicated in writing by the Ministry of Culture and Patrimony; and (viii) Construction work will resume only after authorization is given by the responsible local authorities and the Ministry of Culture and Patrimony concerning the safeguard of the heritage.
102 VII. Disposal of Construction and Vehicle Waste
33. Debris generated due to the dismantling of the existing structures shall be suitably reused, to the extent feasible, in the proposed construction (e.g., as fill materials for embankments). The disposal of remaining debris shall be carried out only at sites identified and approved by the project Engineer. The Contractor should ensure that these sites: (i) are not located within designated forest areas; (ii) do not impact natural drainage courses; and (iii) do not impact endangered/rare flora. Under no circumstances shall the Contractor dispose of any material in environmentally sensitive areas.
34. In the event any debris or silt from the sites is deposited on adjacent land, the Contractor shall immediately remove such debris or silt and restore the affected area to its original state to the satisfaction of the Supervisor/Engineer.
35. Bentonite slurry or similar debris generated from pile driving or other construction activities shall be disposed of to avoid overflow into the surface water bodies or form mud puddles in the area.
36. All arrangements for transportation during construction including provision, maintenance, dismantling, and clearing debris, where necessary, will be considered incidental to the work and should be planned and implemented by the Contractor as approved and directed by the Engineer.
37. Vehicle/machinery and equipment operations, maintenance and refueling shall be carried out to avoid spillage of fuels and lubricants and ground contamination. An oil interceptor will be provided for wash down and refueling areas. Fuel storage shall be located in proper bounded areas.
38. All spills and collected petroleum products shall be disposed of in accordance with standard environmental procedures/guidelines. Fuel storage and refilling areas shall be located at least 300 meters from all cross drainage structures and important water bodies or as directed by the Engineer.
103 Attachment 8: Guidelines for Preparation of Environmental and Social Management Plans
1. The Environmental Assessment (EA) process involves the identification and development of measures aimed at eliminating, offsetting, and/or reducing environmental and social impacts to levels that are acceptable during implementation and operation of the projects. As an integral part of EA, ESMP provides an essential link between the impacts predicted and mitigation measures specified within the EA and implementation and operation activities. The World Bank guidelines state that detailed ESMPs are essential elements for Category ‘A’ projects, but for many Category ‘B’ projects, a simple ESMP will suffice. While there are no standard formats for ESMPs, it is recognized that the format needs to fit the circumstances in which the ESMP is being developed and the requirements that it is designed to meet.
2. The PIU is preparing a standard ESMP in a format suitable for inclusion as technical specifications in the contract documents. ESMPs should be prepared after taking into account comments and clearance conditions from both the relevant agency providing environmental clearance and World Bank. Given below are the important elements that constitute an ESMP. a. Description of Mitigation Measures
3. Feasible and cost-effective measures to minimize adverse impacts to acceptable levels should be specified with reference to each impact identified. Further, the ESMP should provide details on the conditions under which the mitigation measure should be implemented. The EMP should also distinguish between the type of solution proposed (structural and nonstructural) and the phase in which it should become operable (design, construction and/or operation). Efforts should also be made to mainstream environmental and social aspects wherever possible. b. Monitoring program
4. In order to ensure that the proposed mitigation measures have the intended results and comply with national standards and World Bank requirements, an environmental performance monitoring program should be included in the EMP. The monitoring program should give details of the following:
• Monitoring indicators to be measured for evaluating the performance of each mitigation measure (for example: national standards, engineering structures, extent of area replanted, and so on). • Monitoring mechanisms and methodologies. • Monitoring frequency. • Monitory locations. c. Institutional arrangements
5. Institutions/parties responsible for implementing mitigation measures and for monitoring their performance should be clearly identified. Where necessary, mechanisms for institutional coordination should be identified, as often monitoring tends to involve more than one institution.
104 d. Implementing schedules
6. Timing, frequency, and duration of mitigation measures with links to the overall implementation schedule of the project should be specified. e. Reporting procedures
7. Feedback mechanisms to inform the relevant parties on the progress and effectiveness of the mitigation measures and monitoring itself should be specified. Guidelines on the type of information wanted and the presentation of feedback information should also be highlighted. f. Cost estimates and sources of funds
8. Implementation of mitigation measures mentioned in the EMP will involve an initial investment cost as well as recurrent costs. The EMP should include cost estimates in the subproject design, bidding, and contract documents to ensure that the contractors will comply with the mitigation measures. The costs for implementing the EMP will be included in the subproject design, as well as in the bidding and contract documents.
105 Attachment 9: General Guidelines for Preparation of Medical Waste Management Plan Based on the Health Care Waste Management Guidance Note (Johannessen et al., May 2000)
Facility Assessment Checklist
1. General facility information
• How many employees does the facility have? • How many beds does the facility have, and what is the bed occupancy rate? • What medical and supporting departments does the facility have? (Include pharmacy, laboratories, kitchen, and general store.)
2. Handling of health care waste
• How much health care waste is generated daily by each department or at each ward/lab within the health care establishment? (Waste quantity may be measured using a small handheld scale.) • How much of this is special health care waste? (See Attachment 7.1 for waste definitions). The answer to this question will help determine the magnitude of the problem and treatment method. • What is the general composition of the waste, i.e., the percentage of plastic, cotton, food waste, sweepings, and pathological waste? Visit all wards, specialized departments, laboratories (including blood bank), pharmacy, kitchen, and general store to note the waste composition at each location. This can be determined visually, by glancing through the waste at the waste end-point inside the health care establishment. • How and where is the facility’s health care waste stored before collection? • Does any formal or informal separation of waste take place? For example, are syringes kept separately for resale? This type of operation (resale of syringes) should not be condoned. Are plastic I.V. sets kept separately for recycling? Are x-ray films collected for extraction of silver? • Does the establishment generate any wastes of special concern, such as radioactive waste, cytotoxics, pathological waste, reagents, or outdated pharmaceuticals? How and in which department are each of these special wastes generated? How is their disposal handled? • How is liquid waste handled? Specify for cytotoxics, reagents, and used x-ray film processing liquids. If the liquid waste is discharged in the sanitation system, where does the latter discharge and what is its capacity?
3. Treatment and disposal of health care waste
• What treatments (if any) are done to the waste before disposal? How efficient are the treatments and how are residuals handled? • Is the health care waste disposed of at the health care facility or off-site?
106 • If any waste is taken off-site, how is the waste transported outside the premises of the health care facility? How is the waste packaged? What types of vehicles are used to transport the waste? • Is any of the waste taken to a dump or landfill site? If so, what happens to the waste at this facility? Is the health care waste buried immediately after arriving at the landfill/dump? Is it burned on the site? Is it left unattended at any time after being unloaded? • If there is open access to the landfill/dump, to what extent do waste pickers, children, or others have access to the health care waste?
4. Management issues
• Who is responsible for health care waste management at the health care facility? • What are the current operational standards for health care waste and what are the applicable national, regional, and local policies? • How many people are involved in waste collection and are special skills required by the health care facility? What sort of worker safety measures are in place? • Is procurement of new health care materials reviewed to reduce the waste stream and to avoid potential treatment problems (such as PVC)? • What are the daily waste collection routines, including waste packaging? • What are the transportation needs and costs? • How much does health care waste management cost the facility? Does the budget provision cover these costs?
5. Risks of the current waste management system
• Does the management of the health care facility have concerns about the facility’s current health care waste practices? If so, what problems do they identify? • Does the assessment above indicate that the facility’s current waste management practices pose any health risks to patients, nurses or doctors, other staff, or visitors? If yes, what kind of risks? • Does the waste pose any risk to waste collectors? If yes, what kind? • What are the risks for spillage of waste or for scavenging along the transportation route? • Does the waste disposal system pose any risk to waste-pickers or users of resold/recycled waste? If yes, what kind?
Basic Steps in Medical Waste Management
1. Raise awareness at the management level and develop an integrated waste management Plan
6. The managers of the health care facility need to recognize the importance of good health care waste management, and should designate a special group with responsibility for overseeing the situation. This may be done by setting up a waste management team or by working with an existing infection control committee. A waste management team should include, at a minimum,
107 the manager of the health care facility and a representative for each of the following: procurement or accountants, physicians, nurses, and waste collectors. It is important to move beyond the committee and develop a waste management plan (including health care waste) for the facility that is integrated into the daily operations.
2. Ensure segregation of special health care waste from other waste generated at the establishment
7. Using the information gathered in 2.1 categorize the waste generated at the facility as either municipal solid waste or special health care waste (see definitions in Attachment 7.1). The first priority should be segregating sharps and pathological waste from all other waste. Sharps must be put into rigid, puncture-proof containers, which should be available at the health worker’s workplace. Pathological waste should be put into nontransparent plastic heavy-duty bags. When three-quarters full, the containers and bags should be disposed of safely. Toxic liquid and pharmaceuticals should also be separated from regular solid waste materials, and disposed of properly.
8. From a cost- and waste-management perspective, syringes that can be re-used (after proper cleaning and sterilization in a steam sterilizer) are preferable to disposable syringes. However, from a public health perspective, one-time use or auto-destruct needles are safer. Evaluation of local conditions is needed to make an informed decision. Badly designed needle crushers can lead to contamination of the crusher and the area around it, and/or generate many small sharps.
9. The report entitled Vital to Health? Briefing Document for Senior Decision-Makers (WHO/USAID 1998) listed in Section 6, contains more information on disposal of sharps. WHO has a new initiative devoted to the study and use of proper, safe injections (Safe Injection Global Network).
3. Determine the most appropriate treatment and disposal site for the facility’s waste
10. Generally speaking, small health care facilities in urban areas should choose off-site treatment and disposal for both economic and safety reasons—most often in the municipal landfill. Landfills must be carefully sited away from water sources, agricultural land, and land where other development might take place and should include liners to protect leaching (Technical Guide on Solid Waste Landfills, WHO). Landfills should be protected from human and animal waste pickers. Burial of health care waste and other municipal solid waste in a municipal landfill could be done by the person who delivers the waste from the health care facility, or by a person employed at the landfill. In either case, this person must receive specific instructions for such burial. Cytotoxics and other hazardous chemical wastes (see Attachment 7.1) should never be buried in a landfill, however. Instead, they need to be returned to the original supplier or incinerated at a central facility (see Annex D for the difference between burning and incineration). Other special HCW should also receive more intensive treatment to ensure a reduction in public health and environmental consequences.
108 11. Small, isolated facilities with limited resources and without access to centralized waste treatment and disposal may find burial of special health care waste their best solution. Such burial should be done only under controlled circumstances, in a secluded area following landfill principles, including liners, water diversion, groundwater monitoring, careful sitting, and gas release mechanisms.
4. Develop and implement a health care waste management plan
12. Every health care facility should have or develop a waste management plan that includes daily routines for collection, handling, segregation, and packaging of the different categories of waste. Facility managers should ensure that this plan is in place, with adequate budget and personnel to implement it. Implementation of the health care waste management plan and routine monitoring should be carried out in parallel with the information/training program described below.
5. Train health care workers in proper health care waste procedures
13. All health care staff should be aware of the facility’s basic health care waste management plan and their role in the plan. This includes management and regulatory staff, medical doctors, nurses and nursing assistants, cleaners, waste handlers, and visitors to the facility. The waste management plan should be presented in simple terms and displayed in a diagram at all points of waste generation. Better health and environmental working conditions for waste handlers should be addressed in planning resources for waste management. This includes but is not limited to the use of protective clothing and specialized equipment to ensure worker safety as well as safety for the general public.
14. Hands-on staff training in the details of the waste management plan is optimal. Training should include:
• Basic information about HCW and the risks of bad management of HCW. • Basic information on the facility’s waste management plan. • Each employee’s responsibility and role in health care waste management. • Technical instruction on application of the practices described in the waste management plan.
For more information on conducting training programs, refer to the Teacher’s Guide: Management of Wastes from Healthcare Activities (WHO, 1998) listed in Section 6.
109 Attachment 7.1: Types of Health Care Waste
Health care waste (HCW): The total waste stream from health care facilities, research facilities, and laboratories. Can be divided into municipal solid waste and special health care waste.
• No risk health care waste includes all waste comparable to domestic waste, such as packaging materials, noninfectious bedding, building rubble/demolition waste, hotel function waste (household, kitchen, administration), and other such wastes generated from patient wards and other patient care not related to medical care.
The WHO definition for special HCW is found in the box below.
Health Care Waste* is defined as the total waste stream from a health care establishment, research facilities, laboratories, and emergency relief donations. HCW includes several different waste streams, some of which require more stringent care and disposal:
1. Communal Waste is all solid waste not including infectious, chemical, or radioactive waste. This waste stream can include items such as packaging materials and office supplies. Generally, this stream can be disposed of in a communal landfill or other such arrangement. Segregation of materials which are able to be reused or recycled will greatly reduce the impact burden of this waste stream.
2. Special Waste consists of several different subcategories: • Infectious: Discarded materials from health-care activities on humans or animals which have the potential of transmitting infectious agents to humans. These include discarded materials or equipment from the diagnosis, treatment and prevention of disease, assessment of health status or identification purposes, that have been in contact with blood and its derivatives, tissues, tissue fluids or excreta, or wastes from infection isolation wards. Such wastes shall include, but are not limited to, cultures and stocks; tissues; dressings, swabs or other items soaked with blood; syringe needles; scalpels; diapers; blood bags. Incontinence material from nursing homes, home treatment or from specialized health-care establishments which do not routinely treat infectious diseases (e.g. psychiatric clinics) is an exception to this definition and are is not considered as infectious health-care waste. Sharps, whether contaminated or not, should be considered as a subgroup of infectious health-care waste. Includes: Syringe needles, scalpels, infusion sets, knives, blades, broken glass. • Anatomic: Consists of recognizable body parts. • Pharmaceutical: Consisting of/or containing pharmaceuticals, including: expired, no longer needed; containers and/or packaging, items contaminated by or containing pharmaceuticals (bottles, boxes). • Genotoxic: Consisting of, or containing substances with genotoxic properties, including cytotoxic and antineoplasic drugs; genotoxic chemicals. • Chemical: Consisting of, or containing chemical substances, including: laboratory chemicals; film developer; disinfectants expired or no longer needed; solvents, cleaning agents and others. • Heavy Metals: Consisting of both materials and equipment with heavy metals and derivatives, including: batteries, thermometers, manometers. • Pressurized containers: Consisting of full or empty containers with pressurized liquids, gas, or powdered materials, including gas containers and aerosol cans. • Radioactive materials: Includes: unused liquids from radiotherapy or laboratory research; contaminated glassware, packages or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclides; sealed sources. * WHO (1999), Safe Management of Wastes from Health-Care Activities.
110 Annex 10: Economic and Financial Analysis
MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
1. The underlying rationale for Madagascar Emergency Recovery Credit for an Emergency Support to Critical Education, Health and Nutrition Services Project – to provide financial assistance for basic education, health and nutrition service delivery in the most vulnerable communities needed to maintain basic social service delivery by making these services available and affordable – is a valid one.
Introduction: Macroeconomic Context
2. With a per capita GDP of US$459 in 2012 and about 77 percent of its population living in poverty58, Madagascar is one of the poorest countries in the world. After becoming independent in 1961, the country witnessed a long period of economic decline caused in part by poor governance and protectionist and inward looking policies. Two liberalization episodes in the late 1980s and 1990s improved economic performance. After the second episode, the country experienced a period of growth powered by industries that benefited from preferential trade access. Between 1997 and 2001, GDP grew at about 4 percent per year, while inflation was kept under control. However, the political crisis in 2003 halted this trend as GDP dropped by about 12 percent.
3. After 2002, the new Government’s sound macroeconomic management consolidated the gains of previous liberalizations and, despite large external shocks (e.g. cyclones, high oil prices, and the elimination of the multi-fiber agreement), growth resumed and continued until 2008 at about 5.6 percent per year. GDP growth came largely from improvements in agriculture, increased tourism receipts, and public investments. Through a tight monetary policy, inflation was also brought under control after a 27 percent rate in 2004 to 10.3 percent estimated for 2007 (period average).
4. In 2009, an un-constitutional transfer of power plunged the country into a second political crisis with severe socio-economic consequences. Since early 2009, the political crisis has led to a decline in economic growth, which at the beginning had been exacerbated by the negative impact of the global financial turmoil on export-oriented activities. In 2009, there was negative GDP growth of approximately 4 percent (compared to a positive growth of 7 percent in 2008), however by 2010 there was a weak rebound with an estimated growth slightly above 0 percent. Contrary to some other countries such as Guinea, some prudent fiscal and monetary policies have helped to keep the macroeconomic framework under control, with reasonable fiscal and external balances, and relatively stable financial indicators. In 2011, the GDP in real terms had not yet reached the 2008 level.
58 Household Survey, 2010
111 Table 1. Key Macroeconomic Indicators
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 GDP growth -12.4 9.8 5.3 4.6 5.0 6.2 7.1 -4.1 0.53 0.54 (1.94) Per capita GDP US$ 269 325 251 282 299 387 481 422 421 467 Inflation rate CPI1 16.2 -1.1 14.0 18.4 10.8 10.4 9.2 9.0 9.2 10.6 (9.54) fiscal revenue2 7.7 10.0 10.9 10.1 10.7 11.4 13.0 10.7 10.9 11.0 Non-fiscal revenues2 0.33 0.30 1.17 0.82 0.53 0.25 0.31 0.47 1.47 0.18 Grants2 1.6 4.5 8.2 5.7 9.8 4.3 3.4 1.2 1.0 1.9 Total Government 14.7 19.0 25.1 21.2 21.3 18.7 18.7 15.5 14.2 14.8 Expenditure3 Current account -10.8 -5.9 10.3 -11.6 -9.5 -11.9 -18.7 -21.4 -9.8 -5.9 balance3 Poverty rate 81 72.1 68.9 776 Poverty rate rural 86 77.3 73.5 826 Poverty rate urban 62 53.7 52 546 Source: World Bank calculations and World Economic Outlook Database, April 2012 IMF Notes: 1 percentage change in annual average of consumer prices; 2 as percent of GDP, PREM Madagascar data; 3Current account balance as percent of GDP after current grants, PREM Madagascar data; 4 Household Survey, 2010; 6Madagascar PREM team projection for 2011
5. The dramatic fall in GDP growth, combined with an increase in population growth of about 2.8 percent annually has led to a sharp decline of per capita GDP during 2009 and 2010. Per capita GDP rebounded in 2011, but did not yet reach 2008, pre-crisis level.
Figure 1: GDP growth rate and per capita trends since 2000 15 500
10 9.8 450 7.1 6.0 6.2 5 4.5 5.3 4.6 5.0 400 1.9 0 0.5 350
-5 -4.1 300 growth rate -10 250 -12.4 per capita -15 200
Source: Madagascar PREM team
6. The capacity to generate resources from tax revenues is one of the lowest in SSA and has been decreasing since 2008. Fiscal revenue, already low before the crisis at 13 percent of GDP in 2008, only constituted 11 percent of GDP in 2011. External funding for recurrent expenditures has also been on the decline, from MGA 128 billion in 2008 (pre-crisis) to about MGA 18 billion in 2010 (mostly HIPC initiative related), but reached about MGA 72 billion in 2011, which represents 57 percent of the pre-crisis external aid for recurrent expenditures. The
112 suspension of many donor activities led to significant cuts in investments and a sharp decline in the delivery of social services, since external aid financed at least 40 percent of the total government budget.
7. In 2008, in an effort to improve public resource management and strengthen the system of delivery of public services, the government strengthened the role of the regions by integrating de-concentrated services of the public administration under the authority of the regional chiefs. For the first time, budgetary resources were allocated to the regions, making them responsible for the implementation of a small part of the investment budget, but the budget management capacity and efficiency of the regional administrations is uneven.
Education Financing
8. Government budget constraints due to the decrease in external aid and domestic revenues since the start of the crisis severely impacted service delivery in education. Public expenditures on education, as a share of GDP, decreased from 3.6 percent in 2008 to only 2.6 percent in 2010 (see figures 2 and 3), representing a 30 percent reduction in constant 2010 prices. External aid to education for recurrent expenditures dropped by 44 percent between 2008 and 2011. Spending per capita, i.e. per primary student decreased by MGA 10,000 (about US$5), i.e. 15 percent decline from 2008 to 2011, whereas the education price index rose considerably over only two years, by 14.1 percent from 2010-2012, compared to the four years prior to the crisis 2004-2008, and 7.6 percent respectively (see figure 4). In comparison, overall annual consumer price inflation in Madagascar was 9.3 percent in 2010.
Figure 2: Total Education Expenditure as Percentage of Total Government Expenditures and in Percentage of GDP
Source: Estimates from World Bank, The Impact of the Crisis on Household Education Choices, 2012, (draft September 2012).
113 Figure 3: Education Expenditures in 2011 constant billion MGA 2011
Source: Estimates from World Bank, The Impact of the Crisis on Household Education Choices, 2012, (draft September 2012).
Figure 4: Education Price Index
Source: INSTAT in: World Bank, The Impact of the Crisis on Household Education Choices, 2012, (draft September 2012).
9. In spite of the government’s overall limited fiscal space, there is strong commitment for achieving the MDGs of primary education for all and gender equity, as indicated by the clear budget priority for education. Total recurrent public education spending constituted 19 percent of total recurrent government spending in 2011. Primary education receives the largest share of recurrent education expenditure, with 56 percent in 2011, which is a higher share than in most Sub-Saharan African countries. Recurrent expenditure consists predominantly in paying salaries, i.e. 89 percent for primary in 2011. Goods such as learning supplies and services only account for a small share, about 11 percent. The relatively low recurrent spending on pedagogical supplies and materials negatively impacts the availability of basic learning materials in schools and necessitates household contributions to meet this gap in public spending. This contributes to inequities in access to education.
114 10. In addition to public financing, households contribute substantially to the financing of education. In 2010, parents financed about 19 percent of total primary education expenditures and 30 percent of lower and upper secondary total education expenditures. 59 Families spent 3.1 percent of their total household expenditure on education in 2010, compared to only 2.1 percent in 2005. Family spending on schooling did not only increase in relative, but also in absolute terms: per capita education spending amounted to MGA 16,897 (US$8.45) in 2005 and MGA 18,926 (adjusted to constant 2005 prices, US$9.46) in 2010 respectively. The percentage of family education expenditures also grew for each consumption quintile, including the poorest (see table 2) from 2005 to 2010.
Table 2: Education Expenditure of Total Household Expenditure by Quintile (percentage)
Consumption 2005 2010 quintile (%) 1 2.2 2.4 2 1.9 2.6 3 1.5 2.6 4 1.8 3.0 5 2.4 3.4 Total 2.1 3.1
11. In 2010, the largest share of private primary spending went to school fees, (42 percent) which to a large extent finance community teachers in public schools, followed by pedagogical materials (35 percent), food expenditures (14 percent) and other such as e.g. transport (8 percent). This composition of household expenditures for education has remained stable over the period (2001-2010). The above only represent the direct costs of schooling to households, but do not reflect indirect costs such as opportunity costs, e.g. children not being available to help with field work or household chores60.
12. In summary, public expenditure for education decreased, requiring parents to cover this gap by raising private contributions to public primary education, in relative and absolute terms; in an environment of increasing prices for inputs such as learning supplies, further aggravating this situation.
Health Financing
13. Compared to other sub-Saharan countries, Madagascar spent little on health prior to the crisis, and under the current situation where donor financing decreased drastically the situation worsened. As seen in Table 3, the per capita spending on health is below the median in the region, and much below the US$30 to US$40 per person per year recommended
59 2010 Household survey 60 Analysis from the 2010 household survey indicates that the number of children below 5 years of age in a family increases the probability of school drop out of older siblings. This suggests that children are requested to quit school to take care of younger siblings.
115 by the WHO to finance a package of essential services61. At the current level of expenditures, the country will not be able to achieve the health related MDGs. Furthermore, since 2008 the per capita health expenditure decreased from US$22 to US$16 in 2010 jeopardizing many of the public health gains achieved. The political coup in March 2009 triggered the suspension of donor aid which accounted about 20 percent of sector expenditure according to the 2007 National Health Accounts (NHA).
14. Since 2009, the share of out-of-pocket expenditures in the total expenditure on health is increasing having a further negative impact on households’ well-being. Household expenditures, which constitute about 70 percent of private financing, are out-of-pocket expenditures in both public and private facilities, as pre-payment mechanisms only cover a small proportion of the formal sector workers. Prior to the crisis, in 2008, out of pocket expenditures accounted to 21 percent of total expenditures on health, their share increasing to 27 percent by 2010. The proposed project aims at reducing the burden on households and at making the services more affordable for the most vulnerable segments of the population. This in turn, will likely have a positive impact on demand of health services and translate to public health gains.
Table 3: Comparison in public health expenditure indicators between Madagascar and other SSA countries
Public health Public Health Public health Health expenditure expenditure as Expenditure as expenditure as Countries per capita (current percentage of percentage of GDP percentage of total $US) government (2010) health expenditure expenditure Madagascar (2010) 15.9 2.3 60.3 14.7 Ethiopia 15.7 2.6 53.5 13.5 Kenya 36.8 2.1 44.3 7.3 Malawi 25.6 4.0 60.2 14.2 Mozambique 21.3 3.7 71.7 12.2 Rwanda 55.5 5.2 50.1 20.1 Tanzania 30.9 4.0 67.3 13.8 Uganda 46.7 2.0 21.7 12.1 Zambia 72.9 3.6 60.3 15.6 Sub-Saharan African countries 85.0 2.9 45.3 10.8
Analysis of Main Education Features of the Project
15. The critical role of education in human capital formation, economic growth and development has been extensively documented.62 At the individual level, people with more schooling tend to be more productive, earn more, be healthier, have fewer children and are more likely to send their children to school.63 The priority investment in primary education in
61 Commission for Health and Macroeconomics, WHO 2002. 62 Hanushek and Woessmann 2007, Heyneman, Jamison and Montenegro 1984; World Bank 2011. 63 Hanushek and Woessmann 2009.
116 Madagascar is justified, because access to primary education continues to be a challenge in Madagascar despite almost a decade of progress. Madagascar had made substantial and continued progress in achieving the MDG of education for all up until the political crisis in 2009, though many challenges remained in terms of improving the quality of the education system. The primary completion rate doubled from 35 percent in 1999 to 71 percent in 2008. This enormous expansion in access was made possible by strong government commitment and a comprehensive set of ambitious reforms such as (i) government subsidies for community teachers; (ii) introduction of school management committees and school grants; and (iii) pedagogical reforms. However, the crisis wiped out a decade of progress in just a few years and the system’s performance has been on a path of progressive decline since then. The primary completion rate fell to only 61 percent in 2011. In 2010, more than 1.8 million of 10 to 18 year olds (41 percent) were still out--of-school. Among these, 0.7 million had never attended school and 1.1 million had dropped out. Moreover, severe disparities in access to education remain, especially between urban and rural children, as well as by level of income. The likelihood of being out of school for a girl is 1.3 times higher than for a boy, and being a girl in a rural area provides the least opportunity for enrolling and staying in school.
16. The main objective of the proposed project interventions in education is to preserve basic education service delivery by supporting community teacher salaries and providing school grants for learning supplies and school maintenance. Indirectly, this would contribute to preserving access and improving equity in primary schooling, especially for vulnerable groups, such as poor and rural children (the majority of schools in the regions supported by the project are in rural areas), and girls by reducing the costs of schooling for households and to help address shortages in public resources currently met by families. It would also strengthen community participation and enhance accountability for education service delivery. In addition, it plans to fund a basic school health package to enhance students’ health status and thus indirectly contribute to improving student attendance, and thus increase the ability to benefit from education services.
Cost Efficiency of Interventions in Education Supported by the Project
Cost Efficiency of Support to Community Teacher Salaries:
17. At the primary level, two categories of teachers exist in public schools: civil servant and community teachers. These community teachers are hired and are/were originally or partially financed by parents’ associations. To cope with rapidly increasing enrolment in primary education, which grew from 2.4 million in 2001 to 4.31 million in 2010, and to alleviate the financial burden on parents, the government decided in 2002 to subsidize the payment of progressively greater numbers of these community teachers. Since then, the number of community teachers has grown rapidly, from 31,512 in 2006 to 55,686 in 2010. This massive recruitment of community teachers and the financial support of their salaries by the government enabled a significant expansion of the total primary teaching force at lower cost, from 49,410 in 2000 to 81,791 in 2010 and constituted a reduction in the direct costs of education to families. By 2010, about 67 percent of all public primary school teachers were community teachers, of which nearly 71 percent received government subsidies for their salaries in 2011. Parents have had to step in to bridge the government financing gaps arising from the crisis.
117 18. To alleviate the direct costs of education to poor families, the project plans to support four months of salary payments to about 12,000 community teachers (non-civil servants) in the targeted five, largely rural and vulnerable regions.
19. The unit cost of one month of community teacher salary is MGA 110,000 (about US$55). Compared to the monthly unit cost of a civil servant teacher, which on average is MGA 380,000 (about US$175). The average annual salary of a civil servant teacher was MGA 4,580,000 (about US$2,290) in 2011, while annual subsidies allocated to a FRAM teacher amounted to about MGA 1,200,000 (about US$600). An analysis of spending on teacher salaries/subsidies demonstrates that the cost of community teachers is considerably lower than that of civil servant teachers, even if expenditures for community teacher subsidies were to increase gradually over time. Table 4 and 5 below illustrate the results of estimates of the numbers of teachers, expenditures on civil servant salaries, as well as subsidies to FRAM teachers assuming that the Government fully supported all of them.64 Therefore, project support to community teacher salaries is cost efficient.
Table 4: Estimate of the Number of Teachers
Actual Projections 2010 2011 2012 2013 2014 2015 2016 Existing civil servant 26,235 26, 698 25, 630 24, 605 23, 621 22, 676 21, 769 New civil servant 0 0 2, 825 5, 967 9, 430 FRAM subsidized 37,481 39, 585 44, 294 50, 446 54, 180 57, 707 63, 002 FRAM unsubsidized 16, 712 16, 101 13,316 10, 530 7, 745 4, 960 0
Table 5: Estimate of Salary and Subsidy Expenditures (in billion MGA)
Actual Projections 2010 2011 2012 2013 2014 2015 2016 Community teachers 41,19 44,98 51,74 62,68 77,28 90,05 103,99 Civil servant teachers 128,09 120,18 120,33 114,05 108,97 115,0 123,05
Cost Efficiency of Support to School Grants:
20. All primary schools, i.e. the school-based management committees have been receiving annual school grants on a per capita basis since 2002 to cover part of their operating expenses. Two approaches could be adopted for the acquisition of basic supplies and school maintenance: (i) centralized acquisition by the ministry or district and subsequent distribution to schools or (ii) local acquisition based on each school’s individual needs. Although centralized purchasing may reduce unit costs due to larger quantities, direct costs are associated with transporting and stocking materials, and indirect costs are associated with the distribution of centrally purchased supplies through the administrative chain to schools. Another consideration is that centralized purchasing may not correspond to the actual needs of schools. The second approach is currently used and will be adopted by the project, because it is considered more cost- efficient.
64 These projections and estimates are based on the following assumptions: (i) annual attrition rate of civil servant teachers of 4 percent; (ii) no more unsubsidized community teachers by 2016; and (iii) a new, downwardly revised pay scale for new civil servant teachers.
118 21. This component also comprises capacity building for school-based management committees (FAF) consisting of parents, teachers, the school director, and other community members65 to improve budget transparency and the effective administration and use of the grant, based on a school action plan. These school management committees have been in place since 2002 in all schools, are very active, and play a critical role in improving accountability of service delivery and promoting community engagement and social dialogue among local stakeholders. This type of institution was highlighted as a critical element in improving community social ties and reducing fragility.66 Many African countries have introduced school grants, with largely positive effects, such as improved enrolment and attendance.67
Cost Efficiency of School Health and Nutrition Package:
22. The Basic School Health Package funded by the project will consist of interventions including deworming and the provision of folic acid as preventive care for neglected tropical diseases—particularly lymphatic filariasis and malaria, which are endemic in the areas targeted for intervention. In accordance with the new WHO strategy on the use of anthelminthic drugs, the intervention will provide school-based deworming. The goal of these interventions is to increase school attendance and enhance learning capacities. Student illness is a major factor contributing to absence at school. School-age children usually have the highest intensity of worm infection of any age group,68 which can lead to lethargy, anemia and stunting. School-based deworming in African settings can generate immediate improvements in children’s appetites, growth and physical fitness69 and a large reduction in anemia.70 Although recent data specific to Madagascar are not currently available, intestinal worms account for an estimated 11 and 12 percent, respectively, of the total disease burden for girls and boys aged 5 to 14 in low- income countries. Intestinal worms therefore represent the single largest contributor to the disease burden of this group71. Furthermore, studies have found an association between worm infection and absenteeism: infected children have a greater number of absences from school than uninfected children. The frequency of the absences is linked to the intensity of the infection, to the extent that some infected children attend school half as much as their uninfected peers.72 Infections have also been found to have negative effects on child learning and cognitive function. One study of Tanzanian schoolchildren, for example, found that heavier worm infections such as those experienced by about 60 million schoolchildren could account for differences in learning ability tests equivalent to a six-month delay in development.73
65 World Bank (2012a). 66 World Bank, Political and Social Dynamics in Madagascar: Implications for the Design of a New Multi-sector Program (draft, June 8, 2012). 67 World Bank (2007). 68 World Bank 2006, Disease Control Priorities in Developing Countries, Second Edition, p. 473 69 Stephenson et al, 1993 70 Guyatt et al., 2001, Stoltzfus et al., 1997 71 World Bank 2003, “School Deworming at a Glance,” November 2003. 72 Nokes C, Bundy D. 1993, “Compliance and absenteeism in schoolchildren: implications for helminth control,” Transactions of the Royal Society of Tropical Medicine and Hygien, 87:148-1521. 73 Partnership for Child Development 2002, “Heavy schistosomiasis associated with poor short-term memory and slower reaction times in Tanzanian schoolchildren,” Tropical Medicine and International Health, 7, pp. 104-117.
119 23. With regards to the proposed school health interventions, studies have shown that school-based deworming is far cheaper than alternative methods of boosting school participation.74 In their 2004 evaluation of a Kenyan project in which seventy-five rural Kenyan primary schools were phased into deworming treatment, Miguel and Kremer75 found that the program is a highly effective way to boost school participation among young children. Besides, the evaluation of the Kenyan program also found evidence for positive externalities, namely improved health and school participation, for untreated children in both treatment schools and neighboring schools. Moreover, recent findings suggest that in the long term, deworming treatments for young children positively impacts educational investments and later income. A study in which treatment individual received two to three more years of deworming treatment more than the comparison group, found that self-reported health improved and years enrolled in school increased by approximately 0.3 years.76 Furthermore, the project will undertake mass drug administrations against lymphatic filariasis which usually occurs early in life but the impacts, temporary or permanent disability hindering full participation in social and economic activities, only emerge during adulthood.77
24. School-based deworming is a highly effective intervention to mitigate these issues, due to its low cost and high returns to education. Schools provide a readily-available structure for implementing such programs, as teachers require only a few hours of training to understand the rationale and learn to administer the medications. In a randomized evaluation of school-based deworming in Kenya, absenteeism was reduced by 25 percent. An investment of US$4 in deworming led to a gain of one additional year of primary schooling, at a significantly lower cost than other interventions (such as school feeding or the provision of uniforms) for the same effect.78 In addition, deworming has been found to increase the net present value of discounted wages by more than US$30 per treated child compared with per treatment costs of under US$1, constituting a high return for a small investment.79
25. Finally, deworming has positive spillover effects for untreated children and communities as a whole in that it reduces the transmission of infections. This effect leads to substantial improvements in the health and school participation of both treated and untreated children, in treatment schools and in neighboring schools.80
Cost-benefit of Investment in Basic Education
26. A multitude of international studies highlight the key role of education in economic and social development. In the context of human capital theory, many works of applied
74 Miguel and Kremer, 2004 75 Miguel and Kremer, 2004 76 Baird et al., 2011 77 Lymphatic Filariasis, WHO 2012 78 Miguel E. & Kremer M. 2002, “Worms: Identifying Impacts on Health and Education in the Presence of Treatment Externalities.” 79 World Bank 2006, Disease Control Priorities in Developing Countries, Second Edition, p. 478 80 Bundy, D. A., M. S. Wong, L. L. Lewis, and J. Horton. 1990. “Control of Geohelminths by Delivery of Targeted Chemotherapy through Schools.” Transactions of the Royal Society of Tropical Medicine and Hygiene 84: 115–20.
120 microeconomics have shown that education has a positive effect on the income of individuals and social outcomes.81
27. International evidence indicates that primary education provides the highest benefit in terms of social outcomes per dollar spent on education, compared to lower and upper secondary education. Table 6 highlights the positive effect of educational attainment on total social outcomes (defined as the average across the social outcomes of child bearing, antenatal health, child health and development and poverty, HIV/AIDS and the use of media).
Table 6: Contribution to Social Outcomes by Year of Education, Average for Sub-Saharan Africa
Lower secondary Upper secondary Basic education education education (6 years) (4 years) (2 years) Share of total change in social outcome (0-12 years) contributed by (average across all 47.7% 34.0% 18.3% social dimensions) Contribution to total social outcome per year of 8.0% 8.5% 9.2% schooling (a) Per student cost per year of schooling (expressed 11.5 24.4 57.1 in multiples of GDP per capita) (b) “Benefit to cost ratio” (a/b) 69 35 16 Source: Majgaard and Mingat, 2011
28. Each year of basic education contributes 8.0 percent to the total impact, compared to 8.5 percent for each year of lower secondary year, and 9.2 percent for an additional year of upper secondary schooling. The benefit-to-cost ratio, defined as the ratio of the contribution to total social outcome of each year of schooling to per student cost per year of schooling is 69 for basic education. Given the much higher costs of secondary education, the benefit-to-cost ratio drops to 35 for lower secondary, and to 16 in the case of upper secondary education. This implies that it is much more cost-effective to invest in basic education than in secondary education.
29. The results of the 2010 Madagascar household survey indicate that annual salaries increase with the level of schooling. These are estimated at MGA 676,000 for those who have never been to school, about MGA 2,830,000 for those with a university degree. As the proposed project focuses on primary education, it is therefore important to examine the gains that an additional year of primary education can provide, by estimating the wage income of an individual (or consumption per adult in a household) according to age (or age of the head of household) and number of years of education, according to whether the individual has never attended school or has a primary level education.
81 Duflo, E. (2001), “Schooling and labor market consequences of school construction in Indonesia: evidence from an unusual policy experiment”, American Economic Review, 91(4), pp. 795-814. Psacharopoulos, G. (1993), “Returns to investment in education. A global update.” Working Paper, No. 1067, the World Bank. Majgaard, K. and Mingat, A. (2012), “Education in Sub-Saharan Africa. A comparative analysis”, The World Bank, p.245.
121 30. Given the cost-effectiveness of investing in primary education overall, and the imperatives of the EFA and MDG goals within a resource-constrained environment, component 1 of the proposed project will therefore focus on primary education.
Analysis of Main Health and Nutrition Features of the Project
31. The five regions experience some of the worst public health outcomes in Madagascar. According to the 2008 DHS, Vatovavy Fitovinany had the highest infant mortality rate (98), and the highest under five mortality rate (187), highest fertility rate (6.5) in the country; Androy experienced the lowest vaccination coverage (30 percent) and the highest percentage of pregnant women who did not attend an antenatal consultation while pregnant (25 percent); Anamaron’I Mania and Haute Matsiatra had the highest malnutrition rates among children. Given the economic and political crisis, it is clear that the situation did not improve since the 2008 survey, and it is likely that the indicators worsened.
32. The health and nutrition components seek to reduce the out-of-pocket costs, through the removal of fees for certain essential drugs. There are currently no user fees associated with the delivery of basic health services in public health centers in Madagascar. Public health centers provide Malaria and Tuberculosis drugs, HIV tests, contraceptives, and vaccinations free of charges to their patients. Patients therefore have to pay out of pocket for all other essential drugs. This has contributed to the 20 percent82 decrease in the utilization rate of Basic Health Centers. It is in that light that the project will provide basic health centers with a few essential drugs: namely vitamin A, folic acid, benzathine penicillin, Zinc, Oral Rehydration Solution and Mebendazole. Furthermore, the distribution of the drugs will be made in conjunction with the delivery of specific health services. For instance, pregnant women will receive folic acid free if charges during prenatal consultations and children 6-12 months will receive free Vitamin A supplementation during vaccination consultations.
Costs of inaction on health outcomes
33. The impact of the current crisis on health outcomes are already seen and the costs of inaction are high in terms of mortality, morbidity, and losing previous achievements. Preliminary data from the MICS 2012 is showing deteriorating health outcomes in the project regions. Between 2008 and 2012 infant mortality rates in Androy and Atsimo Atsinanana have increased by 23 percent and 14 percent respectively to 65 and 72 per 1,000 live births respectively, from rates that are already higher than the national average of 48 deaths per 1,000 live births in 2008. Child mortality rate in Androy reached 100 deaths per 1,000 live births, increasing by 30 percent from the 2008 estimate.
82 Household Survey, INSTAT 2010
122 Figure 5: Trend of infant mortality rates in Androy and Atsimo Atsinanana between 2008 and 2012
80 70 2008 2012 2008 2012 72 60 65 63 50 53 40 2008 30 2012 20 10 0 Androy Atsimo Atsinanana
34. The poor outcomes are a result of worsening trends in health care utilization. Less children access antimalarial treatment for fevers, less births are attended by a trained medical provider, and fewer women deliver in a health center.
Figure 6: Trend in antimalarial treatment received by children who suffered a fever episode, 2008-2012
35 30 2008 2012 2008 2012 29.7 25 20 20.8 22.1 2008 15 2012 10 13.4 5 0 Androy Atsimo Atsinanana
35. These worsening trends are likely to accentuate especially since health center infrastructure is deteriorating, financing is low, and households have been pushed into deeper poverty. The proposed project seeks to avoid such scenario.
Costs and benefits of the interventions in health and nutrition
36. The maternal and child health subcomponent of the project seeks to expand access to an integrated basic package of health, nutrition and reproductive health services to 182,000 pregnant and lactating women and 750,000 children in the catchment area of 347 health centers, during the three years of implementation for a total cost of US$20 million.83 There are three essential packages: (i) the maternal and reproductive health package which includes assisted delivery, antenatal care, malaria prevention, and syphilis testing and syphilis
83 Since costs of implementation (PIU, training, monitoring and evaluation) are typically standard across interventions, these are not included in the cost / beneficiary discussion.
123 treatment antenatal care at a cost of prevention at an estimated cost of US$US$14.00,84 (ii) the child health package that includes routine immunization, malaria prevention and treatment, iron, Vitamin A and deworming, diarrhea treatment and acute respiratory treatment estimated at USD 3.30 per child, and (iii) the basic equipment package for the health center that ensures its functionality, estimated at USD5,900. The choice of integrated packages allows for increased synergy and efficiency across different groups of beneficiaries and in project financing.
37. The proposed maternal health interventions will not only reduce the death risk of these women, but will also diminish the neonatal mortality risk of their children. Maternal mortality in Madagascar has stagnated since 2000 and was estimated at 498 in 2008/09. The top four causes of maternal deaths worldwide occur during childbirth (hemorrhage, infections, eclampsia, and obstructed labor). Although Madagascar lacks an adequate referral and emergency system, many of these complications can be prevented at the basic health center through the interventions proposed by the project. Another way to improve pregnancy outcomes, and in the end influence the risk of maternal and neonatal mortality is through proper antenatal care which provides both the opportunity to reach a woman with important information regarding safe delivery, as well as necessary pregnancy related care and monitoring. Currently in Madagascar, these opportunities are largely ignored. Consequently, the proposed project activities will contribute to reducing maternal and child mortality in the project areas thereby strengthening the local economic activity in the long run. In fact, in the ‘human capital’ valuation approach, the cost of premature mortality is associated with loss of lifetime earnings for the individual and the economy as a whole.
38. Child health component of the project seeks to improve preventive and treatment services at the health facility: routine immunization, vitamin A supplementation, treatment for acute respiratory infections and malaria. These interventions will decrease morbidity rates and therefore decrease both direct and indirect costs to health systems and households for each case of vaccine-preventable diseases, avert vaccine-preventable deaths, and avoid caretakers’ lost productivity. With low cost and high efficacy, many vaccines are estimated to be cost-saving — the up-front expenditure for vaccination is entirely offset by costs averted through disease prevention.85 Jamison et al. estimated that the basic childhood vaccine program costs $14-20 per year of healthy life gained in low-income countries.86 In addition, there are broader economic impacts of immunization over the medium to long term. These impacts include protection against the effects of illness on physical, cognitive and emotional development, education attainment, labor productivity, income, savings, investment and fertility.87
39. For the HIV/STI component, the project will primarily focus on preventing transmission of HIV and syphilis in vulnerable risk groups with a particular focus on pregnant women. Although HIV prevalence is low in the general population, rates of STI are significant, with the prevalence of syphilis amongst pregnant women at 3.4 percent, with wide
84 UNFPA, 2005 85 Kim, J.J. The Role of Cost-Effectiveness in U.S. Vaccination Policy N Engl J Med 2011; 365:1760- 1761November 10, 2011, DOI: 10.1056/NEJMp1110539 86 Jamison, D. T., Mosley, W. H., Measham, A. R., Bobadilla, J. L. (1993): Disease Control Priorities in Developing countries. Oxford University Press. 87 Bloom, David E., David Canning and Mark Weston, "The Value of Vaccination," World Economics, 2005, Vol. 6(3), pp 15-39. 14.
124 regional differences. If left untreated during pregnancy, syphilis is associated with spontaneous abortion, stillbirth, premature delivery, low birth weight, and perinatal death.88 Screening and treatment of syphilis during pregnancy is considered to be highly cost effective.89 If all pregnant women were screened and those who tested positive were treated with one dose of penicillin before 28 weeks gestation, no stillbirths or neonatal deaths would be due to syphilis.
40. Nutritional interventions costs and beneficiaries. The nutritional interventions valued at USD 8.0 million for the duration of the project, will support interventions for approximately 575,600 of the 750,265 children under five accounted for in the health component. Approximately 6,000 community nutrition agents will be trained to continue providing services after the completion of the project. Two of the five regions targeted by the project, Matsiatra Ambony and Amoron’i Mania, have high prevalence of chronic malnutrition; and 4 out of 5 of the regions suffer high stunting rates for children 0-5 years spanning averages of 60 percent to 25 percent for moderate to severe chronic malnutrition. Through the provision of fortified food and nutrition education campaigns, the project aims to tackle acute malnutrition. A recent multi-country study showed that for every 10 percent increase in levels of stunting among children, the proportion of children reaching the final grade of school dropped by almost 8 percent90. A study in Guatemala demonstrated that improving physical growth among children less than two years of age resulted in a 46 percent increase in adult wages when these children grew up. Similarly, another study in China, which assessed the long-term effects of China’s 1959–61 famine, found that exposure to the famine in early life was associated with a reduction in height of 3 cm and lower incomes and wealth. Both studies confirm that improving nutrition in early childhood is a long-term driver of economic growth. 91
41. The focus on the “first thousand days” is crucial. Intervening within this period will have life-long and life-changing impacts on educational attainment, labor capacity, reproductive health and adult earnings.92 Research has illustrated that height-for-age at 2 years was the best predictor of human capital and under-nutrition is associated with lower human capital. In addition, damage suffered in early life leads to permanent impairment, and might also affect future generations and prevention will probably bring about important health, educational, and economic benefits.93
42. The project, building on past experience in Madagascar to scale up nutrition, will focus on proven cost effective interventions estimated at US$6 per capita, which is consistent with the global estimate of US$8-15. In 2008, the Copenhagen consensus ranked nutrition interventions as providing some of the most effective returns of all development
88 http://allafrica.com/stories/201206140101.html 89 McDermott J, Steketee R, Wirima J. Syphilis-associated perinatal and infant mortality in rural Malawi. Bull World Health Organ 1993; 71:773–80. and Terris-Prestholt F, W.-J. D. (2003). Is antenatal syphilis screening still cost effective in sub-Saharan Africa. Sexually Transmitted Infections , 79 (5), 375-81 90 Grantham-McGregor, S. et al (2007), ‘Child Development in Developing Countries: Developing Potential in the First 5 Years for Children in Developing Countries’, The Lancet, Vol. 369, No. 9555: 60-70. 91 Hoddinott, J., Maluccio, J.A., Behrman, J., Flores, R., and Martorell, R., 2008, Effect of a n u tritio n in te rv e n t during early childhood on economic productivity in Guatemalan adults Lancet 2008; 371: 411–16. 92 DFID and Nutrition: An Action Plan, DFID, London, 93 Victora CG, et al, for the Maternal and Child Undernutrition Study Group 2008, Maternal and child undernutrition: consequences for adult health and human capital. Article 2, Lancet 371, 340-57.
125 interventions94. Moreover, The Lancet, one of the world’s most highly respected medical journals, examined evidence from hundreds of studies in a variety of country settings and identified 13 highly cost-effective direct interventions such as vitamin A, and zinc supplements. Iodized salt, and the promotion of healthy behavior including hand-washing, exclusive breastfeeding, and complementary and therapeutic feeding practices. In line with these findings, the project is implementing a subset of the interventions identified by The Lancet in the broader program being supported by the government and other development partners. Namely (i) micronutrient supplementation programs (at less than US$ 50 per Disability-Adjusted Life Years or DALYs gained) and (ii) food supplementation targeted to children under two and pregnant women to yield higher benefits at lesser cost.95
43. The project brings considerable budget support to health and nutrition activities in the targeted regions through cost effective packages. In 2010, the per capital total expenditure on health was about US$16 out of which the per capita government expenditure was US$1096. Since the crisis, the government has had reduced fiscal space for health expenditures and the effect of the financing gaps have been more striking in the regions targeted by the project. The total annual per capita financing for all targeted beneficiaries under the health component is estimated at US$17. The unit cost of the nutrition component is approximately US$10.00. Together, the health and nutrition interventions are estimated at US$27 per capita per annum for all target groups. Thus, we can safely assert that US$27 investment per capital is likely adequate to close the financing gaps and achieve project objectives in the targeted areas. Moreover, this project will provide: (i) services that would not be otherwise available in the current context, (ii) increase the access; and (iii) alleviate out-of-pocket expenditures on maternal and child health and nutrition.
Justification for public sector involvement in the health sector
44. Targeted and effective health and nutrition interventions lie in the domain of the public sector. As a matter of fact, the human benefits surpass the financial costs of implementing them. In addition, poor health outcomes and malnutrition especially in the early period -10 to 59 months have proven cognitive impairments that significantly impact learning potential and negatively affect the overall productivity of the individual over the longer term. Low individual productivity ultimately results in reduced productivity for the local economy, thus affecting the economic well-being of the country as a whole. In this instance, the country, and more specifically the communities lacking an adequate delivery of social services, are better served by the leadership the public sector is taking in resolving this matter.
45. Moreover, the project targets a segment of the population accustomed to using public health services. The goal of any economic investment by the private sector is profit maximization. Thus, the latter is unable to respond to the needs of the poorest given their low purchasing power. Since the existing literature supports that nutrition interventions are more effective when they target the poorest segments of the population; the project rightly focuses on five of the most vulnerable regions in Madagascar also home to the poorest. This group is often
94 A Road Map for Scaling-Up Nutrition (SUN), 2010 95 Implementation Completion and Results Report: Madagascar Community Nutrition II Project. January 2012 96 WHO
126 unable to articulate demand for services as well as bear the economic costs associated with those services hence justifying the public sector’s involvement.
46. Externalities. One of the common justifications for government intervention in markets is the presence of externalities, where economic agents can impose a cost or benefit to others without paying or charging for it. Without government intervention, too much of the negative effect or too little of the benefit would be produced. When preventing or treating an infectious disease, individuals do not necessarily take into account the effect of their action (or lack thereof) on others. Without government intervention, the level of preventive and curative efforts will be lower than optimal. The Emergency Support to Critical Education, Health and Nutrition Services Project aims at financing many activities aimed at prevention and treatment of many of these diseases such as: immunization for childhood illnesses, testing and treatment of sexually transmitted diseases, and malaria control.
47. Public Goods. Some of the interventions used to prevent infectious diseases can be characterized as public goods. Nobody can be excluded from benefiting from a public good and having a person benefiting from it does not decrease the potential benefit to others. These characteristics render almost impossible the private provision of these goods. The Emergency Support to Critical Education, Health and Nutrition Services Project will finance such activities.
48. Equity. In general, a case can be made for the provision of health services that the poor consume more than the non-poor, where the income elasticity of consumption is low. Project regions have the worse poverty rates in the country and worsening poverty gaps. While the national poverty level increased by 9 percentage points between 2005 and 2010, reaching 77 percent of households, the highest rate in Africa97, the project regions are experiencing the worse poverty rates in Madagascar. The poverty gaps in these five regions are also among the worse in the country, and increasing at a rapid pace between 2005 and 2010.
97 According to the World Development Indicators, 2011
127 Figure 7: Poverty rates in 2010; trends in poverty gap index between 2005 and 2010
Source: Household Survey, INSTAT 2010
49. There are large inequalities across incomes and across regions in the utilization of health services in Madagascar, due partly to lower physical access to health services in rural isolated areas, and partly to financial and cultural barriers to access services. Government provision of services can also be justified on the basis of equity considerations. Indeed most of the activities that will be financed by the Emergency Support to Critical Education, Health and Nutrition Services Project meet this criterion by focusing on the poorest regions in the country where the per capita non-monetary return on investment in health is high.
50. There are also major imbalances in the distribution of staff across rural and urban areas and across various levels of service delivery. The current ratio of 1.05 health workers (doctors and paramedical staff combined) per 1,000 population is impacting access of the population, especially in rural areas, to basic health services. Significant percentages of health facilities operate below the Ministry’s own technical norms and standards and cannot provide the minimum package of services. Around 28 percent of doctors serve 75 percent of the population living in the rural areas and the remaining 72 percent serve the urban centers. The basic equipment package for health centers will ensure that the minimum technical and standards criteria are met in project areas.
128 Annex 11: Lessons Learned and Reflected in the Project Design
MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
1. The design of the project reflects key lessons learned from strong analytical work carried out by the Bank on the education and health sectors as well as previous Bank operations in the region (Table 1).
Table 1: Overall key lessons integrated into the project design
Sector Lessons Learned Lessons Learned and Integrated in the Project Design The inclusion of monitoring and evaluation To foster the availability of accurate data for analysis indicators in the project design is without value and use in decision making, the project includes if reliable data are not used in decision making mechanisms and activities to strengthen the existing and if, at project closing, comparable and monitoring and evaluation system and will use reliable information is not available. currently available data. Community involvement is a major success To encourage greater community involvement, the factor for improved governance and project supports capacity-building activities for key accountability throughout project actors at the school and health facility levels. implementation. Collaboration with NGOs has proven to be very The project will scale up this system through
Health and Education effective to reach the most vulnerable and the contracting with NGOs to accelerate progress and most remote areas. reach at-risk groups with critical interventions.
2. Salient lessons from similar health, nutrition, and STI/HIV/AIDS prevention projects in Madagascar have also informed the project design and include:
(i) Alignment with government’s vision and priorities as well as with the national MDG targets. The Ministry of Health and ONN have developed (respectively) an interim health sector strategy 2012–14 and the National Action Plan for Nutrition II 2012–15. The activities of the proposed emergency project are therefore based on the strategies and expected results outlined in both strategies and, as such, clearly reflect the needs and priorities of the health and nutrition sectors. The project design and objectives to be achieved are also aligned with the existing strategic plan and with the national MDG targets, namely MDGs 1b, 4, and 5. Moreover, priority interventions that are being implemented during the AF will be expanded to increase coverage under the new project.
(ii) Keep maximum flexibility to allow for response to urgent needs. The evaluation and implementation completion report for CRESANII showed that a flexible project design was important to permit a rapid response to national emergency needs during implementation. Given that the public health context is constantly evolving and Madagascar is subject to frequent cyclones and disease outbreaks that threaten public health, the proposed emergency project is being designed to allow some flexibility to redirect resources to address urgent needs while protecting priority activities. Although
129 the project design maintains flexibility, the performance indicators should reflect implementation progress as well as interventions actually financed to avoid any disconnect with achievement of the PDO.
(iii)Maintaining support to decentralized levels of the health and nutrition system is critical. Under previous Bank support, the implementation capacity of key technical Ministry of Health and ONN departments improved as a result of technical assistance and capacity building in planning, financial management, and procurement. A number of weaknesses remain, however, especially at the decentralized levels. The recruitment of external technical advisors and/or consultants is therefore required, not only to provide technical support on specific issues but to ensure the quality of services delivered and data reporting at the community level.
(iv) Cultivate complementarity among implementing partners in a context of limited resources. The proposed emergency project will leverage resources from AFD, which is currently funding regional and district budgets. In addition, the Bank is working closely with the EU to ensure that efforts are complementary with respect to geographic scope and interventions. Madagascar is also a recipient of financing from the Global Fund to Fight AIDS, TB, and Malaria (GFATM); owing to the global financial crisis, the GFATM faces a severe shortfall for current and future rounds of funding. The implications for Madagascar are significant, since the GFATM is the primary provider of drugs against those diseases. As a consequence, the current emergency project will support the procurement of STI/HIV and malaria drugs.
(v) Sound institutional arrangements to ensure timely implementation. To facilitate coordination, the project will be developed under the overarching umbrella of the Ministry of Finance and Budget. In addition, to improve collaboration between the heads of PIUs and the responsible agencies or ministries, the responsibilities assigned to each entity will be made clear from the start and documented in the Project Implementation Manual. Additionally, since the implementation of activities under the previous health and nutrition project was disrupted by political interference (particularly in 2002, 2007, and 2012), the current project will closely monitor the political situation and enhance technical dialogue with technical representatives from the Government of Madagascar.
(vi) Continue to support community-based nutrition interventions. The previous Bank- financed nutrition project significantly contributed to the fight against malnutrition in Madagascar. Furthermore, it showcased outstanding partnership between the government and major stakeholders in nutrition that will be pursued during the current project.
(vii) Reduce stunting rates among children under the age of two through close collaboration with PNNC. Since 2009, the PNNC has collaborated with the World Food Programme to produce routine data on underweight children under the age of two. The World Food Programme uses this data to inform its underweight prevalence interventions. The Multi Year Assistant Project, funded by the United States Agency for International Development (USAID) in Southeast, East, South, and Central Madagascar, also currently supports PNNC activities and distributes fortified blended food and vitamin A enriched oil to children under the age of two during the lean season. Thus,
130 support to severely stunted children under this project will build on PNNC capacities and existing mechanisms.
3. In the education sector, key lessons learned from other IDA education projects in the region and from other donor education projects in Madagascar were integrated into the project design and implementation arrangements for the respective activities (Table 2).
Table 2: Key lessons integrated into project design from the education sector
Lessons Learned Integration in Project Design Lessons learned from similar projects in other countries It is essential to be able to demonstrate quick and tangible • The project’s response to immediate needs in results for local communities in a crisis or post-conflict the sector consists of support to school context. Studies of Bank projects in 52 conflict-affected operational expenses, which covers basic countries highlight the importance of projects to quickly address learning supplies for students through school the most urgent needs of the sector, such as keeping schools grants as well as subsidies for community operational, supporting teachers, and providing students with the teacher salaries. necessary educational materials. Active community involvement in service delivery is a major • In parallel, capacity-building activities will success factor in many operations, as demonstrated, for focus on the regional and local level, most example, in the Niger Basic Education Project. School-based notably on school-based management management committees can play a key role in improving committees and parents’ associations. accountability, but their capacity needs to be built and strengthened. Lessons learned from other education projects in Madagascar A focus on capacity building for local stakeholders to • This project will therefore strengthen the improve implementation efficiency is key. The ongoing GPE capacity for the DRENs, CISCOs, and ZAPs grant implemented by UNICEF revealed that some stakeholders for supervision and monitoring of these are not familiar with all procedures related to community activities. teachers and school grants. • School-based management committees will receive training in the use and management of school grants, and parent associations will be trained in the teacher accountability process. Timely and regular communication of interventions to key • The activities include information and stakeholders is critical for an effective and smooth communication activities, such as brochures implementation of the activities. for school health activities. Strengthen accountability of the process on the Certification • Under the project, the format of and process of teachers services rendered. The current certification related to the certificate will be improved by: mechanism used, testifying that a teacher has indeed worked at (i) involving the direct beneficiary (the the particular school during the past two months for which teacher) in the process in addition to the he/she will be paid, does not involve the teacher but is handled school director and parents’ association; (ii) only by the school principal and parents’ association, which adding a section in which the teacher requests creates potential for collusion in creating a ghost teacher. his/her payment before approval by the school principal and the parent association; and (iii) including information on the teacher presence at the school in the form. Ensure school grants are disbursed to schools before the • The timely disbursement of school grants in start of the school year. Due to budget constraints, the advance of or at the start of the school year government has been unable to provide schools with sufficient will be essential to avoid any additional operating budgets in time for the school year for the last few expenses for parents. Mechanisms are years, often resulting in parents having to cover this gap. already in place to ensure the provision of
131 grants to school committees in a timely manner, such as the use of existing, tested financial service providers, among others. Maintain current payment mechanisms. The current GPE • The project will also use microfinance grant implemented by UNICEF has proven that nationally organizations to more efficiently channel accredited microfinance agencies ensure efficient payment in resources to schools and teachers and sustain remote areas where regular banks or post offices do not exist. In the current timely payment of teacher salaries fact, these microfinance agencies are closer to the schools and and school grants. charge lower service fees compared to the post offices.
132 Annex 12: Other Major Donor Interventions
MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
Major Partners
European Current GPE UNICEF France - AFD GPE Union •~US$26 m a •~US$10 m per •~€$10 m per •New project •~US$85 m year, closing year year until ~€10 m for expected to in December inclusive 2015 in 5 4/6 years finance 2012: education, regions to teacher identified gap
community curriculum take over FTI training, in the TESP teacher development, key activities training of (2013-15) salary, school teacher and activities school heads, grant, school training, on teacher institution kits, school preschool, training and development canteen, gender, CPRS institutional and school in vulnerable development management Education construction regions at local level at central level
France - AFD: World Bank European Union
•US$ 10 million (national) •US$ 6 million Additional •€30 million EU: (4th for Calendar Year 2012-13 Financing (AF) quarter 2012) Funding •US$ 30 million for FY14 •SIEF Funding for Nutrition only through NGOs (have (planned) Impact Evaluation (applied already coordinated under
June 2012) AF so regions are not •JSDF (application in overlapping) progress) •HSS Financing (planned Health request to Hub) •Health Results Innovation Task Force Country Grant (planned)
133 Annex 13: Documents in Project Files MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
Pôle de Dakar (2012), Household Education Spending–An Analytical and Comparative Perspective for 15 African Countries, UNESCO-BREDA, Dakar.
World Bank (2012), Les effets de la crise sur le choix éducatifs des ménages (draft, September).
World Bank (2012), Nutrition, education, and household wealth in two districts in Madagascar (draft).
World Bank (2012), Political and social dynamics in Madagascar: Implications for the design of a new multi-sector program (draft June).
MEN (2012), PIE—Plan intérimaire de l’éducation (draft September).
134 Annex 14: Statement of Loans and Credits MG- Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
135 Annex 15: Country at a Glance
MG–Emergency Support to Critical Education, Health and Nutrition Services Project (P131945)
136 137 138 IBRD 33439R 45°E 50°E
AntsirananaAntsiranana
MayotteMayotte MADAGASCAR (France)(France) AmbilobeAmbilobe
VohimarinaVohimarina AmbanjaAmbanja DIANADIANA MaromokotroMaromokotro (2,876(2,876 m)m) MassifMassif SambavaSambava TsaratananaTsaratanana SAVASAVA BealananaBealanana AntalahaAntalaha 15°S AntsohihyAntsohihy 15°S
BefandrianaBefandriana Sofi a MaroantsetraMaroantsetra MahajangaMahajanga SOFIASOFIA MandritsaraMandritsara zambique Channel MampikonyMampikony B SoalalaSoalala em a o y ri MananaraMananara v v Mo a v o v a BOÉNYBOÉNY M a a v a l a h a g ANALANJIROFOANALANJIROFO o h j a a g n BesalampyBesalampy m
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AndilamenaAndilamena B MaevatananaMaevatanana Soanierana-IvongoSoanierana-Ivongo f
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k MaintiranoMaintirano a AndilanatobyAndilanatoby
AnkazobeAnkazobe ToamasinaToamasina ANALAMANGAANALAMANGA BONGOLAVABONGOLAVA ATSINANANAATSINANANA AntsalovaAntsalova TsiroanomandidyTsiroanomandidy ITASYITASY ANTANANARIVOANTANANARIVO MiarinarivoMiarinarivo MoramangaMoramanga TsiafajovonaTsiafajovona INDIAN
(2,642(2,642 m)m) VatomandryVatomandry a AntanifotsyAntanifotsy MiandrivazoMiandrivazo t a OCEAN BeloBelo TsiribihinaTsiribihina r M VAKINANKARATRAVAKINANKARATRA ango a ro Tsiribihina Ma k nia AntsirabeAntsirabe MahanoroMahanoro 20°S n 20°S A MorondavaMorondava MalaimbandyMalaimbandy AMORON’IAMORON’I MMANIAANIA Ambatofinan-Ambatofinan- AmbositraAmbositra VarikaVarika MENABEMENABE drahanadrahana
AmbohimahasoaAmbohimahasoa MandabeMandabe
HAUTE-MATSIATRAHAUTE-MATSIATRA MananjaryMananjary ManjaManja FianarantsoaFianarantsoa BerorohaBeroroha VATOVAVY-VATOVAVY- MorombeMorombe goky Man FITOVINANYFITOVINANY 0 40 80 120 160 200 Kilometers AnkazoaboAnkazoabo PicPic BobyBoby ManakaraManakara (2,658(2,658 m)m) ATSIMO-ATSIMO- IhosyIhosy 040 80 120 Miles ANDREFANAANDREFANA IHOROMBEIHOROMBE M FarafanganaFarafangana 50°E na an ha an ec SakarahaSakaraha ar er a ih F BetrokaBetroka ToliaraToliara ATSIMO-ATSIMO- BetiokyBetioky Midongy-Midongy- nilahy MADAGASCAR O AtsimoAtsimo ATSINANANAATSINANANA SELECTED CITIES AND TOWNS TsivoryTsivory
BeraketeBerakete e REGION CAPITALS This map was produced by v a r the Map Design Unit of The d n NATIONAL CAPITAL World Bank. The boundaries, a
colors, denominations and AmpanihyAmpanihy M ANOSYANOSY any other information shown u RIVERS ra atea on this map do not imply, on nd y Pl ra dro AmboasaryAmboasary the part of The World Bank na An 25°S MAIN ROADS Group, any judgment on the AndrokaAndroka e TolanaroTolanaro M BelohaBeloha AmbovombeAmbovombe legal status of any territory, or any endorsement or ANDROYANDROY RAILROADS acceptance of such boundaries. REGION BOUNDARIES 45°E
MAY 2011