Document of The World Bank
FOR OFFICIAL USE ONLY
Public Disclosure Authorized Report No: 53766-YE
PROJECT APPRAISAL DOCUMENT
ON A Public Disclosure Authorized PROPOSED GRANT
IN THE AMOUNT OF SDR 23 MILLION (US$35 MILLION EQUIVALENT)
TO THE
REPUBLIC OF YEMEN
FOR A Public Disclosure Authorized
HEALTH AND POPULATION PROJECT
December 21, 2010
Human Development Sector Middle East and North Africa Region
Public Disclosure Authorized This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.
CURRENCY EQUIVALENTS (Exchange Rate Effective November 30, 2010) Currency Unit = Yemeni Rial (YER) YER 1 = US$0.00466146 US$1 = YER 214.5250 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS
CAS Country Assistance Strategy HCWMP Health Care Waste Management Plan CBN Community-Based Nutrition HF Health Facility CBY Central Bank of Yemen HMIS Health Management Information System CHV Community Health Volunteers HPP Health and Population Project CPAR Country Procurement Assessment Report HRSP Health Reform Support Project CSI Core Sector Indicator HSR Health Sector Review DA Designated Account HSS Health Sector Strengthening DALY Disability-Adjusted Life Year HTB High Tender Board DC Direct Contracting ICR Implementation Completion and Results Report DHO District Health Office IDA International Development Association DHS Demographic Household Survey IEC Information, Education and Communication EmONC Emergency Obstetric and Neonatal Care IFR Interim Financial Report EOI Expression of Interest IMCI Integrated Management of Childhood Illness EPI Expanded Programme on Immunization IMR Infant Mortality Rate ERR Economic Rate of Return ISA International Standards on Auditing ESIA Environmental and Social Impact Assessment ITA Independent Technical Auditor ESMP Environmental and Social Management Plan ITFF Independent Technical and Financial Firm FA Financial Agreement KAP Knowledge, Attitude, Perception FGM Female Genital Mutilation LCS Least-Coast Selection FGS Female Genital Schistosomiasis M&E Monitoring and Evaluation FMM Financial Management Manual MDGs Millenium Development Goals GAVI Global Alliance for Vaccine and Immunization MIS Management Information Systems GDDCS General Directorate for Disease Control and Surveillance MMR Maternal Mortality Rate GDFH General Directorate of Family Health MNA Middle East and North Africa GHO Governorate Health Office MNCH Maternal, Neonatal and Child Health GoY Government of Yemen MNH Maternal and Newborn Health
Vice President: Shamshad Akhtar Country Director: A. David Craig Country Manager Benson Ateng Sector Manager: Akiko Maeda Task Team Leader: Alaa Mahmoud Hamed Abdel-Hamid
ABBREVIATIONS AND ACRONYMS (continued)
MoE Ministry of Education RFP Request for Proposal MoF Ministry of Finance RH Reproductive Health MoLA Ministry of Local Administration RoY Republic of Yemen MoPHP Ministry of Public Health and Population RRA Rapid Results Approach MoWE Ministry of Water and Environment SBDs Standard Bidding Documents MTR Mid-Term Review SC Steering Committee NGOs Non-Governmental Organizations SCI Schistosomiasis Control Initiative NHA National Health Accounts SCP Schistosomiasis Control Project NHDS National Health and Demographic Survey SFD Social Fund for Development NPV Net Present Value SIL Specific Investment Loan NSCP National Schistosomiasis Control Program SOE Statement of Expenditure NTD Neglected Tropical Disease SSS Single Source Selection OM Operational Manual STD Sexually Transmitted Disease OPRC Operational Procurement Review Committee STH Soil-Transmitted Helminth OTP Outpatient Theraupetic Nutrition Centers STI Sexually-transmitted Infection PAD Project Appraisal Document SWAp Sector-wide Approach PAU Project Administration Unit TFC Therapeutic and Feeding Center PDO Project Development Objectives TFR Total Fertility Rate PFS Project Financial Statements TOR Terms of Reference PHC Primary Health Care ToT Training of Trainers PIP Project Implementation Plan UNDP United Nation Development Programme PMC Project Management Committee UNFPA United Nations Fund for Population Activities PMU Project Management Unit UNICEF United Nations Children's Fund PPA Project Preparation Advance WA Withdrawal Application QCBS Quality- and Cost-Based Selection WHO World Health Organization QS Consultant Qualification YFHS Yemen Family Health Survey YEMEN HEALTH AND POPULATION PROJECT CONTENTS
I. STRATEGIC CONTEXT AND RATIONALE ...... 3 A. Country and Sector Issues ...... 3 B. Rationale for Bank Involvement ...... 5 C. Higher Level Objectives to which the Project Contributes ...... 6 II. PROJECT DESCRIPTION ...... 6 A. Lending Instrument ...... 6 B. Program Objectives and Phases ...... 6 C. Project Development Objectives and Key Indicators ...... 9 D. Project Components ...... 10 E. Lessons Learned and Reflected in the Project Design ...... 14 F. Alternatives Considered and Reasons for Rejection ...... 15 III. IMPLEMENTATION ...... 16 A. Partnership Arrangements ...... 16 B. Institutional and Implementation Arrangements ...... 17 C. Monitoring and Evaluation of Outcomes/Results...... 18 D. Sustainability ...... 21 E. Critical Risks and Possible Controversial Aspects ...... 21 F. Grant Conditions and Covenants ...... 24 IV. APPRAISAL SUMMARY ...... 25 A. Economic and Financial Analyses ...... 25 B. Technical ...... 25 C. Fiduciary ...... 26 D. Social ...... 28 E. Environment ...... 29 F. Safeguard Policies ...... 30 G. Policy Exceptions and Readiness ...... 30 Annex 1: Country and Sector Background ...... 31 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies ...... 37 Annex 3: Results Framework and Monitoring ...... 44 Annex 4: Detailed Project Description ...... 48 Annex 4A: HPP Integrated Outreach, Community and Referral ...... 53 Annex 4B: Strategic Development Communication Strategy ...... 63 Annex 5: Project Costs ...... 65 Annex 6: Implementation Arrangements ...... 67 Annex 7: Financial Management and Disbursement Arrangements ...... 69 Annex 8: Procurement Arrangements ...... 80 Annex 9: Economic and Financial Analysis ...... 93 Annex 10: Safeguard Policy Issues ...... 100 Annex 11: Project Preparation and Supervision ...... 103 Annex 12: References ...... 104 Annex 13: Credits, and Grants ...... 105 Annex 14: Country at a Glance ...... 106 Annex 15: Country Map ...... 108
Republic of Yemen Health and Population Project Project Appraisal Document Middle East and North Africa MNSHD
Date: December 21, 2010 Team Leader: Alaa M. Hamed Abdel-Hamid Country Director: A. David Craig Sectors: Health (100 percent) Sector Manager/Director: A. Maeda/Steen L. Jorgensen Themes: Project ID: P Environmental Screening Category: B Lending Instrument: Specific Investment Loan
Project Financing Data [ ] Loan [ ] Credit [X ] Grant [ ] Guarantee [ ] Other:
For Loans/Credits/Others: Total IDA financing (US$m.): 35.00 Proposed terms: Standard IDA Grant Financing Plan (US$m) Source Local Foreign Total Recipient 2.31 26.04 28.34 International Development Association (IDA) 18.91 16.09 35.00 Total: 21.21 42.13 63.34 Recipient: Republic of Yemen Responsible Agency: Ministry of Public Health and Population
Estimated Disbursements (Bank FY/US$ m) FY 2012 2013 2014 2015 2016 2017 2018 Annual 2.0 3.0 6.0 6.0 6.0 6.0 6.0 Cumulative 2.0 5.0 11.0 17.0 23.0 29.0 35.0 Project implementation period: Start April 1, 2011 End: March 31, 2017 Expected effectiveness date: August 12, 2011 Expected closing date: September 30, 2017
Does the project depart from the CAS in content or other significant respects? [ ] Yes [X] No Does the project require any exceptions from Bank policies? [ ] Yes [X] No Have these been approved by Bank management? [ ] Yes [ ] No Is approval for any policy exception sought from the Board? [ ] Yes [X] No Does the project include any critical risks rated “substantial” or “high” [ ] Yes [X] No Does the project meet the Regional criteria for readiness for implementation? [ X] Yes [ ] No
Project development objective: The objective of the proposed Health and Population Project (HPP) is to improve access to and utilization of a package of maternal, neonatal, and child health services in selected governorates with a high concentration of districts with poor health indicators. The Project will contribute to the goal of achieving of MDGs 4 (decrease in child mortality) & 5 (improvements in maternal health).
1
Project description: The Project includes two components: (i) Component 1: Improving Access to Maternal, Neonatal and Child Health Services (US$30.5 million equivalent) which will support initiatives targeted to improve access to maternal, neonatal and child health (MNCH) services in geographic areas with poor MNCH indicators. Activities will include delivery of Outreach Services and selected upgrading of first level referral facilities. (ii) Component 2: Results-Based Monitoring and Evaluation and Project Administration (US$4.5 million equivalent) which will support activities related to the independent monitoring of project targets and audit of project outreach visits in addition to support for baseline surveys, mid-term and end-of-project evaluations.
Which safeguard policies are triggered, if any? OP 4.01 (Environmental Assessment).
Significant, non-standard conditions, if any, for: Board conditions: None
Covenants applicable to project implementation: The Steering Committee shall have the overall responsibility for Project oversight and policy guidance of the Project in accordance with the requirements, criteria, organizational arrangements and operational procedures set forth in the Operational Manual. The Recipient shall carry out the Project through the General Directorate of Family Health (GDFH), with the assistance of the Project Administration Unit (PAU) and the Outreach Services Team, all in accordance with the requirements, criteria, organizational arrangements and operational procedures set forth in the Operational Manual (OM) and the Financial Management Manual (FMM), and shall not assign, amend, abrogate or waive any provisions of the OM or the FMM without prior approval of the Association. The PAU is responsible for procurement and financial managements for the Project. At all times during the implementation of the Project, the Recipient shall maintain the Steering Committee, the PAU and the Outreach Services Team, all with a composition and resources satisfactory to the Association. The Recipient shall also maintain the PAU with staff whose qualifications, experience and terms of reference shall be acceptable to the Association. For the purposes of proper planning and implementation of Parts A.1 and A.3. of the Project, the Recipient, through the PAU shall: (a) not later than June 30, 2011, appoint, on terms and conditions satisfactory to the Association, an Independent Technical Auditor (ITA) to verify and certify that the planning and implementation of the outreach services and public health campaigns have been conducted in a manner satisfactory to the Association; and (b) not later than June 30, 2012, appoint an ITFF, on terms and conditions satisfactory to the Association for the duration of the Project implementation to verify and certify that the planning and implementation of the outreach services and public health campaigns have been conducted in a manner satisfactory to the Association. The Recipient through the GDFH, and with the assistance of the PAU and the Outreach Services Team, shall carry out the Project in accordance with the requirements and procedures of the ESIA (including the health care waste management plan and the ESMP) and shall not assign, amend, abrogate or waive any provisions of the ESIA (including the health care waste management plan and the ESMP) without prior approval of the Association. Not later than June 30, 2011, the Recipient shall appoint, on terms and conditions satisfactory to the Association, an environmental consultant to assist with implementation of the ESIA and ESMP.
2
I. STRATEGIC CONTEXT AND RATIONALE
A. Country and Sector Issues
1. The Republic of Yemen (RoY) was formed in 1990 by the unification of North and South Yemen and has a multi-party democratic system. The country has a diverse geographical topography, ranging from high mountainous regions to coastal terrains, deserts and islands. Based on 2009 data, Yemen has a population of 23.1 million living in approximately 136,000 settlements over an area of around 500,000 square kilometers. Almost three-quarters of the population live in rural areas.
2. Poverty is a nation-wide phenomenon with a higher concentration in rural areas (where 73 percent of Yemenis live). For nearly a decade after unification, Yemen achieved a reasonable annual GDP growth rate (5.2 percent), securing a decent 2 percent per-capita growth. Since 2000, GDP growth has steadily dropped as the Government became distracted from maintaining the momentum of reforms. First, pressures for fiscal prudence lessened as revenues increased significantly from the dramatic increases in oil prices since 2000. Second, security concerns have gained increasing political attention both in Yemen and in the region. During this period, the quality of governance also remained inadequate. Several reform initiatives floundered: the privatization process stalled, introduction of a general sales tax and the reduction in petroleum subsidies were repeatedly shelved, political commitment for legal and judicial reforms wavered, and the implementation of civil service modernization and health sector reforms slowed.
3. Yemen ranks 138th out of 179 countries on the 2008 Human Development Index. There has been an increase in average life expectancy (up from 41.6 years in 1970 to 62 in 2006) with the life expectancy of women mirroring the overall trends.1 Similarly, there has been a significant increase in enrollment rates in basic education (up from 3 million in 1996 to 4.1 million in 2004), yet female literacy rates remain low at 28.5 percent in 2002. There are many remaining areas of concern which are affecting the country’s development, despite achievements over the last three decades. Those most prominent and population- related are: (i) high and stagnated maternal, infant, and child mortality; (ii) high prevalence of malnutrition particularly for children under 5; (iii) rapid population growth (population growing at over 0.5 million people per annum); and (iv) high prevalence of malaria and schistosomiasis. Given these challenges, it is unlikely that Yemen will achieve the 4th Millennium Development Goals (reduce child mortality) or the 5th (improve maternal health) by 2015.
4. Infant and child mortality rates are among the highest in the region (lower than Djibouti and Iraq) and the maternal mortality rate is among the highest in the world. Almost half the population is underweight and more than 50 percent of the children are malnourished. Population growth is high (over 3 percent per annum) due to cultural preference for large families, limited access to modern contraceptives, and the desire for many children as a means to compensate for high infant mortality and the limited social safety net. The lower social status of women and girls, and their restricted mobility, has a negative effect on their health status and ability to get care when ill. Moreover, there is evidence that HIV/AIDS prevalence is rising, more than 3 million are infected with schistosomiasis (Bilharziasis); 1.2 million are suffering from malaria; and about 20,000 people are infected by tuberculosis. The health situation might be compounded by the perverse effects of qat chewing.
5. Total public spending on health remains among the lowest in the Middle East and North Africa (MENA) region, both as a percentage of total government spending (5.3 percent in 2006) and as a percentage of GDP (1.7 percent of GDP in 2007). Private health spending comprises the bulk of total health expenditures. About 67 percent of all spending on health is private, and of that 99 percent is direct
1 Human Development Index, UNDP, 2008 Statistical Update. 3
out of pocket spending (which has major implications, particularly for the poor, for access health services). Total per capita health spending (public and private) was about US$57 in 2006. A recently completed Bank-financed Health Expenditure Review (August 2009) highlighted a number of compelling challenges: (i) investment in building and equipping new facilities has outpaced the government’s budgetary capacity to staff them; (ii) at the same time investment spending has ballooned, the share of the budget devoted to maintenance and repair of existing equipment and facilities has been inadequate (at about 2.7 percent of total recurrent spending); and (iii) planning and budgeting has political undertones (with several programs which are not cost-effective being financed because they produce tangible outputs).
6. The challenges to improving the health status are enormous. There are limited financial resources both public and private, limited infrastructure (less than half the population has access to basic health services), and few systems in place to support service delivery (e.g., for medical supplies, drugs, etc.). In addition, most of the population lives in isolated rural communities which make the delivery of services at the community level difficult, and make it difficult for these people to travel to larger referral facilities. Moreover, the quality of health services is generally poor.
7. The Ministry of Public Health and Population (MoPHP) has set its highest priority to address the high rates of child mortality and maternal mortality, as well as addressing disease-specific health needs such as the high prevalence of schistosomiasis and malaria. To formulate a strategic approach for these priorities, in 2005 the MoPHP and its development partners initiated a dialogue to revisit the health sector strategy and evaluate the Government of Yemen’s (GoY) and donors’ approaches in order to improve health sector performance and its efficiency in the form of a Health Sector Review (HSR).2 However, it will take some time before the HSR is fully developed into a national sector strategy and program.
8. The ongoing HSR, once finalized, is expected to set priorities, define benchmarks, and develop detailed future strategic directions for the MoPHP to address these challenges and contribute to the design of a national program that better delivers health and population services. While these medium to long- term solutions are being defined, the pressing need to deliver services through population-based and disease-specific programs continues in order to address the major public health problems that face Yemen. This approach will be required until a routine system that can deliver integrated health services is in place, which will take years to introduce. During this interim period, the most realistic option is for the GoY and donor partners to continue to collaborate on the delivery of programs which address specific themes such as reproductive health, malaria, and schistosomiasis.
9. In light of these immediate priorities and pressing health needs, the Bank has responded by supporting two projects: (i) the Schistosomiasis Control Project (SCP)3 to decrease the high prevalence and intensity of infection of schistosomiasis in partnership with WHO and Schistosomiasis Control Initiative (SCI); and (ii) the proposed Yemen Health and Population Project (HPP) to contribute to the acceleration of the achievement of MDG 4 & 5 (reduction in childhood mortality and improvement of maternal health) through support for key initiatives targeted to improve access to and utilization of maternal, neonatal and child health (MNCH) services in selected governorates with poor MNCH indicators. The HPP is being prepared in partnership with UNICEF, UNFPA, and WHO. Malaria is being supported by the Global Fund to fight AIDS, tuberculosis and malaria.
2 This is the second HSR conducted by the MoPHP. A first draft was completed but is still subject for an intense review within the MoPHP. However, the draft developed would still require additional extensive work to be operational and can be used as a basis for IDA financing projects. A first HSR was finalized in 2000. 3 The SCP became effective on August 3, 2010. 4
10. The HPP will support the implementation of a program that delivers a basic package of MNCH services in rural and urban slum districts, where most of the population live, through an enhanced model of Outreach Services, building upon the service delivery model developed under the Global Alliance for Vaccine Immunization (GAVI)-funded Health Sector Strengthening (HSS) project, which is scheduled to close in 2010. The Project will be responding to a need to provide access to those populations which have no or poor access to MNCH services in geographic areas with poor MNCH indicators. This access is expected to contribute to addressing some of the major constraints to the achievement of MDGs 4 and 5.
11. There are five important improvements to the HSS delivery model being proposed: (i) expansion of the services provided to include reproductive health and nutrition; (ii) integration of the delivery of two public health programs, namely malaria and schistosomiasis, to enhance the sustainability of their delivery through the routine system as they are currently implemented through campaigns; (iii) expansion to reach ‘Needy Group Settlements’ (i.e., areas inhabited by neglected/vulnerable groups) and ‘Special Needs’ areas (i.e., remote areas or those with security concerns) for whom the use of mobile teams to match the current environment in the area would be more appropriate and effective; (iv) better linkage of MNCH Outreach Services with first level referral health facilities to ensure that a minimum of EMOnC (referral centers for reproductive health), Therapeutic Feeding Centers (TFCs)/Outpatient Clinics (OTPs) (referral centers for nutrition), Integrated Management of Childhood Illness (IMCI), and Basic Emergency Services are available; and (v) expansion of provision of MNCH services at the community level to complement and link the delivery at outreach sites and to link the referral of community-based services to the first level of the referral health facilities.
B. Rationale for Bank Involvement
12. The rational for Bank involvement is based primarily on the Bank’s: (i) comparative advantage in providing the funding and TA needed to support delivery of an enhanced HSS model; and (ii) considerable experience in both supporting Yemen's health program and collaborating with donor partners in the health sector as detailed below.
13. The GoY has requested the Bank’s assistance to support the provision of Outreach Services and its inclusion as an essential element of the health service delivery system to complement delivery at fixed health facilities. Since the majority of the population is living in rural areas4 that cannot be served by fixed facilities,5 Outreach Services are needed in Yemen given the particular geography, topography, and population distribution. Without using an outreach model, it is unlikely that the target population will be reached by services, and therefore their mortality and morbidity status will not improve.
14. Outreach Services were effective in increasing immunization 6 and utilization rates of child services in Yemen.7 The GoY would like to maintain the gains achieved during the last couple of years that have contributed to improvements in MDG 4, and would also likely have an impact on MDG5. Financial assistance is needed to expand geographically the delivery of Outreach Services beyond the regions supported by the GAVI-funded HSS and to expand its package of services to include reproductive health and nutrition services, thereby improving outreach service efficiency.
15. In addition, the GoY, the MoPHP, and the development partners have asked the Bank, given its comparative advantage in providing the necessary and balanced financial and technical assistance, to
4 75 percent of the population of Yemen lives in rural areas. 5 Only 50 percent of the population has access to services at fixed facilities. 6 Child immunization rates improved from 69 percent in 2002 to 87 percent in 2008 due to outreach services. 7 Details of utilization rates of child services in Yemen are provided in Annex 4A. 5
make delivery of the HSS model more efficient (by integrating additional services within the current delivery model), to enhance its opportunities for sustainability and to ensure the proper integration of reproductive health and nutrition services within Outreach Services. Also the Bank has considerable experience supporting the Yemeni health program.
16. During the proposed project period, the GoY, given the difficult budget situation, will not have adequate resources to continue to deliver Outreach Services at a scale that would affect the MDGs and maintain or increase the gains achieved without assistance from IDA. However, the GoY intends to build up gradually its financing of Outreach Services during the HPP project period as a demonstration of its commitment to this model and to ensure sustainability.
C. Higher Level Objectives to which the Project Contributes
17. The proposed Project will support the GoY’s efforts to achieve the 4th and 5th MDGs in reducing child mortality and improving maternal health, respectively. Specifically to support a reduction in child mortality, the Project will provide access to a more comprehensive basic package of child health services to under-served populations, including: (i) immunizations (a proven tool to control childhood infectious diseases); (ii) nutrition services; (iii) select vertical programs (e.g., malaria and schistosomiasis); and (iv) public health messages to address common childhood illnesses. With respect to maternal health, the Project places particular emphasis on delivery of a more comprehensive basic package of maternal health services (family planning, tetanus toxoid vaccines) to currently under-served populations, strengthening home-based delivery services (to address in part the high maternal mortality rates in Yemen) and referral services for complicated cases.
18. Moreover, the HPP is clearly linked to the FY10-FY13 IDA/IFC Country Assistance Strategy (CAS report no. 47562-YE, April 29, 2009) under the third strategic objective which is to foster human and social development (including health). In addition, results to be achieved under HPP are captured in the results framework of the CAS. Specifically for the health sector, the CAS calls for strengthening capacity and efficiency for the delivery of a basic package of health services (to be addressed under the HPP), improving the delivery of reproductive health services (to be addressed under the HPP), and reducing the prevalence of schistosomiasis (to be addressed under the SCP and HPP).
II. PROJECT DESCRIPTION
A. Lending Instrument
19. The proposed Project will be a Specific Investment Loan (SIL), to be implemented over six years and financed by an IDA grant. B. Program Objectives and Phases
Evolution of Outreach Services in Yemen
20. The Yemeni health delivery system depends mainly on fixed facilities to provide health services to populations living in the vicinity of the facilities as well as vertical programs to address priority public health problems.
6
21. The 2000 Health Sector Reform Strategy (HSR)8 criticized the overdependence on public health fixed facilities9 because of their inability to reach the entire population and meet their health needs. The HSR reflected a number of consequences as follows: (i) low outpatient utilization rates ranging between 0.58 to 2.7 in different areas of the country; (ii) underutilization of public health facilities due to issues of access and quality with an average daily health care visit to staff ratio of only 2.2; and (iii) lack of provision of health services and essential drugs in public health facilities leading to a bypass rate between 42 and 73 percent. Low geographic access (only 30 percent of the rural population have access to health care), and an overall access of 67 percent led to large inefficiencies in the use of public health sector capital and human investments and low health coverage; e.g., the immunization coverage rate declined to 66 percent in 2003 compared to 76 percent in 2000.
22. The strategy argued for introducing outreach health services to those with no or poor access to health services, as well as making efficient use of resources spent on national and sub-national polio campaigns; these were early activities carried out to reach the population with services beyond fixed health facilities. The strategy considered providing and making available low cost essential drugs and packaging of health services through outreach. It aimed to ensure coverage of the entire population, including the poor and the near-poor as an approach to poverty alleviation. It recommended payment of lower transportation and direct service provision costs. The HSR also stressed the importance of integration of services and considered it as one of the main basic principles of District Health Systems and argued to integrate resources and activities of the different vertical programs, e.g., vehicles and supervision visits. Service integration was identified as one of the areas where donor support is most needed.
23. Outreach Services evolved through different phases. In the first phase, EPI Outreach Experience (2004-2007), the MoPHP started its outreach services to overcome the accessibility barrier to improving vaccination coverage. By December 2005, Penta3/DPT3 through outreach achieved remarkably better results than fixed facilities (85 percent vs. 58 percent) and maintained these results throughout 2005 to 2009. More importantly, the percentage of districts achieving more than 80 percent immunization coverage has progressively increased and nearly tripled compared to the 2003 level. In 2009, coverage showed that outreach services constantly provided nearly one third of the coverage. In the second phase, the IMCI/Child Outreach Experience (2007-2008), another model of delivery of outreach services was piloted using mobile teams. However, this model did not plan their visits based on principles of micro planning at the district level, and accordingly provided services irrespective of the size of targeted population or the geography of the area. It did not achieve results comparable to the GAVI-HSS Outreach.10 In its third phase, the GAVI- HSS Outreach Experience (2008-2011), a GAVI-funded Health Systems Strengthening (HSS) project was launched aiming to improve nation-wide efforts to reduce child and maternal mortality, and to halt/reverse the spread of malaria and TB building on the success of the EPI (Expanded Programme on Immunization) program outreach model. It supported functional integration of seven vertical health programs [EPI, Reproductive Health (RH), Malaria, TB, IMCI, nutrition, and bilharzias] in 64 districts in 17 governorates between 2008 and 2011. The HSS conducts
8 Health Sector Reform in the Republic of Yemen: Strategy for Reform. Ministry of Public Health, Sana'a, Republic of Yemen, Final Version, October 2000. 9 In addition, the current health system model results in a lack of outreach services and over-dependence on stationary care facilities. This is an unrealistic strategy given the geography and level of health care awareness of the population of Yemen. The geographic dispersal of the population means that they cannot easily reach these stationary facilities for all their needs, and low health awareness means that many remain unaware of the need for preventive and early curative services, and as such need a proactive health service. 10 Comparing results in 11 districts, the IMCI model reached 5548 child with services in 2008 compared to 53,783 child reached using HSS mobile team model in 2009. In addition, as family planning services were integrated, the IMCI model reached 1,373 in 2008 with services compared to 8,561 women reached using the HSS model in 2009. 7
quarterly outreach rounds; i.e., 4 rounds per year. In 2008, the results of the HSS integrated outreach activities showed remarkable improvements, as follows:
• Coverage of EPI increased: Penta3 by 35 percent, measles by 34 percent, tetanus toxoid 2 by 72 percent. • In certain geographic areas, other services, including IMCI, RH and Nutrition, were piloted as part of outreach. • Outreach became more efficient as the cost per child during the EPI outreach decreased from US$1.3 to US$1 for integrated outreach.
Target Population, Target Areas, Intervals of Outreach Rounds and Staff Pattern (2011-2016)
24. The HPP will support the evolution of the delivery of Outreach Services in its fourth phase. A package of MNCH services will be provided gradually in a phased and incremental approach to provide access to populations which have no or poor access to MNCH in geographic areas with poor MNCH indicators. This access is expected to address some of the major constraints to the achievement of MDGs 4 and 5.
25. Decisions to support a follow up phase of incremental upgrading/integration of the package of Outreach Services (for example: broadening the package of services to include reproductive health services and/or nutrition at the basic or advance level, linkage to referral centers, and provision of community services) will depend on furnishing evidence that the efforts to support the implementation of an earlier phase were successful as well as to demonstrate that the criteria required to advance to a follow up phase were met.
26. The package will be provided initially in priority rural/urban slums areas11 where most of the population is not reached by health services and is most affected by child and maternal morbidity and mortality. This will be done through an enhanced model of Outreach Services, building upon the lessons learned from the service delivery model developed under the GAVI-funded HSS project. It is planned to be delivered using mobile teams through outreach rounds approximately every two months (6 rounds per/ year on average).12
27. The package will be provided in selected governorates 13 before rolling it out to new rural governorates targeting children under 5 and child bearing age women. The whole community will be targeted for health education messages as well as for public health programs: malaria and schistosomiasis, which will be integrated within the package to sustain the delivery of these vertical public health programs.
The Service Delivery Model
28. The delivery of the integrated package of services will be based on standards and guidelines for integrated service delivery and facility-based health planning that are suited to the topography, geography, and population distribution in Yemen and that are consistent with the current and planned capacity development.
11 Second and third levels of catchment areas. 12 Previous studies show that such interval will not allow for the immunity that developed after immunization to fade. 13 Sana’a, Ibb, Reimah, Al Dahla’a, Al Baydah, and Aden (urban slums only). 8
29. The model will achieve a balance among the delivery of MNCH services based on the principle of continuum of care throughout the lifecycle (childhood, adolescence/adulthood, pregnancy, childbirth, postnatal period), and between places of service delivery (including clinical care settings, outreach, and household and communities). The model will complement: (i) service delivery in fixed facilities where fixed facilities cannot operate; and (ii) community-based services provided through government as well as development partner resources. It is planned that an integral part of the delivery mechanism will be to: (i) reach on a permanent basis populations living in areas that are not covered by fixed facilities; and (ii) reach on a temporary basis populations in areas that could be covered by fixed facilities in the future.
The Service Delivery Package
30. The model of service delivery to be supported under the HPP, which will upgrade the HSS model, will comprise provision of services at three levels: (i) integrated Outreach Services to deliver a defined core package of maternal and child health services at temporary sites using mobile teams on a periodic basis (reaching an average of six rounds by the end of the project); (ii) complementary community-based services focusing on health education, active case finding, and referral by Community Health Volunteers (CHVs) in addition to home-based delivery by midwives; and (iii) referral facilities for management of complicated cases that cannot be treated at the outreach level. This model will complement the routine delivery of services through fixed facilities and is not intended to replace it.
31. The outreach level, provided through mobile teams, will include teams of four health workers originating from fixed health facilities to provide PHC services to children under 5 years old and women of reproductive health age (including pregnant and lactating women). CHVs will join outreach rounds to provide health education activities and identify cases which would benefit from follow up services at the community level in between outreach rounds.
32. The referral level, provided through fixed facilities, will include at least one referral facility to provide secondary/tertiary care services at the governorate and/or district level for cases that need additional nutrition and/or maternal health care services. Cases will be referred based on screening during outreach rounds and/or active case findings at the community level. The referral facilities will provide EmONC (basic and/or comprehensive) for reproductive health, TFCs and OTPs for nutrition. Referral to this level will be based on a defined set of criteria.
33. The community level, provided particularly between outreach rounds, will include: (i) CHVs to provide health education, active case finding of complicated cases for children and their referral; and (ii) community midwives to provide maternal health services including normal delivery, and active case finding for risky cases of pregnant and lactating women.
C. Project Development Objectives and Key Indicators
34. The objective of the proposed Project is to improve access to and utilization of a package of maternal, neonatal, and child health services in selected governorates with a high concentration of districts with poor health indicators.
35. The Project will contribute to the GoY’s goal of achievement of MDGs 4 (decrease in child mortality) and 5 (improvements in maternal health). Direct project beneficiaries are expected to include the people receiving the Outreach Services provided through the project’s activities.
36. The key indicators to measure achievement of the PDO include:
9
• Increase in access to MNCH services due to Outreach Services. • Increase in utilization rates of MNCH services due to Outreach Services.
D. Project Components
37. The project cost is estimated at SDR 23 million (US$35million equivalent) and will include the following components:
38. Component 1: Improving Access to Maternal, Neonatal and Child Health Services (US$30.5 million equivalent). This component will support initiatives targeted to improve access to MNCH services in geographic areas with poor MNCH indicators. Activities will include delivery of Outreach Services and selected upgrading of first level referral facilities. It will comprise three subcomponents.
39. Sub-component 1.1: Delivery of Outreach Services (estimated US$17.5 million equivalent). This sub-component will support the following set of activities:
(i) Provide/expand access to a basic MNCH package of services to populations with no or limited access to health services, using a service delivery model of routine mobile outreach health services (Outreach Services). This model will complement service delivery in fixed facilities as well as community-based services provided through GoY and development partner resources.14 It will also increase the demand for the delivery of services through fixed facilities and strengthen referral of cases to these facilities. (ii) Integrate reproductive health and nutrition services within Outreach Services.15 (iii) Integrate the routine delivery of selected vertical public health programs, such as malaria and schistosomiasis, within Outreach Services.16 (iv) Make available essential drugs, diagnostics, supplies, and equipment for MNCH services (including contraceptives) for Outreach Services. The project will also support strengthening the logistics management system for Outreach Services to ensure the timely availability of quality drugs and health commodities. (v) Strengthen health management information systems and quality assurance to ensure the proper functioning and monitoring of Outreach Services. (vi) Make available program operating costs necessary to roll out Outreach Services.
40. Rolling out of Outreach Services. Specifically, the sub-component will support, in the project governorates, a population-based program that delivers a basic package of MNCH services in rural and
14 UNICEF will be supporting community-based services in the governorates of Sana’a and Ibb to complement the routine outreach services supported by this project in these two governorates. JICA is supporting community-based services in six districts in Yemen in three governorates, two of which (Sana’a and Ibb) are to be supported under the HPP. Community- based services design and plans are based on the experience that was implemented by the GAVI-funded HSS Project. Collaboration with the Social Fund for Development to support community-based services is being explored. 15 Currently the package of Outreach Services focuses primarily on immunization and other basic child health services such as IMCI. Only Sexually Transmitted Diseases (STDs) from reproductive health services are incorporated within the package. 16 Drugs and impregnated bednets will be supplied by the respective national control programs for schistosomiasis and malaria financed by the IDA financed project, Schistosomiasis Control Project, and Global Fund Project. The HPP will finance the operating costs necessary to improve the routine coverage.
10
urban slum districts through an enhanced model of Outreach Services, building upon the service delivery model developed under the GAVI-funded HSS project, which is scheduled to be completed in 2010.17
41. Geographic Targeting. The package of MNCH services is to be provided initially in priority rural areas in the following governorates: Sana’a, Ibb, Reimah, Al Dahla’a, Al Baydah, and urban slums in Aden18,19 before rolling it out to additional rural governorates.20 The delivery would be rolled out gradually in a phased and incremental approach based on a roll out plan.
42. Communication Strategy. The service delivery model will be complemented by demand side activities through the design and implementation of a communication and social mobilization strategy and detailed action plan. The overall goal of this strategy will contribute to the HPP’s objectives of improving access to MNCH services in geographic areas with poor MNCH indicators as well as the delivery of Outreach Services and upgraded first level referral facilities. The impact of the communication interventions will contribute to the reduction of morbidity and mortality and improvements in health status.
43. The objective of the communication strategy will be to: (i) promote the benefits of the new integrated service delivery model; (ii) raise public awareness about the availability of the outreach service interventions as well as the routine-based preventive services through fixed facilities and community- based services, to contribute to increased service utilization and compliance; and (iii) promote behavior modification among targeted communities to improve utilization of low demand services such as maternal health, family planning, and nutrition. The key message will be that attending Outreach Services at regular intervals and visiting fixed health facilities in between, or seeking services at the first referral level of health facilities for complicated cases, will result in reduction of morbidity and mortality and improvements in health status. In support of the above, the strategy will include capacity development of the Outreach Services program in terms of communication planning and implementation.
44. This sub-component will support a formative research study to identify communication needs, key behaviors, targets, beneficiaries, and influencers for child and maternal health and nutrition and prepare a communication strategy and plan in the first year of project implementation. The strategy will propose key messages to be disseminated through communication channels and media and training requirements.
45. Outreach Workforce Development. In addition, this sub-component will strengthen the capacity of the health workforce to administer and deliver basic MNCH services through Outreach
17 The design of the interventions also takes into consideration the relative strengths and lessons learned from a host of other initiatives, including the district level planning process of the HRSP, the MoPHP’s EPI program, and the Dutch-financed MNH program. 18 The governorates were selected through the following process: The relative ‘riskiness’ of each district was evaluated using the following criteria: population density, immunization rate for children, tetatus toxoid immunization rate for women, and ratio of deliveries attended by skilled health personnel. The presence of funding from other development partners was also taken into consideration in order not to duplicate resources. Based on these criteria, 100 districts with poor indicators were identified and grouped by governorate. The governorates with the most concentration of districts with poor indicators were selected. 19 In Aden governorate, the project will support Outreach Services in its rural district (Boureika) and its urban slums districts (Dar Saad, Sheikh Othman, and Crater). 20 The selection of these governorates would be revisited if their situation changes and the above mentioned criteria do not apply anymore such as the presence of a major donor funding them or a change in the governorates security situation before implementation.
11
Services by developing manpower training programs, with priority focus on midwives and health administrators. This upgraded manpower training program will be rolled out in the project governorates.
46. Systems for Outreach Services. This sub-component will focus on strengthening the systems which support the effective delivery of Outreach Services in the project governorates. It will finance technical assistance to assess options for improving: (i) the logistics management system; (ii) Health Management Information Systems (HMIS); and (iii) quality assurance systems for referral health facilities. Based on the findings of the technical assistance assessment, selected applications of the above will be adopted and financed in the project governorates.
47. Sub-Component Inputs. The inputs to this sub-component will include financing for: (i) Outreach Services program operating costs; (ii) procurement of essential drugs, diagnostics, kits, equipment, and supplies (including contraceptives) and other related health commodities which are not currently available through the MoPHP or other donors; (iii) training workshops for health workers, midwives, and health administrators; (iv) design and implementation of communication and social mobilization campaigns; (iv) costs of printing of communication and training materials, production of TV spots, and other capacity-building materials; (v) provision of technical assistance and procurement of goods to apply logistics management, health management information, and quality assurance systems for Outreach Services; (vi) procurement of IT equipment, software, and related training; and (vii) consulting services to support the above.
48. Sub-component 1.2: Upgrade of First Level Referral Facilities and Provision of Community-Based Health Services (estimated US$7.0 million equivalent). This sub-component will support the following set of activities:
49. Referral Centers. Outreach mobile teams and community-based workers will identify and refer complicated cases which require additional services to the appropriate level of fixed facility. This sub- component will provide targeted resources for basic equipment and drugs, and training for physicians, health workers and midwives at health facilities in the project governorates to ensure that (at a minimum) the following services are available: (i) EmONC (the referral services for reproductive health); (ii) TFCs/OTPs (the referral services for nutrition); (iii) referral services for IMCI; and (iv) Basic Emergency Services. 21 Project-financed investments will complement those of ongoing government and development partner programs which are investing in EmONC,22 TFC and OTP 23 services in the project governorates. Support will also be provided to meet the PHC service requirements for the population residing in the catchment area of these facilities.
50. Community-based Delivery Services. This sub-component will support strengthening community-based health services and home-based birth delivery services. This will include the procurement of basic drugs and equipment and training of midwives as follows: (i) two to three years training to produce new midwives to cover existing workforce gaps in the project target governorates; (ii)
21 It is expected that about 70 first level health facilities will be targeted under the project. Technical assistance will be provided to develop health and investment plans for the first level referral facilities in the project governorates. These plans would identify facilities for investment under the project that have high utilization rates, are operational and have adequate capacity to delivery services, and are accessible to the population in the project governorates. 22 Expected to be funded by UNFPA and the Dutch (10 governorates to be expanded to 22 governorates) through a national plan to roll out EmONC services that will be developed by UNFPA. The Social Fund for Development is also contracted by the Dutch to roll out EmONC services. 23 Expected to be funded by UNICEF through a national plan to roll out TFCs and OTPs that will be developed by UNICEF. The EU provided a EUR 5 million grant, managed by UNICEF, to support nutrition. 12
one month training for existing midwives to upgrade their skills; (iii) training of community health volunteers; and (iv) procurement of kits and supplies for community-based services and home-based delivery. Through these investments, it is expected that the midwives will be better able to support home- based deliveries, referring the risky and complicated cases to the first level referral facilities as needed. CHVs will be able to provide health education activities and active case finding of complicated cases and their referral to the appropriate level. Community midwives will be contracted to provide maternal health services at community level.
51. Sub-component Inputs. The inputs to this sub-component will include financing for technical assistance to develop health as well as investment plans, the procurement of medical and non-medical equipment, supplies, drugs, and laboratory equipment and targeted infrastructure investments, and training workshops for health workers, including midwives and CHVs.
52. Sub-component 1.3: Support National Public Health Campaigns (estimated US$6.0 million equivalent). This sub-component will support investments for the implementation of a national immunization campaign for polio, measles, and tetanus toxoid to complement earlier efforts financed by IDA under the HRSP.24 Polio and measles immunization campaigns are targeted to children under 5 to contribute to the elimination of polio and measles in Yemen. In addition, nutrition active case finding of malnourished children under 5 will be integrated as part of the measles campaigns to be referred to nutrition referral centers explained under Component 1.2. It will also support expansion of the implementation of campaigns for immunization of tetanus toxoid for women of 15-49 years of age.
53. Sub-component Inputs. The inputs to this sub-component will include financing for immunization campaign operating costs.
54. Component 2: Results-Based Monitoring and Evaluation and Project Administration (estimated US$4.5 million equivalent). The Project will finance technical assistance to carry out evaluations of the upgraded MNCH Outreach Services to measure the results of the project interventions on the access and utilization of women and children in the project governorates. The evaluations will include a baseline survey, mid-term and end of project evaluation. It will also support the implementation of the National Demographic Health Surveys that will be implemented during the duration of the Project. In addition, this component will support activities related to the design and implementation of independent monitoring of project targets and audit of Outreach Services.
55. Project Administration Unit (PAU). The component will also provide project management support (consultancy services, equipment/supplies, and operating expenses) to support the establishment and operation of a PAU within the MoPHP. The PAU reports directly to the Deputy Minister of Public Health and Population for Primary Health Care and is led by the General Director of Family Health. It is to be attached to the GDFH to administer the Grant funds and to provide full time administrative and technical support with close administrative proximity to the Outreach Team to support their efforts to implement the HPP. The PAU will consist of: (i) Project Administrator; (ii) Procurement Officer; (iii) Financial Manager; (iv) Accountant; and (v) Secretary. The PAU will be complemented with the services of an Independent Technical and Financial Firm (ITFF) for the duration of the project; except for the first year, the Project will engage an Independent Technical Auditor (ITA).
56. The PAU will have the following key functions: management of project monitoring & evaluation (M&E), and financial and procurement managements. The PAU will: (i) assist the Outreach Team in the project implementation and manage the resources of the Project; (ii) facilitate efforts to conduct an early
24 The national measles campaign is planned to be implemented in 2012. 13
mapping survey and a baseline survey, monitor and evaluate the project targets, and evaluate the project results in coordination with the Outreach Team; (iii) handle procurement, financial, and disbursement management, including the preparation of withdrawal applications under the Project; (iv) ensure that an independent audit of the Project is carried out on an annual basis; (v) prepare the financial and procurement sections of the quarterly Progress Report and consolidate with the technical part prepared by the Outreach Program for submission to the Steering Committee (SC) and IDA; (vi) act as the liaison between the Outreach Program and IDA; (vii) ensure that all reporting requirements for IDA are met according to the Project legal agreement; and (viii) provide secretarial services to facilitate the activities of the Steering Committee (SC).25
57. Component Inputs. The inputs to this component will include financing for: (i) the provision of technical assistance, equipment and supplies to conduct the independent monitoring, audit, and project evaluations as well as monitoring of the project; (ii) the provision of technical assistance and procurement of goods for the implementation of national demographic health surveys; (iii) the provision of technical assistance to monitor environmental safeguards; (iv) the organization of training workshops, conferences, and events to dialogue, discuss, and reach consensus on the above mentioned activities; and (v) the provision of technical assistance for project administration, in addition to operating costs, and procurement of equipment, office furniture and supplies to support the PAU.
E. Lessons Learned and Reflected in the Project Design
58. The Project takes into consideration lessons learned from previous World Bank-financed support26 to Yemen as well as the relative strengths and lessons learned from a host of other initiatives, including the district level planning process of the HRSP, the MoPHP’s EPI program, and the Dutch- financed MNH program. Previous experience demonstrates that: (i) the Government's ownership and commitment is crucial to the success of implementation; (ii) the design of projects, especially in Yemen, needs to be simple; (iii) priority should be given to addressing access problems as well as constraints and gaps in service delivery; (iv) investments in health facilities should ensure that these facilities are operational after the closing of the project; and (v) the previous implementation arrangements through PIUs/PMUs adopted under previous projects might not be the best arrangements to address gaps in fiduciary management and does not create government’s ownership for preparation and implementation.
59. There is a need to restore the MoPHP’s ownership and leadership in management of IDA- financed projects.27 The Project will follow the successful implementation arrangements adopted by the SCP to establish a PAU that handles the fiduciary management requirements by IDA under the supervision of the General Directorate of Family Health (GDFH). In addition, the Project is designed to build the financial management capacity of the MoPHP’s health offices in the governorates within the project’s scope by involving one qualified Accountant from each of the governorate offices to be responsible for implementing the financial management arrangements of the campaigns’ operational costs and establishing an FM system acceptable to the Association. The Project will support these Accountants by providing them with training on the Bank’s financial management and disbursement guidelines and training on the project’s financial management manual and the FM system. The GDFH will be
25 The Organizational Charts and key responsibilities of the PAU staffing can be found in Annex 6. 26 Such as the Health Reform Support Project, the Family Health Project, the Child Development Project, etc. 27 Under previous IDA-financed projects; a Project Management Unit (PMU) was established to implement projects activities across different sectors within the MoPHP. However, this project management structure had led to lack of: (i) ownership by MoPHP in project activities; (ii) capacity building within MoPHP; and (iii) linkage and relevance between project funded activities and the actual programmatic needs of different MoPHP departments.
14
responsible for project management and implementation which keeps the ownership of the project and capacity built within the MoPHP. It will be assisted by a PAU for administration of the Grant funds.
60. The MoPHP has demonstrated strong ownership as it has mobilized financing from GAVI to fund Outreach Services, built upon this model, and continued implementation with a MoPHP team. The MoPHP ownership extends to planning Outreach Services as an integral part of the health service delivery system to complement the delivery at fixed health facilities.
61. The Project was designed to be simple and to be led by one sector under the MoPHP focusing on delivery of Outreach Services to complement serviced delivery at fixed facilities. It will address problems of access to fixed facilities and measuring results. It will also provide quality services to needy populations starting the first year of the Project. In addition, the Project limits its support to the first level of referral health facilities that will receive complicated cases referred from Outreach Services to address gaps in its investments. Facilities selected for investments will already be operational and utilized by the population to ensure that the referral system will work. This is expected to address the problems of slow pace of implementation of health and nutrition program projects.
F. Alternatives Considered and Reasons for Rejection
62. Supply versus Demand Side Focus. Being aware of the importance of demand side initiatives, the extent of their inclusion under the project was considered. The 2005/6 Household Budget Survey findings imply that investment in demand-side and macro-supply side factors will bring about limited gains unless coupled with effective micro-supply side investments in the quality, rather than quantity, of health care services. This is due to the presence of other non-demand factors that affect utilization rates such as transportation 28 and quality of services.29 A balanced approach between the supply of services and increasing demand is the approach proposed to be supported under the Project. Focusing on demand side interventions at this stage beyond the level already built into the Project and before improving the supply side, will only lead to raising expectations. Further, demand side activities beyond those planned at the project level would be addressed and coordinated through the ongoing/planned IDA-financed projects being/ planned to be implemented by the Social Fund and other community-based projects.
63. Support to PHC Fixed Health Care Facilities. In terms of deciding on the option of supporting delivery of Outreach Services to reach the population with services, support to delivery through primary health fixed facilities was considered. The weakness of the supply system delivering services through fixed health facilities and the low demand on PHC services posed significant barriers to providing access to the majority of the population living in rural and remote areas with services or motivating them to visit fixed facilities to receive services. In addition, the Bank’s experience in Yemen in supporting delivery of health services through fixed facilities was not positive as many of these facilities were not fully operational by the end of the project due to lack of staff, drugs, and equipment. In addition, many of these facilities were not in compliance with environmental safeguards related to health waste management and the procurement procedures for civil works were cumbersome. Furthermore, there are already substantial amounts of financing available during the project implementation period from other IDA-financed projects such as the Public Works Project and the Social Fund for Development Project, as well as from bilateral donors such as the Dutch and the EU, who have a strong presence in Yemen. Accordingly, the
28 Geographic distribution of health care provision appears to influence which communities have access to any health services in Yemen. Due to a relatively low household capacity to pay in general, out-of-pocket payments are relatively low, but at the same time, those households that do pay tend to travel distances for treatment. 29 While the distribution of health care facilities appears to correlate to population density, the quality of these facilities is more variable, particularly given the highly variable nature of health care goods and services. 15
Project considered limiting its finance to gaps in investments in drugs and equipment for emergency care at the first level of referral for cases referred from outreach and community-based services.
64. Support for Community-based Health Care Services. In addition, the option of supporting community-based health services was considered. This is a new model that is supported by JICA and implemented by the MoPHP. The team’s assessment is that this model of service delivery might not be able to be expanded and replicated in Yemen as a nation-wide approach through the MoPHP system, given the lack of organizational capacity to develop, implement and manage such a program. If a full- fledged community-based services model is to be employed, it should be employed as a complementary strategy in some remote areas, areas with security problems, and areas where there is social exclusion to specific groups such as Akhdam or Somali Refugees. Under the HPP, the community-based health services model will be funded from other sources such as that used by the UNICEF and JICA. However, these models are limited in its geographic coverage. The HPP will consider supporting a core model for community-based services necessary to complement the delivery of Outreach Services.
65. Support to a Donor Harmonized Health Sector-wide Approach (SWAp). In 2005, the MoPHP and its development partners initiated a dialogue to revisit the health sector strategy and evaluate the GoY and donor approaches in order to improve health sector performance and its efficiency in the form of a HSR. This review is meant to formulate a strategic approach for MoPHP priorities. However, it will take some time before a health sector strategy and plan is ready to form the basis for a multi-sectoral project and for a SWAp to be financed through multi-donor funds. The key donors in Yemen, including the Dutch and the EU, would like to move to proceed with the development of a SWAp or a mini programmatic SWAp to support the health sector in collaboration with the Bank as well with other donors through the use of country systems. However, the team’s assessment is that the MoPHP is not yet ready with a health sector strategy and a plan to be the basis for a programmatic SWAp in health sector. In addition, the GoY is not yet ready, through its financial management and procurement systems, to meet the minimum fiduciary management requirements of the Bank, a necessity for a SWAp in the health sector.
66. Support to Population/Reproductive Health Services as a Standalone Vertical Program. Another alternative considered was support to a vertical program, population/reproductive health services, given that MDG 5 is in a much worse state than MDG 4. The HSR and the technical studies done so far in Yemen have identified integrating the delivery of reproductive health services within the current health system as a prerequisite for the successful delivery of these services to reach the target population. Further, it is culturally more acceptable to deliver reproductive health services within a broader package of MNCH services instead of as a standalone program. The team’s assessment was that such support to a vertical program would deepen the current fragmentation of the delivery of MNCH services between the PHC and Population sectors. In addition, most of the bilateral donors (the Dutch, the EU, GTZ, KfW, and USAID), most of the UN organizations (UNFPA, UNICEF, and WHO), and some international NGOs (Mary Stops) already provide extensive support to this program. Given the above, the Project will support an area that is needed, namely the integration and delivery of reproductive health services within the MNCH package of Outreach Services. Finally, there are a number of IDA-financed projects and technical assistance that complement this project and address determinants of population growth such as empowerment of women, girl’s education, and increasing the age of marriage.
III. IMPLEMENTATION
A. Partnership Arrangements 67. A number of partner agencies, such as WHO, UNICEF, UNFPA, were involved in the technical discussions of the project design and are engaged in the design of the Outreach Services. In addition, as
16
noted above, project investments will complement the donor-financed programs underway and planned – particularly those that pertain to the provision of services at the first-level referral facility level. EmONC services are expected to be funded by UNFPA and the Dutch (currently active in 10 governorates, with plans to expend to a total of 22 governorates) through a national plan to roll out EmONC services that will be developed by UNFPA. The Social Fund for Development is also contracted by the Dutch to roll out EmONC services. In addition, UNICEF is planning to support a national plan to roll out TFCs and OTPs, which is to be supported in part through an EU-financed grant to UNICEF of EUR 5 million. Funding options to scale up the outreach health delivery model are also being discussed with GAVI. JICA is supporting community-based health services.
B. Institutional and Implementation Arrangements 68. The MoPHP will have the overall responsibility for implementing the HPP. The Project activities will be implemented by the MoPHP's GDFH and administered by the PAU under the supervision of the Deputy Minister of Public Health & Population for Primary Health Care. In order to manage the Project in an integrated and coordinated manner, and to expedite decisions and actions, the existing MoPHP structure will provide: (i) oversight; (ii) management; and (iii) implementation functions.
69. Project Oversight - Steering Committee (SC). The SC will be chaired by the Minister of Public Health and Population, and it will be composed of the Deputy Minister of PHC, the Head of the GDFH, the Technical Officer of Outreach Services, one representative of the Ministry of Planning and International Cooperation (MoPIC), and one representative of the Ministry of Finance (MoF). The Project Administrator of the PAU will serve as the Secretary for the Committee. The SC will meet at least every three months, and its main tasks will be to: (i) review policy issues relevant to the achievement of Project development objectives; (ii) approve annual work-plans and budgets including the Recipient’s financial contribution; (iii) review Project progress reports and take appropriate actions in support of implementation; and (iv) review and approve the design and budget of the second phase of implementation at the Project midterm review.
70. Project Management - General Directorate of Family Health (GDFH). The GDFH will be responsible for: (i) day-to-day project management activities; and (ii) ensuring coordination between the Outreach Program and PAU. The Head of the GDFH will act as the Project Manager and will be responsible for the overall coordination and management of the Project.
71. Project Implementation - Outreach Services Team. The Outreach Services Team will be responsible for implementing the defined project activities, with the administrative support of the PAU, in order to achieve the PDOs in accordance with the OM (see Annex 4A- Outreach Implementation Arrangements). The Outreach Services Team will be responsible for preparing the technical sections of the Quarterly Progress Reports.
72. Project Implementation (Fiduciary Management Responsibility) - Project Administration Unit (PAU). The Project will have a small PAU attached to the Outreach Services Team to administer the Grant funds and support the Outreach Services Team’s efforts to implement the HPP. The PAU will have the fiduciary management responsibility and will be based within the GDFH in order to be linked to the Outreach Services Team. The PAU is designed to provide full time administrative support with close administrative proximity to the HPP in order to support regular communication. The Outreach Services Team and the PAU will be supervised by the Head of GDFH. The PAU will be complemented with the services of an ITFF for the whole life of the Project, except for the first year when the Project will engage an ITA. The ITFF will conduct technical and financial validation and certification functions.
17
73. The PAU will have the following key functions: management of project monitoring & evaluation, financial management, and procurement management. The PAU will: (i) assist the Outreach Services Team in project implementation and manage the resources of the project; (ii) facilitate efforts to conduct an early mapping survey and a baseline survey, monitor and evaluate the project targets, and evaluate the project results in coordination with the Outreach Services Team; (iii) handle procurement, financial, and disbursement management, including the preparation of withdrawal applications under the Project; (iv) ensure that an independent audit of the Project is carried out on an annual basis; (v) prepare the financial and procurement sections of the quarterly Progress Report and consolidate with the technical part prepared by the Outreach Services Program for submission to the SC and IDA; (vi) act as the liaison between the Outreach Services Program and IDA; (vii) ensure that all reporting requirements for IDA have been met according to the Financing Agreement; and (viii) provide secretarial services to facilitate the activities of the SC.
C. Monitoring and Evaluation of Outcomes/Results 74. The existing M&E system established by the MoPHP will be strengthened and further developed to ensure effective supervision of activities, as well as measurement of the intermediate and final outcomes stemming from the project interventions. Two M&E approaches will be developed/strengthened as follows:
• Program monitoring and evaluation (internal M&E): the GDFH M&E system already in place will be strengthened. • Project monitoring and evaluation (external M&E): an external monitoring and evaluation system will be established to assess the impact and performance of activities conducted under the HPP.
Program Monitoring and Evaluation (Internal M&E)
75. Current M&E arrangements. The MoPHP already has in place an M&E system for assessment of its ongoing Outreach Services (program M&E system). M&E of the ongoing Outreach Services is the responsibility of the GDFH, and is based on measurement of impact and performance indicators. The focus of this program M&E is on the collection and management of data related to outreach activities.
• Impact. The GDFH, through its outreach interventions, conducts service delivery rounds annually (five rounds in high populated areas and four rounds in less populated areas per year), and collects data on utilization rates of MNCH services. The product of this exercise is a long list of districts with data which is then used as a basis for measurement of the results of Outreach Services related to utilization. • Performance. For performance, the GDFH measures the achievements of Outreach Service rounds through the collection of coverage data. At the end of a round day, data on the number of beneficiaries is aggregated and sent via email or fax from the district level, to the governorate office and up to the central level. Data is broken down by target group. At the central level, data is compiled and used for monitoring and reporting purposes.
76. HPP inputs. Building upon the MoPHP’s existing capacity, consultants to be contracted to develop the project M&E activities (see below) will provide technical expertise to bolster the Outreach Services’ capacities and technical skills vis-à-vis program M&E. For example, these consultants will focus on standardization, harmonization and development of the outreach’s practices for data collection and analysis to remove any biases that could hinder comparison of the two data sets (from the outreach and from the independent evaluation). With respect to performance M&E, the consultants would review the approach currently in place to ensure that it is reliable and suggest appropriate changes, if any.
18
Although simplistic, the current performance measurement approach appears to work well in terms of capturing data on the outreach activities and is consistent with the program’s capacities. The consultants will also ensure that the project M&E activities complement and reinforce the program M&E activities more broadly. 77. The program M&E system will continue to track indicators set by the Outreach Services policies and practices. Its activities go beyond those of the HPP and are expected to continue beyond the HPP’s timeline, as an essential component of Outreach Services conducted by the MoPHP.
Project Monitoring and Evaluation (External M&E)
78. For the specific purpose of monitoring and evaluating activities conducted under the HPP, a project M&E program will be established to provide an independent assessment of activities conducted under the HPP. An independent firm will be recruited to develop and support the implementation of this evaluation. The duration of the M&E program is expected to be the duration of the project. However, the consultancy is being designed to ensure knowledge-transfer, and therefore key elements of the project’s M&E program are expected to be adopted by the MoPHP to strengthen the GDFH’s capacity beyond the project period. The M&E activities will include M&E of HPP impact and performance.
79. M&E of impact and performance. A survey of healthcare service delivery is planned to measure the impact and performance of the HPP interventions at the point of service delivery. The survey will be undertaken to establish the baseline, at mid-term, and again at the end of Project period. The survey will be conducted in five of the six governorates to be targeted by the Project (excluding Aden Governorate), using available funding and technical expertise from the World Bank Institute (WBI). 30 Data to be captured through this survey will allow for measurement of several key indicators, including those that pertain to:31
Impact • Utilization of MNCH services through routine Outreach Services. • Utilization of MNCH services at referral services.
Performance • Geographical coverage of population with Outreach Services (proportion of districts covered by Outreach Services). • Program coverage (proportion of individuals covered with Outreach Services out of those targeted).
80. Survey objectives. The objective of the proposed survey is to document three essential elements of service delivery supported under the HPP. The proposed survey will consist of three modules:
(i) Module A - a household survey module aimed at measuring access to, utilization of, and satisfaction with the seven elements of the Outreach Services program, as it is rolled out in the target governorates;
30 Aden Governorate is not included because it does not apply the same model of outreach services implemented in rural areas. The survey model depends on tracing defaulters who drop during utilization of services at fixed facilities, which is not consistent with the model of service delivery in Aden. As such, the results would not be comparable to more rural governorates where access is an issue. 31 See Annex 3 for additional details. 19
(ii) Module B - an ‘exit-poll’ module aimed at measuring outgoing patients’ access to, utilization, quality and integrity of service delivery, in a representative sample of the rural primary healthcare centers in the target governorates; and (iii) Module C - a facilities module targeting medical and administrative staff in the same facilities where Module B will be administered. Module C will document the following: institutional incentives such as regularity and adequacy of providers’ pay and benefits; working hours, incidence of absenteeism; the healthcare centers’ physical and human capacity, including availability of medical supplies and equipment, etc.
81. Survey Implementation. A local survey firm has been identified and contracted to manage data collection and data entry and cleanup, and its output will be a clean dataset. The baseline survey was launched in July 2010, and the data was made available in October 2010.
82. National Health and Demographic Survey (NHDS). In addition, measurement of impact will be supplemented by data from the planned NHDS scheduled to be launched in February 2011 and repeated again in five years. The NHDS will provide useful information on utilization of health services (for women and children in particular), morbidity and mortality, as well as nutritional status for the country as a whole, as well as for the project governorates. Project M&E Reporting Requirements 83. The Outreach Program, with substantive support from the PAU, will be responsible for the preparation of the following types of reports:
• Semi-Annual Progress Reports: These will report on the status of the project activities and cover project implementation over a period of six months. The report should describe the implementation status of key activities, project outputs derived during the previous six months compared to benchmarks, a brief overview of financial status and project disbursement, a summary of project challenges and constraints, and recommended actions. The report will include data that will originate from a synthesis of MIS and monitoring data. Each report will provide important information needed to monitor the project and includes verified figures for all performance and will include monitoring indicators. It should be provided no later than a month after the end of six-month period (January 31 and July 31 of every year). • Annual Progress Reports: Annual progress reports will cover project implementation over the previous year (January to December) and provide a proposed budget and work plan for the subsequent year. It will also provide revised projections for project targets with respect to changes in the Project’s implementation plans. In addition to the semiannual reporting requirements (which would be combined with the annual report for the same period), these reports will include a summary of the project performance, including: updated information on the indicators included in the results framework, status of outreach visits conducted, status of these visits, coverage, monitoring of utilization of services, and quality of outreach visits; availability of drugs; and analyses and recommendations relevant for optimizing project implementation. Data will originate from a synthesis of MIS data, semi annual reports, verification reports, and small scale survey studies. These reports should be provided annually, within forty five days after the end of each calendar year (by February 15). • Project Mid-Term Review (MTR) Report: The MTR report will be prepared at the end of the third year of the project. The function of the MTR will be to review at the mid-term point the project’s overall performance in terms of achieving its expected outcomes. In addition, the MTR will assist in the evaluation of the efficiency and effectiveness of project activities; project management arrangements; the supervision mechanisms and the MIS; the effectiveness of
20
institutional strengthening technical assistance activities; and the Project’s targeting mechanisms. The results of the review will lead to the reclassification of endemic districts, and provide a basis for any modifications to the drug administration strategy to be adopted for the remainder of the project period (e.g., to reflect any changes to WHO guidelines). The MTR will include information about project expenditures and implementation progress compared to planned activities. It will also include a revised project implementation plan, targets, and disbursement projections based on any changes to the strategy for drug administration. • Project Implementation Completion and Results (ICR) Report: The ICR will include an assessment of the achievement of the project development objectives, details on the status of implemented activities and the services provided to the target communities and the overall use of funds. This report will also include a summary of the Project’s performance and monitoring indicators throughout the project’s lifecycle. This report is to be submitted to IDA no later than six months after the Grant Closing Date. Additional post-project reports will be provided by the program for two successive years denoting sustainability of activities and results.
D. Sustainability 84. The MoPHP has launched its Outreach Services through a GAVI-financed HSS Project. For the first time in Yemen for projects financed by development partners, the process was started by MoPHP in preparing and submitting a proposal for funding from GAVI. Planning for project preparation and implementing project activities were completely owned and managed by the MoPHP. In addition, the GAVI-HSS Project provided an excellent opportunity to experiment with different mechanisms of integration that the proposed Project could build upon and scale up to be a national outreach service delivery model. MoPHP ownership to services delivery through outreach activities is a strong basis for its sustainability given the MoPHP’s intention to integrate Outreach Services into its service delivery model to complement facility-based services, especially in areas where fixed facilities cannot operate effectively.
85. One area of concern for sustainability is the future availability of adequate resources by the MoF and the MoPHP for the maintenance and operations of service delivery in the governorates selected for financing under the Project. The Project will make available financial resources for operational costs throughout the life of the Project, to be financed on a declining basis. In addition, financial resources needed for future operational costs will be estimated under the Project. These estimations, combined with demonstrated achievement of project objectives, will provide the MoPHP and the governorate level health directorates with powerful tools for negotiation with the MoF to continue to support the operating costs as the Project comes to a close.
86. The governorates participating in the Project will be requested to commit to the funding of Outreach Services beyond the closing date of the Project. These commitments could be expressed through a Memorandum of Understanding signed between the Minister of Public Health and Population and the Governors of the selected governorates. The governorates will make available adequate staff and budgets necessary to ensure that Outreach Services are operational. As noted above, the Project will initially provide support with financial resources for operational budgets that would gradually and incrementally be replaced by increasing contributions from the selected governorate. Moreover, the Project, through introducing improvements to the design of Outreach Services and by incorporating reproductive health and nutrition services, will produce efficiencies and cost savings at the central and governorate level that could be used to compensate for part of the future operations cost needed.
E. Critical Risks and Possible Controversial Aspects 87. The table below summarizes the potential risks and risk mitigation/minimization.
21
Risk Risk Rating Risk Minimization Measures As noted in the CAS, there are Substantial To stem the unrest, the CAS is very focused on the considerable risks with respect to acceleration and diversification of economic political instability and unrest. growth, as well as good governance to improve both the resources and opportunities available overall, and to improve the performance of the GoY.
The procurement of drugs may be High Drugs will be procured by the UN organizations to delayed and could affect the ensure its timely procurement and that it meets the timely implementation of WHO quality standards. Discussions will continue outreach. Also drugs might not with the UN agencies to agree on specific measures comply with acceptable quality to ensure the quality of procured drugs. standards.
It may be difficult to reach High The Outreach Services will support planned rounds marginalized group or areas given using mobile teams that comprise local personnel the security situation. The from these communities. This would enhance the topography, geography, and opportunities to reach these groups especially in scattered population distribution in high-security areas. Yemen compound the challenge.
It may be difficult to timely High The policies and procedures concerning inventory develop the appropriate policies management are properly recorded in the Project's and procedures to effectively FM Manual, including control procedures over manage the drug supply inventory. receipt and release of inventory and recording of such transactions.
The PAU is a relatively newly The project has prepared a manual which explains established unit and may not have the role of the PAU before the start up of outreach in place the systems and policies rounds. Such controls will ensure proper receipt of to safeguard and manage the assets goods by the MoPHP as evidenced by signed receipt during project implementation. documents confirming the quantity received and Also, the unit may lack the signed by authorized officials validating that the presence of a safe and secure order received is acceptable. warehouse for the storage of the drugs. An Independent Technical and Financial Firm (ITFF) will be appointed to verify that control The drugs are expected to be procedures over inventory management with stored in advance of starting the emphasis on receipt and release of drugs are Outreach Services, which would properly implemented and in compliance with the create risks to proper management FM Manual. The MoPHP will arrange for a secured of the inventory. warehouse to maintain the drugs. Specific controls will be applied over inventory such as inventory register; and an individual will be assigned the responsibility for inventory management (e.g., inventory custodian). Additionally, regular physical checks over inventory will be conducted by the PAU and the review process verified by the ITFF.
22
Risk Risk Rating Risk Minimization Measures
It may be difficult to manage High Outreach Services will be well planned to ensure expenditures at decentralized level proper control over disbursement. Before the during the implementation of implementation of each round, the ITFF will review Outreach Services. these plans and verify their compliance to the national and district level planning guidelines for
mobile outreach rounds. This firm will also review the plan’s proposed budget to verify compliance to the FM’s guidelines and to the budgets indicated in the Project Implementation Plan (PIP). Such planning and controls will be done in an organized manner based on documented procedures, controls and safeguards including the role of the ITFF, to be applied during Project’s implementation phase. Flow of funds will be managed by the PAU through the use of bank transfers from the Project’s Designated Account (DA) to the Project’s sub- account and then checks will be issued by the PAU from the sub-account. The required supporting documents will be indicated in the Project’s FM Manual (FMM) and the documents will be maintained by the PAU. Upon satisfactory assessment by the Association of the FM arrangements at the MoPHP’s health offices at the project’s governorates, funds for campaigns’ operating cost will flow from the Project’s DA to a sub-account at the governorate’s office, to be established after the satisfactory assessment. The first governorate expected to be ready for the assessment as a pilot is Sana’a governorate. The assessment will include ensuring the existing of a qualified accountant from the health office at the governorate and the establishment of the required equipment and FM system. It may be difficult to manage High In addition to recruiting a competent procurement procurement of consulting services staff in the PAU, a short-term Qualified for selection of international firms. Procurement Advisor may be recruited during implementation to support: (i) quality control for project procurement documents and contract management (particularly for the technical services contracts); (ii) on-the-job capacity building for the procurement officer; and (iii) procurement planning, drafting of terms of reference, preparing guidelines and procedures.
23
Risk Risk Rating Risk Minimization Measures
The GoY may not be able to Moderate Funding from GoY resources gradually replacing sustain the expected results of the IDA funds or from a follow-up IDA-financed project after its completion, due to operation in case Yemen’s economic forecast is not lack of financial resources. positive, would be reasonable options to support the follow-up phase at that time. Overall risk rating High
F. Grant Conditions and Covenants 88. Conditions of negotiations: None. 89. Conditions of Board presentation: None. 90. Covenants: • The Steering Committee shall have the overall responsibility for Project oversight and policy guidance of the Project in accordance with the requirements, criteria, organizational arrangements and operational procedures set forth in the Operational Manual. • The Recipient shall carry out the Project through the General Directorate of Family Health (GDFH), with the assistance of the Project Administration Unit (PAU) and the Outreach Services Team, all in accordance with the requirements, criteria, organizational arrangements and operational procedures set forth in the Operational Manual (OM) and the Financial Management Manual (FMM), and shall not assign, amend, abrogate or waive any provisions of the OM or the FMM without prior approval of the Association. The PAU is responsible for procurement and financial managements for the Project. • At all times during the implementation of the Project, the Recipient shall maintain the Steering Committee, the PAU and the Outreach Services Team, all with a composition and resources satisfactory to the Association. The Recipient shall also maintain the PAU with staff whose qualifications, experience and terms of reference shall be acceptable to the Association. • For the purposes of proper planning and implementation of Parts A.1 and A.3. of the Project, the Recipient, through the PAU shall: (a) not later than June 30, 2011, appoint, on terms and conditions satisfactory to the Association, an Independent Technical Auditor (ITA) to verify and certify that the planning and implementation of the outreach services and public health campaigns have been conducted in a manner satisfactory to the Association; and (b) not later than June 30, 2012, appoint an ITFF, on terms and conditions satisfactory to the Association for the duration of the Project implementation to verify and certify that the planning and implementation of the outreach services and public health campaigns have been conducted in a manner satisfactory to the Association. • The Recipient through the GDFH, and with the assistance of the PAU and the Outreach Services Team, shall carry out the Project in accordance with the requirements and procedures of the ESIA (including the health care waste management plan and the ESMP) and shall not assign, amend, abrogate or waive any provisions of the ESIA (including the health care waste management plan and the ESMP) without prior approval of the Association. • Not later than June 30, 2011, the Recipient shall appoint, on terms and conditions satisfactory to the Association, an environmental consultant to assist with implementation of the ESIA and ESMP.
24
IV. APPRAISAL SUMMARY
A. Economic and Financial Analyses
91. Annex 9 presents the complete economic and financial analysis conducted in preparation for the HPP based on the project’s expected and measurable costs and economic benefits to be realized from its successful implementation. A cost benefit analysis was applied to estimate Net Present Value (NPV) of the Project, and Economic Rate of Return (ERR) for a series of scenarios. With an ERR of 53 percent and a NPV of 89.5 million Yemeni Riyals, the results clearly indicate that the Project with outreach immunization activity has a more positive net effect on the economy than one without outreach.
92. The cost effectiveness analysis concludes that the Project is more cost effective with three outreach components (immunization, maternal care, and nutrition) as compared to just providing services through a fixed facility. While the efficiency of the HPP interventions logically depends upon how many individuals are reached by outreach mobile service, with the three Outreach Services, the per capita cost is as low as 735 Yemeni Riyals (US$3.62) if 10 percent of the target population is reached. This number goes even lower if 50 percent or more of the expected targets receive the service (down to a per capita cost of less than US$1.00). The per capita cost of the scenario with just the fixed facility is 3,286 Yemeni Riyals (US$16.2) assuming that 10 percent of the population utilize the services. From a fiscal sustainability standpoint, the cost of the project is assumed to be fully absorbed into the national budget and no affect on fiscal policy sustainability is expected.
B. Technical
93. As noted above, the health sector in Yemen is in transition. There is a short term need to continue to deliver services through population-based and disease-specific programs, while the medium to longer term strategies are defined through the ongoing HSR. During this interim period, the most realistic option is for the GoY and donor partners to continue to collaborate in the delivery of programs which address specific themes such as child services, reproductive health, malaria, and schistosomiasis.
94. To guide the design of the transitional phase, three key principles were proposed to enhance Yemen’s opportunities to achieve the 4th and 5th MDGs:
(i) Achieve a balance among the delivery of MNCH services based on the principle of continuum of care throughout the lifecycle (childhood, adolescence/adulthood, pregnancy, childbirth, postnatal period), and between places of service delivery (including clinical care settings, outreach, and household and communities). (ii) Ensure delivery of an integrated package of services that can be expanded incrementally in scope and complexity over time through a phased introduction of additional interventions appropriate for Yemen and that are commensurate with projected fiscal and financial resources, as well as human resource capacities. (iii) Ensure delivery of an integrated package of services based on standards and guidelines for integrated service delivery and facility-based health planning that are suited to the topography, geography, and population distribution in Yemen, and are consistent with the current and planned capacity development. These standards should stipulate the following: • Delivery through fixed facilities is based on rational distribution of services that ensure efficiency and optimum use of the limited resources. • Routine outreach and community services are designed and planned to complement delivery through fixed services, wherever relevant.
25
• Relevant and effective workforce suitable to Yemen is developed to manage and deliver an integrated package of services.
95. Based on dialogue with the MoPHP about the features of support to the transitional phase, priority was set to: (i) support a phased, gradual, and incremental coverage of the population prioritizing women in reproductive health age and children less than five years of age living in rural and slum areas with no or poor access to health services; and (ii) define MNCH as the core package of services that covers the continuum of care.
96. Based on these principles and priority setting for population coverage, and to address the very high and stagnated maternal and U5-child mortality rates, delivery of MNCH services as a fundamental part of the PHC program would be essential. In addition, to overcome the immense challenges the PHC system faces to deliver quality and accessible services, aggravated by the demography, topography, and geography of Yemen, routine Outreach Services would need to be delivered and introduced as an integral strategy of the healthcare service delivery system.
97. Specifically, the areas that will require support to follow the above mentioned principles are: (i) Providing access to a basic MNCH package of services to populations with no or poor access to health services, using a service delivery model of routine mobile outreach health services (Outreach). (ii) Complement service delivery in fixed facilities as well as community-based services provided through government as well as development partner resources.32 (iii) Integrating reproductive health and nutrition services within Outreach Services.33 (iv) Making available essential drugs, diagnostics, supplies, and equipment for MNCH services (including contraceptives) for Outreach Services, in addition to strengthening its logistics management system to ensure the timely availability of quality drugs and health commodities. (v) Strengthening quality assurance and health management information systems that would ensure the proper functioning and monitoring of Outreach Services.
C. Fiduciary Financial Management (FM) 98. The Project activities will be implemented by the Outreach Team of MoPHP and administered by the PAU. The FM activities under the Project will be carried out by an FM Team (Financial Manager and Accountant) under the PAU structure and will be supported by Accountants at the MoPHP’s governorates offices. Additionally, based on TOR acceptable to IDA, the PAU will contract with an ITFF to verify and certify for IDA that the planning and implementation of the Outreach Services have been conducted at an acceptable level and constitute a reliable base for the disbursement of IDA funds. During the first year of project implementation, the PAU will contract an ITA to independently verify and certify for IDA that the planning and implementation of Outreach Services have been conducted at an acceptable level and constitute a reliable base for the disbursement of IDA funds.
32 UNICEF will be supporting community-based services in the governorates of Sana’a and Ibb to complement the routine outreach services supported by this project in these two governorates. JICA is supporting community-based services in six districts in Yemen in three governorates, two of which (Sana’a and Ibb) are to be supported under the HPP. Community- based services design and plans are based on the experience that was implemented by the GAVI-funded HSS Project. Collaboration with the Social Fund for Development to support community-based services is being explored. 33 Currently the package of Outreach Services focuses primarily on immunization and other basic child health services such as IMCI. Only Sexually Transmitted Diseases (STDs) from reproductive health services are incorporated within the package. 26
99. The PAU is relatively newly established and does not currently have comprehensive defined formal procedures and controls applicable to the Project and the staff may not have prior experience with IDA-financed projects, which creates significant FM risks. To mitigate these risks, the following measures will be implemented: (i) competitive appointment of a qualified FM Team based on TORs acceptable to IDA (complete); (ii) competitive appointment of the ITFF for Outreach Services, and qualified individual ITA for the first year of implementation (dated covenant); (iii) agreement with the MoPHP on the procedures, controls and safeguards including the role of the ITFF to be applied during project implementation and documenting these controls and procedures in the Project's financial manual (complete); (iv) financial recording in a ring-fenced accounting system that will be able to generate project reports on timely basis (complete); and (v) annual audit of the project financial statements by an independent external auditor, selected by Yemen’s Central Organization for Controls and Audit (COCA) and acceptable to IDA (starting from year 1 of implementation).
100. Flow of Funds and Disbursement Arrangements. IDA funds will be channeled through the PAU in the MoPHP and deposited into a segregated US$ Designated Account (DA) at the Central Bank of Yemen (CBY). IDA proceeds will be disbursed in accordance with the Bank's Traditional Disbursement Method in accordance with Disbursement Guidelines. Advances and Replenishment-based disbursement will be the main disbursement method, along with reimbursement, direct payment and special commitments. Requests for payments from IDA will be initiated through the use of Withdrawal Applications (W/As) for advances, Replenishments, Reimbursements, Direct Payments, or issuance of Special Commitments. WAs for replenishments and reimbursements will be accompanied by Statement of Expenditures (SOEs) or Summary Sheets and supporting documents as per the Disbursement Letter. Additionally, the PAU will maintain a sub-account in YR mainly for managing payments related to operating cost. WAs for replenishments/reimbursements for the cost of the campaigns will be accompanied by certification by the ITFF and/or ITA of the expenditures incurred.
101. Reporting Requirements. In line with the Bank guidelines, the PAU will issue the following reports reflecting the project activities: • Quarterly. Interim unaudited Financial Reports (IFRs) prepared by the PAU and reviewed by an independent external Auditor selected by COCA under terms of reference acceptable to IDA. The PAU will be responsible for submitting the IFRs to IDA no later than 45 days after the end of each quarter. • Annually. Audited Project Financial Statements (PFS) to be remitted to IDA not later than six months after the end of the project fiscal year.
102. In addition to the above, the PAU shall furnish to IDA, Independent Technical and Financial Auditors’ reports not later than 60 days after the end of each outreach round or public health campaign. The Project financial management arrangements are further detailed in Annex 7.
Procurement 103. Procurement activities under the Project will be the responsibility of the PAU. The Procurement Officer is already on board. The PAU, on behalf of MoPHP, will need to interface intensively with both the private sector as well as UN agencies from whom a substantial part of procurement is expected to be sourced. As the HPP activities primarily involve the procurement of goods (drugs and medical and non- medical equipment) and managing TA consultant contracts, the procurement capacity in these areas would be specifically developed on a fast-track basis.
104. To strengthen the procurement management at the PAU, it may be necessary to hire a short-term Qualified Procurement Advisor during implementation to provide technical assistance in the areas of: (i)
27 quality control for project procurement documents and process and contract management, particularly for the goods and technical services contracts; (ii) on-the-job capacity building for the Procurement Officer; (iii) procurement planning, drafting of bidding documents, guidelines and procedures; and (iv) establishment of a sound procurement filing system.
105. To mitigate the risk of inadequate handling of ICB procedures for procurement of drugs and medical equipment in Yemen, it is recommended that they be procured through United Nations Organizations, mainly UNICEF, UNFPA, and WHO using the UN Global Agreements approved by the Bank.
106. The overall project risk for procurement is currently high, but would be reduced to substantial upon the following procurement risk mitigation measures being in place: (i) strengthening procurement management capacity through recruitment of competent Procurement Officer and, if necessary, a short- term and qualified Procurement Advisor; (ii) procuring drugs and medical equipment through UN organizations using UN Global Agreements; and (iii) providing descriptive procurement procedures in the project operational manual, taking into consideration the experience of procurement implementation in the Health Sector Reform Project which closed on August 31, 2009.
D. Social
107. An Environmental and Social Impact Assessment (ESIA) has been prepared under the auspices of the MoPHP to analyze the social context and social issues, as well as the distributional impacts of the intended project services on the different stakeholder groups, in particular those under Component 1, at the service delivery level. In the context of the ESIA, a process of stakeholder/beneficiaries consultation and participation was initiated to feed into Component 2 in terms of the impact evaluation process and results based monitoring system to be put in place. The adopted monitoring methodology of the project will be impact-based and results oriented. Thus indicators will be included to measure the level of service quality and the impact on beneficiaries.
108. The findings of the ESIA will help to ensure that project implementation arrangements enhance equitable access to the project benefits and community participation in project implementation and monitoring. Some of the stakeholders consulted included: • Government officials at the central level. • MoPHP staff, particularly the staff working in the project-related departments. • Government officials and service providers at health facilities in the target governorates. • Various community representatives in the targeted governorates, including women, men, mothers-in-law, nongovernmental organizations, donor agencies and the private sector.
109. The Project is expected to have a positive social impact since previously underserved segments of the population will now have access to Outreach Services. Existing efforts have been largely focused on populations living within the vicinity of fixed facilities, leaving large segments of the population with no or limited access to basic health services. These population groups are to be specifically targeted under the project through Outreach Services. Moreover, of the currently underserved population groups in Yemen, the Project is focussing in particular on governorates with high poverty - four out of the five target governorates have poverty rates of about 25 percent to 35 percent (with the exception of Al Baydah governorate where the poverty rate reaches between 50 percent to 60 percent). Addressing the basic health needs of the underserved poor is expected to have a positive social impact.
110. The Project will also have a gender impact as improving women’s access to health can contribute to increased empowerment and is related to access to other social and civic rights.
28
111. Under the Project, the service delivery model to be adopted will use mobile teams to complement the fixed health facility activities, with a scaled up package of services in comparison to the package currently delivered by Outreach Services. This will allow Outreach Services to better reach children and women of reproductive age who are not currently reached with services (especially girls who are more likely to not be reached with services provided at fixed facilities and who would be less able to travel to a fixed site location due to social constraints). In addition, the Project will reach ‘Needy Group Settlements’ (i.e., areas inhabited by neglected/vulnerable groups) and ‘Special Needs’ areas (i.e., remote or areas with security concerns) for whom the use of mobile teams to match the current environment in the area would be more appropriate and effective. The ability of the Project to reach population groups previously unreached by the fixed facilities will be integrated into the internal and external M&E system, and feedback from such beneficiaries provided through the proposed Health Care Service Delivery Surveys (particularly Modules A and B). See Section IIIC for additional details. 112. Raising Community Awareness. As noted in the Environmental and Social Impact Assessment (ESIA), the low level of awareness is one of the important reasons behind the continuing decline of indicators associated with maternal and child health. The Project is expected to have a positive impact in this regard through strengthening communication channels between community members and the various groups of service providers who will have a role in changing the misconceptions and raising awareness of the community. It should be noted that raising awareness will not be limited to women, but will also include other influential groups that play a role in the decision making process (such as mothers-in-law). 113. Social Safeguards. Involuntary physical resettlement and/or involuntary land acquisition are not foreseen in the context of the implementation of the project’s proposed components. Therefore, OP 4.12 has not been triggered. 114. Stakeholder Consultation on Project Design. A Health and Population Project stakeholders’ workshop was launched by MoPHP on June 30, 2010. The workshop demonstrated considerable participation from civil society represented by NGOs especially those working in the health sector and human rights, central government as well as local government in project target areas, and other parastatal organizations interested in the health sector. The participants expressed their concurrence and strong support to the objectives and design of both the HPP and SCP. The discussions extended to emphasize the nature of their roles to enhance community participation and social mobilization interventions including service delivery and facilitating the work of MoPHP at the community level.
E. Environment 115. Environmental Impacts. One safeguard policy is triggered, OP 4.01 for Environmental Assessment. As a result, the Project has been classified as a Category ‘B’ for environmental screening purposes due to the risks associated with handling and disposal of medical wastes. To address the potential negative impacts of this safeguard policy, an ESIA has been prepared that includes a Health Care Waste Management plan (HCWMP). The ESIA provides practical but safe options for handling, segregation, storage, treatment and disposal of general and infectious/hazardous wastes, which are consistent with the WHO guidelines and local laws. The ESIA also provides environmental and waste management guidelines for health facilities. Environmental compliance monitoring of facilities will be done by the PAU in close coordination with Ministry of Water and Environment, the primary environment agency in Yemen. 116. The PAU under the supervision of the Deputy Minister of Public Health and Population for Primary Health Care will include a Focal Point (FP) from MoHPH who will work closely with the Ministry of Environment and Water (MoWE) to ensure that the participating health care facilities (both fixed and mobile facilities in all project governorates) will adhere to the Project’s environment and health care waste management guidelines and comply with the relevant environmental requirements and
29
standards in coordination with the relevant agencies. The FP will carry out routine M&E of the outreach sites with the MoWE to ensure proper handling of the medical waste generated from the project activities during implementation. Training of health care workers on handling of medical waste will be developed and incorporated into the training modules as part of the capacity building activities in the Project under Component 2. 117. In addition, an environmental consultant will be hired under the Project to implement the Environmental and Social Management Plan (ESMP) which includes carrying out monitoring of the Outreach Services in the six governorates twice a year over, reporting on the implementation of the ESMP and developing training modules and guidelines for a proper system for managing hazardous healthcare waste at the project health facilities.
F. Safeguard Policies
Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP 4.01) [X] [ ] Natural Habitats (OP/BP 4.04) [ ] [X] Pest Management (OP 4.09) [ ] [X] Physical Cultural Resources (OP/BP 4.11) [ ] [X] Involuntary Resettlement (OP/BP 4.12) [ ] [X] Indigenous Peoples (OP/BP 4.10) [ ] [X] Forests (OP/BP 4.36) [ ] [X] Safety of Dams (OP/BP 4.37) [ ] [X] Projects in Disputed Areas (OP/BP 7.60) [ ] [X] Projects on International Waterways (OP/BP 7.50) [ ] [X]
G. Policy Exceptions and Readiness
118. No policy exceptions are sought. A project implementation plan was developed with detailed project costing. No problems are anticipated for local contributions as the MoPHP has an account that could be used to fund local contributions in case there are funding delays from MoF. Local contributions were discussed and agreed upon during negotiations. 119. The organizational structures for the implementation of the Project have been established (see Charts 1 and 2, Annex 6). A Project Manager has been appointed. The Procurement Officer, the Financial Manager and the Accountant are already on board. The Financial Management and Operational Manuals (which include the Procurement Manual) have been submitted to the Association and are deemed satisfactory. The FM Manual will adopt the same procedures which were already approved for the Schistosociasis Control Project. The FM accounting software was purchased and is operational. TORs for key consultancy assignments for the first 18 months of the Project are being drafted. The first 18-month activity and procurement plan were reviewed and agreed at negotiation. Most of drugs, medical equipment and supplies will be procured through UNICEF, WHO, and UNFPA using the global agreement that has been approved by the Bank. 120. The key performance indicators have been developed and agreed with the Client. Compliance to environmental safeguards was ensured. An ESIA report was finalized and all stakeholders were consulted on the environmental and social aspects of the Project in a public consultancy workshop held at the MoPHP on June 6, 2010. The stakeholders included representatives from the MoPHP, Local NGOs, the Environment Protection Agency, WHO, different Health Offices from the 6 governorates and the media. An ESMP is in place.
30
Annex 1: Country and Sector Background
1. The Republic of Yemen (RoY) was formed in 1990 after the unification of North and South Yemen. Since unification, Yemen overcame a civil war in 1994 but has continued to experience internal security problems. Yemen is considered a Fragile State i.e., it is among a group of countries that: have weak institutions making them vulnerable in their capacity to deliver services to citizens, control corruption or provide for sufficient voice and accountability; and are at risks of conflict and political instability. Within the typology of Fragile States, Yemen exhibits most of the characteristics of a gradual reformer.
2. Yemen is situated in the southwestern corner of the Arabian Peninsula occupying an area of over 500,000 square kilometers and has a population of 23.1 million, living in approximately 136,000 settlements scattered throughout the highlands and coastal regions.34 The population is predominantly rural and young with 76 percent of Yemenis living in rural areas and the under-15 age group represents 46.3 percent of the population. Population growth is high (3.02 percent per annum) due to a cultural preference for large families, limited access to modern contraceptives, and limited social safety nets.
3. Poverty is a nationwide phenomenon with higher concentrations in rural areas (where 73 percent of Yemenis live). For nearly a decade after unification, Yemen achieved a reasonable annual GDP growth rate (5.2 percent), securing a decent 2 percent per-capita growth. Several factors helped in achieving growth in this period, such as the increased market resulting from the integration of North and South Yemen, an 80 percent increase in oil production as new oil wells came on stream in 1994, steady decline in internal conflicts after the end of the 1994 civil war, and a successful macroeconomic stabilization and reform program in the second half of the 1990s. The reform program focused on inflation control, price and trade liberalization, reduction in subsides, unification of the exchange rate regime and financial sector reforms. The reform efforts were successful and private investment and growth ensued, particularly during the 1995-1999 period.
4. Since 2000, GDP growth has steadily dropped as the Government has become distracted from maintaining the momentum of reforms. First, pressures for fiscal prudence lessened as revenues started to increase significantly as a result of the dramatic increases in oil prices (with the more recent declines in oil prices, the growth trends are not expected to continue). Second, security concerns have been increasingly politically dominant both in Yemen and in the region. Quality of governance also remained weak and several reform initiatives began to flounder including: the privatization process, introduction of a General Sales Tax and the reduction in petroleum subsidies, legal and judicial reforms, and the implementation of civil service modernization and health sector reforms.
Health Status
5. Yemen ranks 138th out of 179 countries on the 2008 Human Development Index.35 There has been an increase in average life expectancy (up from 41.6 years in 1970 to 62 in 2006) with the life expectancy of women mirroring the overall trends. Similarly, there has been a significant increase in enrollment rates in basic education (up from 3 million in 1996 to 4.1 million in 2004). However, there are many remaining areas of concern including: high fertility rates (population growing at over 0.5 million people per annum); infant, child and maternal mortality; malnutrition (18 percent of the population or
34 Estimates based on 2007 population data. 35 Human Development Index, UNDP, 2008 Statistical Update. 31
about 3 million people) particularly for children under 5; and low female literacy rates which stood at 28.5 percent in 2002.
6. The health situation in Yemen is critical and the health sector faces significant challenges to reach the health Millennium Development Goals (MDGs). Infant and children under five mortality rates are the highest in the MNA region. More than 50 percent of children are malnourished, and the maternal mortality rate is among the highest in the world. There is evidence that HIV/AIDS prevalence is rising; about 20,000 people are infected by tuberculosis and more than 1.2 million Yemenis are suffering from malaria. In summary, Yemen is facing a number of key challenges that affects its development: (i) rapid population growth; (ii) high and stagnated maternal, infant, and child mortality; (iii) high child malnutrition prevalence, resulting in stunting in many cases; and (iv) high prevalence of malaria and schistosomiasis. Given these challenges, it is unlikely that Yemen will achieve the 4th and 5th MDGs by 2015.
7. High and stagnated maternal mortality. Maternal mortality ratio (MMR) appears to be stagnating, with little change between the 1997 estimate of 351 per 100,000 live births and the 2003 rate of 365 per 100,000 live births, placing it among the highest in the world. Half of maternal deaths occur during home deliveries. Appropriate services are often too distant, and the main reason for death is hemorrhage.
8. High infant and under-five mortality. Comparison of infant mortality (IMR) and children under-five mortality (U5MR) rates36 reveals a pattern of rapid early mortality reductions followed by a period of dramatic slowing and near stagnation of rates between 1992 and 2003.
9. High child malnutrition. Yemen faces an upsurge in malnutrition, with the percentage of underweight children rising from 29 percent in 1992 to 45.6 percent in 2003. More than 50 percent of children less than five years of age are stunted and more than 12 percent are wasted. Malnutrition could contribute to more than 50 percent of infant and child mortalities.
10. Rapid population growth. Population growth in Yemen stands at 3 percent per annum which is above the MENA region’s average of 1.9 percent, with large differentials among the country’s different geographic regions. As of 2003, the total fertility rate (TFR) is estimated at 6.2, in line with the 1997 estimates of the Demographic and Household Survey (DHS). The desired family size is 4.6. However, only 23 percent of women are using contraceptives, and only 13 percent are using modern methods.
11. Yemen is still in the early stages of an epidemiological transition as the morbidity and mortality rates from communicable diseases are still predominant, and those for non-communicable diseases are also rising. The most prevalent conditions are diarrheal diseases, malnutrition, complications of pregnancy, acute respiratory infections, and Malaria. WHO estimates show that one-third of all deaths amongst Yemeni children under-five years are related to vaccine-preventable diseases. In addition Yemen has one of the highest disease burden rates for measles and neonatal tetanus in the Eastern Mediterranean Region of WHO.37
12. High prevalence of schistosomiasis. Both urinary and intestinal schistosomiasis (caused by Schistosoma haematobium and S. mansoni, respectively) are prevalent in Yemen and are recognized as
36 Using a 1980 database, the Demographic and Household Survey (DHS) 91/92, DHS97, and 2003 Yemen Family Health Survey (YFHS) data. 37 County Cooperation Strategy for WHO and Republic of Yemen (2002-2007). 32
significant public health concerns (Nagi et al., 1999). Clinical manifestations of the disease have been recorded in writings of Arabian physicians since medieval times. Recent surveys show that prevalence of infection with any one form of the disease can exceed 70 percent in many Yemeni communities (Ministry of Public Health and Population, unpublished data). Overall, it is estimated that at a minimum 3 million individuals are infected with schistosomiasis of which about 600,000 suffer from clinical morbidity. The burden of disease has important implications in terms of productivity loss and likely impact on the country’s economic and social development. Chronic exposure to infectious agents is the main factor responsible for the health burden caused by schistosomiasis. The result is a slow progression from a light and reversible disease burden to a heavy and less easily reversible one.
13. Areas of geographical overlapping of urinary and intestinal schistosomiasis are a common finding in Yemen, which results in even higher cumulative prevalence of infection. Transmission of schistosomiasis occurs when the parasite's larvae penetrate the skin of a person, and is related to contact with both natural and artificial water bodies contaminated by parasite eggs passed out in the urine or faeces of infected individuals. Temporary streams and rivers (“wadis”) become torrential during the rainy season, resulting in plentiful surface groundwater, which represents an important transmission site, especially after heavy rainfall during the months of September and October. Widespread and various artificial water supply systems such as dams built on wadis, irrigation canals, tanks, pools and wells, represent equally important transmission sites throughout the year (CNRS & WHO, 1987). A recent review of epidemiological data from the National Schistosomiasis Control Program (NSCP) of the MoPHP shows the following breakdown of the country’s 334 districts:
• 114 districts have been confirmed as endemic by epidemiological surveys carried out in their territory; • 99 districts have reported cases of schistosomiasis through the national surveillance system and are thus considered as suspect endemic; • 121 districts are considered free of transmission and non-endemic.
Organization of the Health System
14. The MoPHP is the main health service provider in Yemen, with an expanding private health sector and the Ministries of Defense and Interior Affairs which run their own tertiary hospitals. The public health system has a three-tier network of facilities. The Local Authority Law of 2001 has devolved the role of MoPHP to subordinate entities: 22 Governorate Health Offices (GHOs) and 334 District Health Offices (DHOs). However, implementation of the decentralization law is challenged by low capacity at the local level and resistance of sectoral ministries to delegate authority. It is also hindered by the predominance of many highly centralized vertical programs, mainly supported by donors, delivering uncoordinated elements of primary health care (PHC) and public health programs.
15. The PHC supply system is suffering from a number of problems. The existing PHC service delivery program is distributed between two MoPHP departments: PHC and Population. This fragmentation of authority is exacerbated by general weakness in the public service delivery system, incomplete decentralization of functions at the governorate level, and domination of national vertical programs over governorate level planning and implementation functions.
16. The health care facilities network has increased significantly over the past two decades, although adequate staffing of facilities has not expanded apace. Between 2000 and 2005, the number of hospitals increased from 121 to 178 (47 percent increase), health centers increased from 688 to 895 (30 percent increase), health units increased from 1,818 to 2,730 (45.1 percent increase), and maternal and child
33
health (MCH) centers increased from 241 to 460 (90 percent increase).38 Despite these developments, only 42 percent of the population has access to public health care. Health personnel are disproportionately distributed between urban and rural areas and between and within governorates. In addition, the quality of existing services is a major concern, with chronic shortage of resources such as drugs, equipment, and manpower, weak governance, and lack of accountability.
Health Finance
17. Findings of the National Health Accounts (NHA) estimates for 2003 indicated that RoY spending on health was 4.9 percent of total government spending, and total health spending was about 5.6 percent of GDP. Total per capita health spending (public and private) was about US$33 in 2003.
18. Funding for the health sector originates from three primary sources: RoY (which represents the public expenditure), private (which is primarily household out-of-pocket payments), and foreign assistance. Private payment constitutes the highest share (75 percent) of total health expenditures, as compared to only 25 percent from the Government, of which about 10 percent comes from foreign assistance.
19. There are also concerns with respect to resources allocation. For example, only about 3 percent of the budget is allocated to maintenance of facilities and equipment of which only about half is actually spent. The financial management issues have been further compounded by the quasi decentralization program whereby local government finances the construction of new infrastructure, which is to be staffed, equipped, and operated by the central MoPHP. To equip and staff the health facilities which are currently under construction would require unrealistic increases - 18 percent annual increase in recurrent expenditures (against the current 6 percent annual increase), and 92 percent increase in the number of staff by the end of 2009.39
Donor Support
20. Multiple initiatives funded by development partners led to: (i) increased competition of qualified personnel to implement these initiatives in different geographic areas; (ii) fragmented efforts to develop a strategic approach; and (iii) availability of a funding beyond the absorptive capacity of the MoPHP.
Health Sector Reform Initiatives
21. In 1998, the MoPHP launched a Health Sector Reform program in response to the challenges facing the health system. The 1998 Health Sector Reform Strategy aimed at addressing the lack of quality, efficiency, and accessibility of the health care system. Three policies were defined: improvement of effectiveness and efficiency of the system, decentralization of management and financial functions to district level, and redefining the role of MoPHP from services provider to a stronger policy and regulatory role.
22. The 1998 Health Sector Reform program was very ambitious with broad objectives. It attempted to address all challenges and did not make strategic prioritization. It was found unfeasible and
38 Ministry of Planning and International Cooperation (MoPIC), The 3rd Socio-Economic Plan for Poverty Reduction (2006- 2010). 39 Fairbank, Alan (2006). Public Health Expenditure Review: Health Sector Republic of Yemen, 1999-2003. Bethesda, MD: The Partners for Health Reform plus Project, Abt Associates, Inc., Tables 16 & 17, pp. 47-49.
34
unaffordable given the existing capacities and the country’s socioeconomic context.40 The MoPHP review of the 1998 Reform Program concluded that the program did not achieve its objectives and defined the constraints to the implementation of the program, including: (i) weak ownership of the reform program at all levels of the system (reflected by a non-participatory process for strategy development); (ii) strategy was not translated into a costed implementation plan; (iii) lack of monitoring and evaluation to support regular review of progress; and (iv) emergence of the decentralization process, and policy contradictions between the health and the decentralization strategy.
23. In addition to the current health sector challenges mentioned above, there were several other reasons for the GoY to launch a joint review of the health sector, including: (i) GoY’s endorsement of the Third Five-year Health Development Plan (2006-2010), which constitutes the framework for health planning and includes policies and strategies for execution; (ii) urgent need to update the previous Health Sector Reform strategy in order to accommodate several policies which have emerged after the launch of the strategy, including the MDGs; and (iii) Yemen Poverty Reduction Strategy.
Health Sector Review (HSR) and Strategy Development
24. In 2005, the MoPHP and its development partners initiated a dialogue to revisit the Health Sector Reform strategy and evaluate the donors’ approach in order to improve health sector performance and its efficiency. A Joint MoPHP - Development Partners Statement on Alignment and Harmonization was signed, followed by launching a comprehensive HSR process led by the MoPHP - through the Health Policy Unit - and supported technically and financially by the development partners, including the World Bank within an agreed framework.
25. Development partners have made a commitment to support the HSR process and align their future support to fund the updated health reform strategy. Under this framework, the Bank is initiating a dialogue with the MoPHP and development partners on the design of a new IDA-financed Health and Population Project (HPP), expected to be delivered in FY11, which would support strategic directions as defined by the future outcome of the HSR process.
26. The HSR process aims at strengthening the health system by contributing to achieve: (i) an updated Health Sector Reform strategy; (ii) political commitment and sufficient resource allocation to implement these reforms; (iii) consensus among stakeholders in the health sector on the mechanism and approaches to implement the strategy; and (iv) commitment to the harmonization and alignment of donors’ support to the strategy implementation.
27. The HSR is being implemented as a three-step process: (i) identifying and assessing the important elements of the current situation in the sector -“Status Quo Phase” – the output of this phase was the “Yemen Health System Profile Report”; (ii) exploring alternatives for policy direction and developing targets for improvements in the areas identified as leading to poor performance in the status quo phase - “Benchmarking Phase” – the output of this phase will be a conceptual framework for results-based policy options and targets for improved performance; and (iii) “Strategy Development Phase” – development of the new strategy and setting action lines and costing of the strategy implementation.
28. The MoPHP proudly owns the HSR process and is committed to a highly participatory implementation. The process involves extensive consultations at national, regional, and local levels and is designed to involve all relevant stakeholders and at the same time coordinated with other relevant national planning initiatives, e.g., the Mid-term Review of the Third Five-Year Development Plan 2006-
40 World Bank (2000), Republic of Yemen: Health Sector Strategy Note.
35
2010 (led by MoPIC), Mid-Term Expenditure Framework 2009-2011 (lead by MoF), and the review of the decentralization law (lead by MoLA). The new strategy resulting from this process will likely form an important basis for the Fourth Five-Year Development Plan (2011-2015), and is expected to provide the framework for all sectoral programming, including donor assistance.
29. Phase I of the review process was finalized in March 2008, based on a situation analysis implemented across eight thematic areas: leadership, planning, health finance, human resources, drugs/ medical supplies and medical technology, infrastructure, service delivery (quality and governance), partnership. Preparations for Phases II and III were launched in parallel. The HSR will conclude with the endorsement of the Health Sector Reform Strategy (2009–2015) in a national conference. The reform strategy will provide the framework for future directions of the sector and will serve as the planning context for future donors’ support, including World Bank support for the sector.
30. Preparations for Phases II - “Benchmarking Phase” and Phase III - “Strategy Development Phase” were launched and build on the findings of Phase I. However, it will take some time before the HSR is fully developed into a national sector strategy and program. The MoPHP has identified integration of health services as a pressing non-controversial theme and has decided to go forward with it and maintain its linkage to new developments in the health sector. Integration of the PHC program would improve efficiency and quality of services; and would address weaknesses of the public service delivery system. Program emphasis has been on incremental and phased integration of vertical programs.
Planned IDA-Financed Support to the Health Sector
31. The Minister of Public Health and Population has set as the MoPHP’s highest priority to address the high rates of child and maternal mortality, and the high prevalence of schistosomiasis and malaria. The ongoing Health Sector Review, once finalized, is expected to set priorities, define benchmarks, and develop detailed future strategic directions for the MoPHP to address these challenges and contribute to the design of a national program that delivers health and population services.
32. While these medium to long-term solutions are being prepared, dependence on vertical programs will continue in order to address the public health problems that face Yemen. This approach will be required until a routine system that can deliver integrated health services is in place, which is not envisaged in the near future. Partnerships between donors are being formulated around specific themes such as reproductive health, malaria, and schistosomiasis, where it becomes feasible to collaborate.
33. In light of these priorities, the MoPHP’s request for Bank support has led to the preparation of two IDA-financed projects: (i) SCP; and (ii) HPP. The SCP aims to decrease the high prevalence and intensity of infection of schistosomiasis in partnership with WHO and the Schistosomiasis Control Initiative (SCI); and the HPP is being designed to contribute to the acceleration of the achievement of MDG 4 & 5 (reduction in childhood mortality and improvement of maternal health) in partnership with UNICEF, UNFPA, and WHO. Malaria is being supported by the Global Fund.
36
Annex 2: Major Related Projects Financed by the Bank and/or other Agencies
1. Schistosomiasis Control Project (SCP113102)--US$25 million (IDA financing), approved in December 2009, aims to reduce the prevalence and intensity of infection of both urinary and intestinal schistosomiasis among school-age children by 2015 in endemic regions of Yemen. The project will contribute to the the Government of Yemen's goal of achieving control of morbidity due to schistosomiasis on a nationwide basis. The beneficiaries are those who will receive anthelminthic drugs through the project interventions. Based on the program drug administration strategy, it is expected that 6 million people (half of whom are expected to be female) will directly benefit from the SCP activities over the life of the project. The project will support two anthelminthic drug delivery strategies (campaign- based preventive chemotherapy using fixed and temporary sites, and routine preventive chemotherapy), as well as technical assistance to support implementation, monitoring and evaluation of these strategies; training; and IEC (information, education and communication) activities and social mobilization activities to support the effective application of the strategies.
2. In addition, the project will include in its distribution package another anthelminthic drug, albendazole (or mebendazole), which will therefore be co-administered with praziquantel in all the areas endemic for schistosomiasis with the aim of treating STH infections. The project has established strong partnerships with WHO and Schistosomiasis Control Initiative (SCI), an international agency specialized in this area. WHO will provide assistance through: (i) donation of albendazole/mebendazole required to treat STH infections and the timely procurement of praziquantel; and (ii) procurement and assurance of the quality of drugs. SCI will provide technical assistance to the project during the first 12-15 months of implementation to ensure success of the program.
3. Health Reform Support Project (HRSP P043254)--US$29.6 million (IDA financing). Closed August 31, 2009. The project was designed to: (i) improve access to and quality of priority national family health and reproductive health programs; and (ii) develop the capacity of the MoPHP to manage, plan, and deliver basic health services and priority public health programs at the central level and in 8 selected regions. The HRSP was a ‘problem’ project during the first two and a half years of implementation. By Mid-Term Review (MTR), June-October 2005, disbursement was only about 6 percent. Explanation of the poor performance of the project included: (i) inadequate project preparation (e.g., the governorates which were to be targeted were selected 18 months after the project was declared effective); (ii) problems with the project design (e.g., under-estimation of the risks related to the decentralization and policy reform processes); (iii) a general lack of ownership and commitment within the MoPHP and the weak coordination among the different sectors/departments within the MoPHP; and (iv) bureaucratic hurdles which slowed the day-to-day progress.
4. The MTR concluded with the recommendation for project restructuring. The most significant elements of the project restructuring were: (i) formal revision of the PDO; (ii) formal assigning of the civil works to the Public Works Project, which had a proven track record of implementing small scale civil works in rural areas; and (iii) the extension of project closing date by one additional year. Further, the Bank (in collaboration with the WBI) provided technical assistance for introducing the Rapid Results Approach (RRA) in support of project implementation. Three rounds of results-based planning and assessing progress using the RRA were successfully implemented during 2006. The RRA was also instrumental in planning project activities for the remaining two years of implementation (2007-2008). Project performance improved considerably following the project restructuring. The project rating was upgraded from unsatisfactory to moderately satisfactory in June 2006, was upgraded further to satisfactory in December 2006, and was rated moderately satisfactorily in the ICR .
37
5. Most of the performance indicators that were selected to monitor the PDOs were achieved, and even exceeded in some cases as follows: (i) at 87 percent for 2008, the national coverage of fully immunized children under one year of age came close to the 90 percent target. Particularly noteworthy is the eradication of polio. On the other hand, at 60 percent the BCG immunization somewhat lags behind; (ii) the percentage of women using modern family planning methods continued to increase, with figures for 2006 (contraceptive prevalence rate of 19 percent) slightly above the target increase of 5 percent set for 2008; (iii) the percentage of the MoPHP recurrent expenditures spent for maintenance also exceeded the target increase of 10 percent. More important than the increase in the percentage, between 2004 and 2007, the actual amounts spent on maintenance showed a significant increase in real terms (about 65 percent, assuming that the inflation averaged 8 percent per year); (iv) the coverage of Long Lasting Insecticide Nets (LLIN) in the targeted districts reached 45 percent of households, compared with the 5 percent target; (v) the Integrated Management of Childhood Illnesses (IMCI) Program is now available on a daily basis in the 22 targeted health facilities in the 10 project districts, and in many more health facilities nationwide; (vi) in the three targeted Governorates, comprehensive Emergency Obstetric Care (EmOC) services are provided in the 3 project district hospitals, and basic EmOC services are provided in 11 (out of 12) health centers; (vii) District Health Plans were prepared in all 10 project districts and 20 percent of plans were implemented with Government’s budget; (viii) one hundred and forty health management personnel (100 percent of target) were trained by NCHMT in health planning; (ix) three hundred and fifty laboratory technicians (100 percent of target) were trained on malaria diagnosis; and (x) three project governorates were covered by the interactive health GIS.
6. Health Sector Review (TA-P109978-TF091473). The Bank team is working with the Policy Unit of the MoPHP and development partners in providing technical support to the analysis and framework development for the review and strategy development. World Bank technical support to the review process is focusing on: the development of a results-based policy framework; (ii) analyzing the performance of health sector finance in relation to health outcomes, and proposing policy options for results-based financing mechanisms to be considered in the strategy; and (iii) supporting donor coordination and harmonization through facilitating the development of a Sector Wide Approach Program to deliver an outcome-based integrated MCH services. A Status Quo report that was disseminated in March 2008 implicitly identifies opportunities for systems and services-level integration. During the benchmarking process, the work groups engaged in selecting results indicators and strategic actions to achieve them will explicitly identify cross-impact of these indicators and actions and consider opportunities for effective synergies.
7. Queen of Sheba Safe Motherhood Project (P104946): The US$6.5 million GPOBA Grant is scheduled to close in June 2012. This is a four year community-based project which supports the provision of a defined ‘Mother-Baby package’ of essential quality services as defined by WHO. Services provided to eligible women of reproductive age (15-49 yrs) in Sana’a, Yemen includes: antenatal care, natal, postnatal care, and family planning education. This project addresses barriers to these services by providing defined quality maternal services including working with the targeted communities to increase utilization of these services and ensuring birth attendance by skilled birth attendants. It allows the disbursement of funds to private sector service providers using an output-based disbursement arrangement, which is intended to improve the project performance by directly linking disbursements against actual outputs and performance achievements.
8. ‘Health’ as a Component of Other Bank Operations. Strengthening health services at the community level and improving the capacity of the Health Manpower Institutes are key elements supported by the strategy and activities of the Social Fund for Development. In addition, the MoPHP is one of the pilot ministries for reform under the Civil Service Modernization Project and the Mid-term Expenditure Framework initiative (see description under Governance); and health facilities have been
38
constructed under the Public Works Project. Efforts are also underway to create a school-based nutrition program that, with Bank support, would involve both the MoPHP and the Ministry of Education.
9. Child Development Project (P050483) - US$45.3 million. The project was closed on December 31, 2005. The project aimed to improve nutritional status of children under five, and the educational status of girls in primary schools, in under-served districts through: (i) a community readiness program, (ii) strengthening districts' health care system, (iii) counseling, nutrition education, growth monitoring, and micro-nutrient supplements, (iv) expanding girls' access to quality primary education through innovative community-based schools, and (v) Early Child Development (ECD) pilot with 64 percent of its activities health-related.
Other Development Agencies Projects
10. Health System Strengthening, HSS-GAVI Alliance (US$6.33 million) (2007-2010). The MoPHP is currently implementing the Health System Strengthening (HSS) Project supported by the GAVI. The project aims to improve the performance, efficiency and reach of district health systems, through initiation of a model that integrates the resources and operations of vertical programs, that complements fixed site health care provision with outreach, and that utilizes results-based motivational systems. The ultimate goal is to improve MDG performance nation-wide in reducing child and maternal mortality, and to halt and reverse the spread of malaria and TB. The HSS project identifies over-reliance on inefficient vertical fixed site services as one of the main constraints on the Yemeni public health system that resulted in low coverage of the population with basic health services, especially in rural areas.
11. The project aims that within three years, the integrated outreach system will have been successfully implemented in 64 districts (reaching 30 percent of the total population), and supported by policy measures and by a strengthened management and health information system at all levels of the Ministry. Improved coverage and impact of immunization and other essential health services are to be achieved. By 2010, the model will have been adjusted through experience, presented to all major HSS stakeholders, and used as the road map for the National Health Service provision strategy to be implemented within the following five year sector development plan, and supported by donors through shared national programming. Implementation started with a pilot integrated training course for health workers in fixed facilities. Integrated commodity service delivery is proposed as a next step in this experiment.
12. The project’s key priorities are: (i) improve the accessibility, quality and utilization of district health systems to underserved populations, through the provision of targeted, integrated, and results-based outreach interventions, and through strengthening and creating demand for the fixed site services that support them; (ii) improve the efficiency and coordination of vertical programs for greater impact and sustainability through their functional integration; (iii) improve central, governorate, and district level managerial systems to support these two process of outreach and integration; (iv) develop through piloting in 64 districts, and building national consensus for country-wide implementation of a results- based model of district health service provision that incorporates the core elements of outreach and integration. This model is designed to: (a) use underutilized female health staff, (b) encourage and motivate health workers and district and governorate level local authorities to improve service provision in high priority areas, (c) efficiently use all available resources in-country, and (d) attract greater funding to the sector.
13. WHO (US$30 million) (2008-2013). The strategic directions for WHO collaboration with the RoY for 2008–2013 are based upon the national priorities stated in the 3rd Five Year National Health Development Plan, identifying health and development challenges and gaps emanating from the extensive consultations, and WHO’s own global and regional priorities. WHO’s support is focusing on the
39
following areas: (i) improving the performance of the health system that assures an adequate and fair financing of the health system and provides social protection to the poor and vulnerable segments of the population; (ii) promoting integrated reproductive and child health services for improved maternal and child health outcomes including nutrition based on the comprehensive PHC approach; (iii) supporting well performing, functionally integrated and efficient communicable disease prevention and control program that target malaria, TB and HIV/AIDS and other prevalent and emerging communicable diseases responsible for the major burden of disease; (iv) establishment of a comprehensive countrywide health promotion and protection programs that covers the broad range of risk factors responsible for non- communicable and communicable health problems; (v) strengthening the health management information and surveillance system, and building capacity for health systems and operational research that provides valid, reliable and timely information for decisions at all levels of the health system; (vi) tackling the social, economic and environmental determinants through promotion of inter-sectoral action for health at the policy, program and grass root levels; and (vii) improving donor coordination mechanism for increased aid effectiveness in line with national priorities in the health sector.
14. Since 2002, WHO has been supporting the NSCP through its three levels of intervention: (i) WHO Country Office (WHO/YEM), Sana'a assisted the MoPHP in planning, implementing and following up on disease control activities; (ii) WHO Regional Office for the Eastern Mediterranean (WHO/EMRO), Cairo, provided technical support and allocated financial resources; and (iii) WHO Headquarters (WHO/HQ), Geneva, through the Preventive Chemotherapy Unit of the Department of Control of Neglected Tropical Diseases (PCT/NTD) made available to the MoPHP the latest recommendations on disease control strategies, as well as the experience and examples offered by other endemic countries on a global scale.
15. WHO financial support to the NSCP amounts to approximately US$840,000 for the period 2004- 2009. Funding is mainly directed to support the following strategic interventions: (i) capacity building (training and provision of fellowships on management and planning of schistosomiasis control activities); (ii) procurement of anthelminthic drugs and contribution to operational costs related to their distribution to the target population; and (iii) epidemiological mapping aiming at identifying schistosomiasis endemic districts across the country with the purpose of stratifying them according to level of risk. These key interventions were instrumental to start implementation of large-scale control of schistosomiasis in over 60 districts throughout Yemen.
16. UNFPA Reproductive Health Program (US$13.5 million) (2000-2011). The UNFPA program seeks to ensure that the National Reproductive Health and Population Strategy and related policies are translated into effective interventions. UNFPA is planning to support a sector wide approach to planning and budgeting. The program has three components: (i) reproductive health; (ii) population and development, and (iii) gender.
17. The focus of the program is on vulnerable groups, including young people, migrants and rural populations. UNFPA is following, in coordination with the GoY, a process of identification and selection of the geographical areas and priority governorates for program interventions according to specific and objective criteria including population size, poverty rate, population growth, fertility rate, coverage of reproductive health services and commitment of local authorities. However, to keep balance between comprehensible and focused coverage, the program is working at two levels: nationwide through specific interventions including reproductive health commodities, policies, standards, planning monitoring and evaluation, while at the decentralized levels in the target governorates and districts, the focus will be put on service delivery, advocacy, capacity building, strengthening community based health providing system, expanding innovative service delivery systems to rural underserved remote areas and community participation.
40
18. The previous program supported the training of community based midwives, an innovative approach that helped to expand services at decentralized levels. Although the number of midwives and access to services has generally increased in the areas covered by the previous program, lessons learned demonstrate that many women still have problems visiting midwives (and vice versa) due to the socio- cultural dimensions and poverty. Also, many midwives who were trained were not employed by the GoY. Therefore, the new program will explore how to reduce those barriers, as well as to pilot innovative approaches aimed at bringing services even closer to the clients’ houses. In addition, the previous program piloted the use of mobile health services to expand coverage to hard-to-reach areas and scattered populations and was successful in enabling women to access services close to their homes. An assessment of the mobile services approach confirmed their effectiveness in the Yemeni harsh terrain as a means of bringing services to the doors of clients. The program registered notable achievements in assisting people in making informed choices about reproductive health, and introduced population issues into the formal educational curriculum.
19. UNICEF - The Young Child Survival and Development Program (US$25.00 million) (2007- 2011). The program is strengthening the coverage and quality of basic health care services to address the main causes of high infant and child morbidity and mortality by improving access to and utilization of life saving interventions. Based on lessons learned from previous programs, integrated community based interventions are being expanded to support families to adopt appropriate practices for maternal and child health, better parenting, infant feeding, and care-seeking practices. Specific attention is being given to the integration of community-based communication interventions and the institutionalization of monitoring systems to measure progress.
20. In close collaboration with WHO and GAVI, the child health component provides support to expand and strengthen routine immunization activities to eliminate measles and maternal-neonatal tetanus and sustain polio-free status. Ongoing provision of services for integrated management of childhood illnesses is supported by community-based interventions related to prevention and case-management of malaria, diarrhea and acute respiratory infections with special focus on marginalized and underserved population groups.
21. The maternal and new born health component aims to improve emergency obstetric care services by upgrading delivery facilities and referral services for emergency obstetric cases to reduce high maternal-neonatal mortality rates. More home deliveries are being assisted by trained community midwives with close monitoring of child and maternal health during the first month to contribute to better maternal and newborn health. Meanwhile referral services for emergency obstetric cases are being improved between the three levels of health care facilities. Access and timely utilization of obstetric services are being promoted especially among marginalized and underserved population groups through a human right based approach. The existing partnership with UNFPA and WHO is being strengthened through a joint program to ensure complementary services.
22. In collaboration with WHO and WFP, the nutrition component is promoting best practices in child nutrition such as immediate breast-feeding after delivery and exclusive breast-feeding for up to six months, improved feeding and child care practices with special emphasis during illnesses, and focusing on the nutritional status of pre-pregnant and lactating women. The ongoing fortification program for flour, cooking oil and salt is being supported, especially through social marketing to achieve better coverage, and Vitamin-A supplementation. The community based approach to early childhood care, growth and development is being expanded in selected communities, closely linked to interventions promoting early learning and readiness for school.
41
23. The safe water and personal hygiene component focuses on household water security and sustained good hygiene behavior to help reduce the incidence of water-borne diseases. In collaboration with UNDP, this component expands water schemes with proper water resource management such as conservation and tariff for long term sustainability. It ensures provision of water and sanitation facilities in primary schools and health facilities. Hygiene education is integrated with other community-based interventions promoting young child survival and development. This intervention is being complemented by school health program including de-worming of school children.
24. Health Sector and Demography Support Program, HSDS- European Commission €8.0 million (2007-2010). The overall objective of the project is to contribute to the improvement of the health status of the population of Yemen. The project purpose is the effective provision of and increased population coverage by a sustainable basic package of essential health services in the two governorates of Lahej and Taiz. Major emphasis is being given to underserved areas and to improved reproductive health services.
25. The project aims at achieving the following results: (i) funding of health services and financial management of health expenditure rationalized; (ii) rational management of human resources at governorate and district level established supporting effective provision of quality health services; (iii) planning, budgeting, managerial and monitoring capacity built at governorate level; (iv) district health system, geared towards efficient provision of the basic package of essential health services, fully implemented; (v) rational health infrastructure and equipment plan implemented; (vi) community participation in the management of their health enhanced; and (vii) national Population Council contribution to an improved utilization of reproductive health care services increased.
26. Community-based Nutrition (CBN) – (2001-2005): The program was funded by WHO and JICA, covering 20 districts. This nutrition program is currently implemented by the MoPHP, supported by WHO and JICA. It is a continuation of the CBN component of the Child Development Program (2001 - 2005 WB/UNICEF). The program works with Community Volunteers who conduct Growth Monitoring and Promotion41 for children < 5. Acute severely malnourished children ((Weight/ Height, wasting) with complications are admitted in Therapeutic Feeding Centers (TFCs), those without complications are referred to the Outpatient Therapeutic Units (OTPs) for close weight monitoring and food supplementation (plumpy-nut). Education and counseling on breastfeeding and infant and young child feeding is given to mothers of the non-acutely and moderately malnourished children, as well as IMCI case management. 27. Program of Improving Reproductive Health - GTZ US$5 million. The project’s focus is on improving health care for mothers and children as well as on family planning. In addition, other basic health services, for example for young people, are also to be developed and the entire organization of the health system modernized. 28. Yemen Basic Health Services Program (BHS) - USAID (2006-2008). The three year project assisted the RoY in improving maternal and child health in the five northern and eastern governorates of Amran, Sa’ada, El Jawf, Marib, and Shabwa. No results or outputs documents were available.
29. Reproductive, Maternal and Child Health Services – USAID (US$27 million) (2005-2010). Reproductive, Maternal and Child Health Services project funded by USAID is planned to end December 2010. This project has been implemented in five remote and underserved Governorates to increase access to quality health services; increase knowledge and healthy behaviors at the community level; and improve physical and policy environment for health. Although a low profile project its approach is integrated in
41 Until recently Weight/Age was measured (underweight) for GMP, now the program starts to use MUAC (Middle Upper Arm Circumference) for Age for children between 3 and 59 months. 42
the RH sense that it addresses supply and demand; facility upgrade and service provider; health education and service care seeking behavior as well as community support issues.
30. Community communicator strategy for community development (2006 – 2010 in 11 districts in 5 governorates). UNICEF merged the strategy of two programs that were implemented during 2002- 2006, the Community Based Nutrition (CBN) with the Community Communicators. The new program integrates nutrition with other development objectives, e.g., health services (including HIV/AIDS), girls education, Female Genital Mutilation (FGM) and birth registration. The community development program is implemented through a network of Community Communicators (trained volunteers with prior education) and is implemented in the same governorates/districts as the MNH program. However, it is not clear to what extent MNH is integrated with the community based program. UNICEF will also provide training on management of acute moderate and severe malnutrition to all doctors and nurses who have been trained on IMCI in 2008. This will enable the health facilities with IMCI to deliver more integrated health services and serve as OTPs. In addition, UNICEF is implementing an Emergency Nutrition program with one TFC and five OTPs in refugee camps in Sa’ada governorate.
31. School Nutrition Project (WFP supported in 2,000 schools in 95 districts). This project is implemented by the Ministry of Education in collaboration with the World Food Program. It is at the beginning of its second five year phase and aims to increase the enrolment of girls in primary schools. 150 kg wheat and 9 kg oil are provided every quarter to families that send their girls to school.
43
Annex 3: Results Framework and Monitoring Results Framework
PDO: The objective of the proposed Project is to improve access to and utilization of a package of maternal, neonatal, and child health services in selected governorates with a high concentration of districts with poor health indicators.
PDO Project Outcome Indicators Use of Project Outcome Information
1. Access to 1.1 People with access to a basic package of Results of the overall project MNCH services health, nutrition, or population services outcome indicators will inform increased in (percent increase based on number of people) ex-post project assessment and project target – Core Sector Indicator. policy design recommendations. areas. 1.2 Direct project beneficiaries (number), of This includes whether the which female (percentage) – Core Sector outreach mobile team services Indicator. should be: (i) an integral part of the service delivery system; (ii) expanded to other regions; and/ or (iii) amended. Policy design options will be based on the success of the project at targeting and improving the access and utilization of the target population for the following components: A) Child health services. B) Nutrition services. C) Reproductive health services.
2. Utilization of Utilization of Child Services MNCH services 2.1 Percentage of infants vaccinated with penta increased in 3/polio 3 in the project target areas. project target areas. Utilization of Reproductive Health Services 2.2 Percentage of women of reproductive health age in target areas receiving an ANC visit. Intermediate Intermediate Outcome Indicators Use of Intermediate Outcome Outcomes Monitoring 3. Geographical 3.1 Number of outreach rounds conducted in Results of interim project and program target areas. monitoring will inform the coverage of 3.2 Number of targeted U5 children reached by progress of the project and outreach outreach services (program coverage). whether project timelines and services. components should be maintained 3.3 Number of targeted women of reproductive or amended as appropriate to health age reached by outreach services increase the likelihood of (program coverage). achieving the PDO.
44
Intermediate Intermediate Outcome Indicators Use of Intermediate Outcome Outcomes Monitoring
4. Availability of 4.1 Health facilities in project areas equipped to MNCH services provide EmONC, nutrition TFC, and OTP increased in services. project target Child Health Services areas. 4.2 Children immunized (number) – Core Sector
Indicator. Nutrition Services 4.3 Number of U5 children screened by MUAC in target areas. 4.4 Children receiving a dose of Vitamin A – Core Sector Indicator. Reproductive Health Services 4.5 Pregnant women receiving antenatal care during a visit to a health provider (number) – Core Sector Indicator. 4.6 Number of pregnant women and those of reproductive age vaccinated against tetanus (TT2) in target areas 4.7 Number of women receiving modern contraceptives in target areas.
5. Capacity 5.1 Health personnel receiving training (number) development – Core Sector Indicator.
45
Arrangements for Results Monitoring
Target values Reporting Data Collection Baseline Y1 Y2 Y3 Y4 Y5 Y6 Frequency Instrument Responsibility
Project Outcome Indicators
People with access to a basic package of health, nutrition, or population services (percent increase based on number of people)- MoPHP 1 0.90 1.00 1.50 2.00 2.25 2.50 2.50 Annual MoPHP Core Sector Indicator (CSI) Statistics Note: Numbers are cumulative and in millions of people. 42
Direct project beneficiaries (cumulative number – CSI 43 MoPHP 2 0.00 0.20 0.25 0.30 0.34 0.40 0.45 Annual MoPHP Statistics Note: Numbers are in millions of people. MoPHP 3 Percentage of direct project beneficiaries which are female - CSI. 44 0.00 75% 75% 75% 75% 75% 75% Annual MoPHP Statistics Percentage of infants vaccinated with penta 3/polio 3 in the project MoPHP 4 85% 75% 75% 80% 85% 90% 90% Annual MoPHP target areas.45 Statistics MoPHP 5 Percentage of pregnant women in target areas receiving an ANC 7% 7% 10% 12% 15% 17% 20% Annual MoPHP care visit through Outreach Services.46 Statistics
Intermediate Outcome Indicators MoPHP Following 1 Number of outreach rounds conducted in target areas.47 0 150 200 250 300 350 400 outreach MoPHP outreach round records
42 This indicator represents the increase in the number of people in the project areas who will have access to a basic package of HNP services. The services are to be delivered through outreach, and the targeted population is women of reproductive health age and children under 5 years of age. The baseline represents the number of people currently reached with basic HNP services through existing outreach programs. 43 The direct project beneficiaries are the cumulative number of women, infants, and children expected to receive the outreach services. 44 It is estimated that of the project beneficiaries, 50 percent of the infants and 50 percent of the children under U-5 will be female. Of the adult population, only women of childbearing ache will be targeted. Therefore, of the total beneficiaries, about 75 percent will be female. 45 Number of infants vaccinated with penta 3/polio 3 through outreach activities/total number of infants living in the project target areas. Not less than 80 percent coverage at district level in each governorate. 46 Number of pregnant women receiving an ANC care visit through outreach services/total number of pregnant women in project target areas. 47 Year 1: Three rounds in each of the 67 districts. Year 2: Four rounds in each of the 67 districts. Year 3: Five rounds in each of the 67 districts. Year 4-6: Six rounds in each of the 67 districts. 46
Target Values Reporting Data Collection Baseline Respon- Y1 Y2 Y3 Y4 Y5 Y6 Frequency Instrument sibility Number of targeted U-5 children reached by Outreach Following MoPHP outreach 2 Services supported by the project (program coverage) - 0 100,000 150,000 200,000 250,000 300,000 350,000 MoPHP outreach round records numbers are annual (not cumulative). Number of targeted women of reproductive health age reached by Outreach Services supported by the project Following 3 0 20,000 30,000 40,000 50,000 60,000 70,000 Records MoPHP (program coverage) - numbers are annual (not outreach round cumulative). Health facilities in project areas equipped to provide 4 EmONC, nutrition TFC, and OTP services (cumulative 0 0 15 30 40 50 60 Annual MoPHP records MoPHP number). Following MoPHP Outreach 5 Children immunized (cumulative number) - CSI. 48 0 50,000 60,000 70,000 80,000 90,000 100,000 MoPHP outreach round Records Number of U-5 children screened by MUAC in the target Following MoPHP Outreach 6 areas through project Outreach Services - numbers are 0 5,000 10,000 15,000 20,000 25,000 30,000 MoPHP outreach round Records annual (not cumulative) Children receiving a dose of Vitamin A - CSI (cumulative Following MoPHP Outreach 7 0 5,000 10,000 15,000 20,000 25,000 30,000 MoPHP number). outreach round Records
Pregnant women receiving antenatal care during a visit to Following MoPHP Outreach 8 0 2,000 5,000 10,000 15,000 20,000 30,000 MoPHP a health provider (cumulative number) - CSI 49 outreach round Records
Number of pregnant women in project areas vaccinated Following MoPHP Outreach 9 0 2,000 5,000 10,000 15,000 20,000 30,000 MoPHP against tetanus (TT2) through project Outreach Services - outreach round Records numbers are annual (not cumulative) Following MoPHP Outreach 10 Number of women receiving modern contraceptives in 0 2,000 5,000 10,000 15,000 20,000 30,000 MoPHP target areas - numbers are annual (not cumulative) outreach round Records
11 Health personnel receiving training (cumulative number) - 0 1,000 1,200 1,400 1,600 1,800 2,000 Annual MoPHP Records MoPHP CSI
48 In the Yemen context, this indicator is going to be measured as the cumulative number of infants vaccinated with penta 3/polio 3. 49 In the Yemen context, this indicator will be measured as the number of pregnant women receiving antenatal care during a visit to a health care provider through project outreach services. 47
Annex 4: Detailed Project Description
1. Project objective. The objective of the HPP is to improve access to and utilization of a package of maternal, neonatal, and child health services in selected governorates with a high concentration of districts with poor health indicators.
2. Project description. This is a six-year project. The estimated project cost is SDR 23 million (US$35 million equivalent) and will include the following components:
3. Component 1: Improving Access to Maternal, Neonatal and Child Health Services (US$30.5 million equivalent). This component will support initiatives targeted to improve access to MNCH services in geographic areas with poor MNCH indicators. Activities will include delivery of Outreach Services and selective upgrading of first level referral facilities. It would comprise three subcomponents.
4. Sub-component 1.1: Delivery of Outreach Services (estimated US$17.5 million equivalent). This sub-component will support the following set of activities:
(i) Provide/expand access to a basic MNCH package of services to populations with no or limited access to health services, using a service delivery model of routine mobile outreach health services (Outreach). This model will complement service delivery in fixed facilities as well as community-based services provided through GoY and development partner resources.50 It will also increase the demand for the delivery of services through fixed facilities and strengthen referral of cases to these facilities.
(ii) Integrate reproductive health and nutrition services within Outreach Services.51
(iii) Integrate the routine delivery of selected vertical public health programs, such as malaria and schistosomiasis, within Outreach Services.52
(iv) Make available essential drugs, diagnostics, supplies, and equipment for MNCH services (including contraceptives) for Outreach Services. The project will also support strengthening the logistics management system for Outreach Services to ensure the timely availability of quality drugs and health commodities.
(v) Strengthen health management information systems and quality assurance that would ensure the proper functioning and monitoring of Outreach Services.
(vi) Make available program operating costs necessary to roll out Outreach Services.
50 UNICEF will be supporting community-based services in the governorates of Sana’a and Ibb to complement the routine outreach services supported by this project in these two governorates. JICA is supporting community-based services in six districts in Yemen in three governorates, two of which (Sana’a and Ibb) are to be supported under the HPP. Community- based services design and plans are based on the experience that was implemented by the GAVI-funded HSS Project. Collaboration with the Social Fund for Development to support community-based services is being explored. 51 Currently the package of Outreach Services focuses primarily on immunization and other basic child health services such as IMCI. Only Sexually Transmitted Diseases (STDs) from reproductive health services are incorporated within the package. 52 Drugs and impregnated bednets will be supplied by the respective national control programs for schistosomiasis and malaria financed by the IDA financed project, Schistosomiasis Control Project, and Global Fund Project. The HPP will finance the operating costs necessary to improve the routine coverage.
48
5. Rolling out of Outreach Services. Specifically, the sub-component will support, in the project governorates, a population-based program that delivers a basic package of MNCH services in rural and urban slums districts through an enhanced model of Outreach Services, building upon the service delivery model developed under the GAVI-funded HSS project, which is scheduled to be completed in 2010.53
6. Geographic Targeting. The package of MNCH services is to be provided initially in priority rural areas in the following governorates: Sana’a, Ibb, Reimah, Al Dahla’a, Al Baydah, and urban slums in Aden54,55 before rolling it out to additional rural governorates.56 The delivery would be rolled out gradually in a phased and incremental approach.
7. Communication Strategy. The service delivery model will be complemented with demand side activities through the design and implementation of a communication and social mobilization strategy and detailed action plan. The overall goal of this strategy will contribute to the HPP project objectives of improving access to MNCH services in geographic areas with poor MNCH indicators, as well as the delivery of outreach services and upgraded first level referral facilities. The impact of the communication interventions will contribute to reduction of morbidity and mortality and improvements in health status.
8. The objective of the communication strategy will be to: (i) promote the benefits of the new integrated service delivery model; (ii) raise public awareness about the availability of the Outreach Services interventions as well as the routine-based preventive services through fixed facilities and community-based services, to contribute to increased service utilization and compliance; and (iii) promote behavior modification among targeted communities to improve utilization of low demand services such as maternal health, family planning, and nutrition. The key message would be that using Outreach Services at regular intervals and visiting fixed health facilities in between, or seeking services at the first referral level of health facilities for complicated cases will result in reduction of morbidity and mortality and improvements in health status. In support of the above, the strategy will include capacity development of the Outreach Services program in terms of communication planning and implementation.
9. This sub-component will support a formative research study to identify communication needs, key behaviors, targets, beneficiaries, and influencers for child and maternal health and nutrition and prepare a communication strategy and plan in the first year of project implementation. The strategy will propose key messages to disseminate communication channels and media to be used, and training requirements. 10. Outreach Workforce Development. In addition, this sub-component will strengthen the capacity of the health workforce to deliver basic MNCH services through Outreach Services using
53 The design of the interventions also takes into consideration the relative strengths and lessons learned from a host of other initiatives, including the district level planning process of the HRSP, the MOPHP’s EPI program, and the Dutch-financed MNH program. 54 The governorates were selected through the following process: The relative ‘riskiness’ of each district was evaluated using the following criteria: population density, immunization rate for children, tetatus toxoid immunization rate for women, and ratio of deliveries attended by skilled health personnel. Presence of funding from other development partners was also taken in consideration in order not to duplicate resources. Based on these criteria, 100 districts with poor indicators were identified and grouped by governorate. The governorates with the most concentration of districts with poor indicators were selected. 55 In Aden governorate, the project will support Outreach Services in its rural district (Boureika) and its urban slums districts (Dar Saad, Sheikh Othman, and Crater). 56 The selection of these governorates would be revisited if their situation changes and the above mentioned criteria do not apply anymore such as the presence of a major donor funding them or a change in the governorates security situation before implementation.
49
manpower training programs, with priority focus on midwives and health administrators. In the project governorates, the component would support the roll out of this upgraded manpower training program.
11. Systems for Outreach Services. This sub-component will focus on strengthening the systems which support the effective delivery of Outreach Services in the project governorates. It would finance technical assistance to assess options for improving: (i) the logistics management system; (ii) health management information systems (HMIS); and (iii) quality assurance systems for referral facilities. Based on the findings of the technical assistance assessment, selected applications of the above would be adopted and financed in the project governorates.
12. Sub-component Inputs. The inputs to this sub-component will include financing for: (i) Outreach Services program operating costs; (ii) procurement of essential drugs, diagnostics, kits, equipment, and supplies (including contraceptives) and other related health commodities which are not currently available through the MoPHP or other donors; (iii) training workshops for health workers, midwives, and health administrators; (iv) design and implementation of communication and social mobilization campaigns; (v) costs of printing of communication and training materials, production of TV spots, and other capacity-building materials; (vi) provision of technical assistance and procurement of goods to apply logistics management, health management information, and quality assurance systems for Outreach Services; (vii) procurement of IT equipment, software, and their related training; and (viii) consulting services to support the above.
13. Sub-component 1.2: Upgrade of First Level Referral Facilities and Provision of Community-Based Health Services (estimated US$7.0 million equivalent). This sub-component will support the following set of activities:
14. Referral Centers. Outreach mobile teams and community based workers will identify and refer complicated cases which require additional services to the appropriate level of fixed facility. This sub- component will provide targeted resources for basic equipment and drugs, and training for physicians, health workers and midwives at health facilities in the project governorates to ensure that (at a minimum) the following services are available: (i) EmONC (the referral services for reproductive health); (ii) TFCs/OTPs (the referral services for nutrition); (iii) referral services for IMCI; and (iv) basic emergency services.57 Project-financed investments will complement those of ongoing government and development partners programs which are investing in EmONC,58 TFC and OTP59 services in the project governorates. Support will also be provided to meet the PHC service requirements for the population residing in the catchment area of these facilities.
15. Community-based Delivery Services. This sub-component will support strengthening community-based health services and home-based birth delivery services. This would include the procurement of basic drugs and equipment and training of midwives as follows: (i) two to three years training to produce new midwives to cover existing workforce gaps in the project target governorates; (ii) one month training for existing midwives to upgrade their skills; (iii) training of community health volunteers; and (iv) procurement of kits and supplies for community-based services and home-based
57 It is expected that about 70 first level health facilities will be targeted under the project. Technical assistance will be provided to develop health and investment plans for the first level referral facilities in the project governorates. These plans would identify facilities for investment under the project that have high utilization rates, are operational and have adequate capacity to delivery services, and are accessible to the population in the project governorates. 58 Expected to be funded by UNFPA and the Dutch (10 governorates to be expanded to 22 governorates) through a national plan to roll out EmONC services that will be developed by UNFPA. The Social Fund for Development is also contracted by the Dutch to roll out EmONC services. 59 Expected to be funded by UNICEF through a national plan to roll out TFCs and OTPs that will be developed by UNICEF. The EU provided a 5 million Euro grant, managed by UNICEF, to support nutrition. 50
delivery. Through these investments, it is expected that the midwives will be better able to support home- based deliveries, referring the risky and complicated cases to the first level referral facilities as needed. CHVs will be able to provide health education activities and active case finding of complicated cases and their referral to the appropriate level. Community midwives would be contracted to provider maternal health services at the community level.
16. Sub-Component Inputs. The inputs to this sub-component would include financing for technical assistance to develop health as well as investment plans, the procurement of medical and non-medical equipment, supplies, drugs, laboratory equipment and targeted infrastructure investments, and training workshops for health workers, including midwives and CHVs.
17. Sub-Component 1.3: Support National Public Health Campaigns (estimated US$6.0 million equivalent). This sub-component will support investments for the implementation of national immunization campaigns for polio, measles, and tetanus toxoid to complement earlier efforts financed by IDA under the HRSP.60 Polio and measles immunization campaigns are targeted for children under five to contribute to the elimination of polio and measles in Yemen. Nutrition active case finding of malnourished children under five will be integrated as part of the measles campaigns to be referred to nutrition referral centers explained under Component 1.2. Expansion of the implementation of campaigns for immunization of tetanus toxoid for women 15-49 years old will also be supported.
18. Sub-component Inputs. The inputs to this sub-component would include financing for immunization campaign operating costs.
19. Component 2: Results-Based Monitoring & Evaluation and Project Administration (estimated US$4.5 million equivalent). The Project would finance technical assistance to carry out evaluations of the upgraded MNCH Outreach Services to measure the results of the project interventions on the access and utilization by women and children in the project governorates. The evaluations would include a baseline survey, mid-term and end of project evaluation. It will also support the implementation of the National Demographic Health Surveys that would be implemented under the Project. In addition, this component would support activities related to the design and implementation of independent monitoring of project targets and audit of Outreach Services.
20. Project Administration Unit (PAU). The Project would also provide project management support (consultancy services, equipment/supplies, and operating expenses) to the establishment and operation of a PAU within the MoPHP. The PAU reports directly to the Deputy Minister of Public Health and Population for Primary Health Care and is led by the General Director of Family Health. It is to be attached to the GDFH to administer the Grant funds and to provide full time administrative and technical support with close administrative proximity to the Outreach Team to support their efforts to implement the HPP. The PAU will consist of: (i) Project Administrator; (ii) Procurement Officer; (iii) Financial Manager; (iv) Accountant; and (v) Secretary. The PAU will be complemented with the services of an Independent Technical and Financial Firm (ITFF) for the duration of the Project, with the exception of the first year, when the Project will engage an ITA.
21. The PAU will have the following key functions: management of project monitoring & evaluation (M&E), and financial and procurement management. The PAU will: (i) assist the Outreach Team in project implementation and manage the resources of the Project; (ii) facilitate efforts to conduct an early mapping survey and a baseline survey, monitor and evaluate the project targets, and evaluate the project results in coordination with the Outreach Team; (iii) handle procurement, financial, and disbursement management, including the preparation of withdrawal applications under the Project; (iv) ensure that an independent audit of the project is carried out on an annual basis; (v) prepare the financial and
60 The national measles campaign is planned to be implemented in 2012. 51
procurement sections of the quarterly Progress Report and consolidate with the technical part prepared by the Outreach Program for submission to the Steering Committee (SC) and IDA; (vi) act as the liaison between the Outreach Program and IDA; (vii) ensure that all reporting requirements for IDA are met according to the Project’s financing agreement; and (viii) provide secretarial services to facilitate the activities of the SC.61
22. Component Inputs. The inputs to this component would include financing for: (i) the provision of technical assistance, equipment and supplies to conduct the independent monitoring, audit, and project evaluations as well as program monitoring; (ii) the provision of technical assistance and procurement of goods for the implementation of national demographic health surveys; (iii) the provision of technical assistance to monitor environmental safeguards; (iv) the organization of training workshops, conferences, and events to dialogue, discuss, and reach consensus on the above mentioned activities; and (v) the provision of technical assistance for project administration, in addition to operating costs, and procurement of equipment, office furniture and supplies to support the PAU.
61 The Organizational Charts and key responsibilities of the PAU staffing can be found in Annex 6. 52
Annex 4A: HPP Integrated Outreach, Community and Referral
Evolution of the Service Delivery Model, Description, and Integration Strategy
Evolution of Outreach Services in Yemen
1. The Yemeni health delivery system depends mainly on fixed facilities to provide health services to populations living in the vicinity of the facilities as well as vertical programs to address priority public health problems.
2. The 2000 Health Sector Reform Strategy (HSR)62 criticized the overdependence on public health fixed facilities63 because of their inability to reach the entire population and meet their health needs. The HSR reflected a number of consequences as follows: (i) low outpatient utilization rates ranging between 0.58 to 2.7 in different areas of the country; (ii) underutilization of public health facilities due to issues of access and quality with an average daily health care visit to staff ratio of only 2.2; and (iii) lack of provision of health services and essential drugs in public health facilities leading to a bypass rate between 42 to 73 percent. Low geographic access (only 30 percent of the rural population have access to health care) and an overall access of 67 percent led to large inefficiencies in the use of the public health sector’s capital and human investments and low health coverage; e.g., the immunization coverage rate declined to 66 percent in 2003 compared to 76 percent in 2000.
3. The strategy argued for introducing outreach health services to those with no or poor accesses to health services as well make efficient use of resources spent on national and sub-national polio campaigns. The strategy considered providing and making available low cost essential drugs and packaging of health services through outreach. It aimed to ensure coverage of the entire population, including the poor and the near-poor as an approach for poverty alleviation. It recommended payment of lower transportation and direct service provision costs. The HSR also stressed the importance of integration of services and considered it as one of the main basic principles of District Health Systems and argued to integrate resources and activities of the different vertical programs e.g., vehicles and supervision visits. Service integration was identified as one of the areas where donor support is most needed.
EPI Outreach Experience (2004-2007)
4. In 2004, the MoPHP started its Outreach Services to overcome the accessibility barrier to improving vaccination coverage. The system depended on simplified micro-planning at the health facility level and organized four rounds of outreach activities. In 2005, outreach was better organized and mainstreamed as a routine coverage mechanism. As a result, marked improvement of EPI coverage has been achieved compared to fixed facilities. By December 2005, Penta3/DPT3 through outreach achieved remarkably better results than fixed facilities (85 percent vs. 58 percent). Such improvement in coverage was constant throughout 2005 to 2009. More importantly, the percentage of districts achieving more than 80 percent immunization coverage has progressively increased and nearly tripled compared to the 2003
62 Health Sector Reform in the Republic of Yemen: Strategy for Reform. Ministry of Public Health, Sana'a, Republic of Yemen, Final Version, October 2000. 63 In addition, the current health system model results in a lack of outreach services and over-dependence on stationary care facilities. This is an unrealistic strategy given the geography and level of health care awareness of the population of Yemen. The geographic dispersal of the population means that they cannot easily reach these stationary facilities for all their needs, and low health awareness means that many remain unaware of the need for preventive and early curative services, and as such need a proactive health service.
53
level. In 2009, coverage showed that Outreach Services constantly provided nearly one third of the coverage.
The IMCI/Child Outreach Experience (2007-2008)
5. In 2007, another model of delivery of Outreach Services was piloted using mobile teams. Two districts in two governorates with a large population and a low fixed-base facility were selected to pilot Integrated EPI and IMCI/Child Services Mobile Teams. Two mobile teams per district were organized using cars for transportation. Each team included a physician trained in IMCI, a midwife, an EPI staff, and a health education staff. Each team stayed in the areas for a period of five days. This model gradually was used in more districts and was supported by different donors including WHO, UNICEF, and HRSP. However, this model did not base its visits on micro planning at the district level, and accordingly provided services irrespective of the number of targeted population or geography of the area. It did not achieve comparable results like integrated HSS outreach each.64
The GAVI- HSS Outreach Experience (2008-2011)
6. In 2008, a GAVI-funded HSS project was launched aimed at improving nation-wide efforts in reducing child and maternal mortality, and to halt/reverse the spread of malaria and TB. The HSS built on the success of the EPI program outreach model and planned to impose on the model by supporting a functional integration of seven vertical health programs [Expanded Programme on Immunization (EPI), Reproductive Health (RH), Malaria, TB, IMCI, nutrition, and bilharzias] in 64 districts in 17 governorates between 2008 and 2011. The HSS conducts quarterly outreach rounds, i.e., four rounds per year.
7. The main parts of the GAVI vertical integration model (GAVI-VI model) are:
• Provision of services through an integrated outreach team originating from PHC facilities targeting community sites at the sub-district and village levels. • Payment based on results for health workers and for district staff. • Strengthening district level management to improve support for health workers. • Strengthening central/governorate level management to support district level staff.
8. In 2008, the results of the HSS integrated outreach activities showed remarkable improvements, as follows:
• Coverage of EPI increased: Penta3 by 35 percent, measles by 34 percent, tetanus toxoid 2 by 72 percent. • In certain geographic areas, other services were piloted as part of outreach including IMCI, RH, and Nutrition. • Outreach became more efficient as the cost per child du ring the EPI outreach decreased from US$1.3 to US$1 for integrated outreach.
64 Comparing results in 11 districts, the IMCI model reached 5548 child with services in 2008 compared to 53,783 child reached using HSS mobile team model in 2009. In addition, as family planning services were integrated, the IMCI model reached 1,373 in 2008 with services compared to 8,561 women reached using the HSS model in 2009. 54
9. Integrated Outreach Services are delivered universally in all HSS targeted districts. EPI outreach is still delivered in areas with low immunization coverage or emerging outbreaks (e.g., measles outbreak). The levels of outreach are defined as follows:65
• Outreach strategy (second level):66 covers the catchment population unable easily to reach a health facility without much difficulty within 5 km/or one hour walking distance. Services are provided by walking or simple transport method, e.g., bicycle. This level was planned with the intention to cover EPI through outreach. For integrated services, a transport vehicle would be required.
• Mobile team (third level): covers the remote catchment population unable to reach a health facility at all beyond 5 km/or one hour walking distance. Its coverage needs a transport vehicle.
Outreach strategy (Second level) Mobile team strategy (Third level)
Fixed base strategy
(First level)
Target Population, Target Areas, Intervals of Outreach Rounds and Staff Pattern (2011-2016)
10. A package of MNCH services will be provided gradually in a phased and incremental approach to provide access to populations which have no or poor access to MNCH in geographic areas with poor MNCH indicators. This access is expected to address some of the major constraints to the achievement of MDGs 4 and 5.
11. Decisions to support a follow up phase of incremental upgrading/integration of the package of Outreach Services (for example: broadening the package of services to include reproductive health services and/or nutrition at the basic or advanced level, linkage to referral centers, and provision of community services) will depend on furnishing evidence that the efforts to support the implementation of an earlier phase were successful as well as demonstrating that the criteria required to advance to a follow up phase were met.
67 12. The package will be provided initially in priority rural/urban slums areas66F where most of the population is not reached by health services and most affected by child and maternal morbidity and mortality. This will be done through an enhanced model of Outreach Services, building upon the lessons
65 PHC Sector Policy towards strengthening coverage by essential health services through outreach services. 66 The first level is the level covered by a fixed health facility. 67 Second and third levels of catchment areas. 55
learned from the service delivery model developed under the GAVI-funded HSS project. It is planned to be delivered using mobile teams through outreach rounds planned approximately every two to three months (4-6 rounds per/ year on average). 68
13. The package will be provided in selected governorates 69 before rolling it out to new rural governorates targeting children under five and child-bearing-age women. The whole community will be targeted for health education messages as well as for public health programs: malaria and schistosomiasis, which will be integrated within the package to sustain the delivery of these vertical public health programs.
The Service Delivery Model
14. The delivery of the package of services will be based on standards and guidelines for integrated service delivery and facility-based health planning that are suited to the topography, geography, and population distribution in Yemen and are consistent with the current and planned capacity development.
15. The model will achieve a balance among the delivery of MNCH services based on the principle of continuum of care throughout the lifecycle (childhood, adolescence/adulthood, pregnancy, childbirth, postnatal period), and between places of service delivery (including clinical care settings, outreach, and household and communities). The model will complement service delivery: (i) in fixed facilities; and (ii) through community-based services. It is planned to be an integral part of the delivery mechanism to: (i) reach on a permanent basis populations living in areas that are not covered by fixed facilities; and (ii) reach on a temporary basis populations in areas that could be covered by fixed facilities in the future.
Service Delivery Package
16. The model of service delivery, supported under the HPP and upgrading the HSS model, will comprise provision of services at three levels: (i) integrated Outreach Services to deliver a defined core package of maternal and child health services at temporary sites using mobile teams on a periodic basis (will reach an average of six rounds by the end of the project); (ii) complementary community-based services focusing on health education, active case finding, and referral by Community Health Volunteers (CHVs) in addition to home-based delivery by midwives; and (iii) referral facilities for management of complicated cases that cannot be treated at the outreach level. This model will complement the routine delivery of services through fixed facilities and is not intended to replace it.
17. The outreach level, provided through mobile teams, will include teams of four health workers originating from fixed health facilities to provide the primary health care services to children under five and women in reproductive health age (including pregnant and lactating women). CHVs will join outreach rounds to provide health education activities and identify cases that need follow up services at the community level in between outreach rounds.
18. The referral level, provided through fixed facilities, will include at least one referral facility to provide secondary/tertiary care services at the governorate and/or district level to cases that need nutrition and/or maternal health care and referred to that level based on screening at outreach rounds and/or active case finding at the community level. The referral facilities will provide EmONC (basic and/or comprehensive) for the RH, TFCs and OTPs for nutrition. Referral to this level will be subject to criteria that will need to be met.
68 Previous studies show that such interval will not allow for the immunity that developed after immunization to fade. 69 Sana’a, Ibb, Reimah, Al Dahla’a, Al Baydah and Aden (urban slums only). 56
19. The community level, provided especially between outreach rounds, will include: (i) CHVs to provide health education, active case finding of complicated cases for children, and their referral; and (ii) community midwives to provide maternal health services including normal delivery, active case finding risky cases for pregnant and lactating women. A detailed description of the package of services at each level is detailed below.
Main Duties of the Outreach Team
20. The outreach team will be responsible for the following: (i) screening, management and referral of sick and/or malnourished children or pregnant or lactating women; (ii) provision of preventive services such as vaccination, maternal health services, etc; and (iii) registration and recording of patients.
Staff Pattern
21. The outreach team will deliver the services in the form of mobile teams at selected community sites. Each outreach site will have at least one team but it may have multiple teams depending on population density. The team would be comprised of: (i) one medical doctor /medical assistant to provide child health services (IMCI including child nutrition and malaria) and provide children 6 years and above and adults with drugs for schistosomiasis; (ii) one trained midwife to provide reproductive health services; (iii) one health staff (PHCW) to provide vaccination; and (iv) one health worker responsible for management of outreach logistics and registration of patients. The outreach team that will implement outreach rounds is based in the nearest facility.
Main Duties of the Community Team
22. The community team will be responsible for the following: (i) active case finding and referral of sick and/or malnourished children or pregnant or lactating women; (ii) complementing the management of malnourished children; (iii) provision of health and nutrition education and provision of counseling on selected preventive/ curative services such as infant and young child feeding, home based care for diarrhea and fever, etc; (iv) registration and recording of cases; (v) home based delivery and care (community midwife); and (vi) social mobilization for outreach rounds and public health campaigns.
Staff Pattern
23. The community team would be comprised of: (i) community midwife to provide reproductive health services; and/or (ii) community health volunteer to provide child health services including nutrition. The composition of the team will differ based on the availability of community midwives.
57
Outreach Service Model
Interventions/Conditions Treated Type of No. of Facility Equipment Required Staff Staff Required Drugs Required General IEC IEC materials • Counseling on FP and method dispensing. • Iron /Folate • ANC, Perinatal (manage normal delivery, triage of MW 1 Private • Delivery kit (imminent • OCP combined and complicated cases). closed delivery). POC, injectables and • Postnatal (newborn care and postpartum). room • Measuring tape (fundul level). condoms) Maternal and Newborn Health • Counseling on postnatal and breastfeeding (early (RH) • Pinard stethoscope. • Vitamin A (MNH)/Reproductive Health (RH) initiation & exclusive). • BP measure. • Anti-acids • Refer the high risk and complicated pregnancy, • Dip test. • Anti emetics delivery and postpartum. • Thermometer. • Folic Acid and Iron for pregnant and lactating, • Scales. vitamin A after delivery. • Nutrition education pregnant women. • IMCI drugs • Case management of ARI, Diarrhea, Malaria, Doctor OR 1 Tent/ IMCI package • Anti-malaria & Bed Integrated Management of Childhood malnutrition, anemia. Medical School Nets Illness (IMCI) and Malaria (children). • Identify danger signs and refer severely ill child. Assistant • De-worming, and Vit.A two times per year • Zinc Tab • MUAC screening and start case management of • Tape measure for nutrition • Micronutrients severe acute malnutrition (provide the first dose of assessment (MUAC), sprinkles RTUF for 2 weeks and standard med). mothers and children. • Refer the uncomplicated malnourished child (MAM • Height measure. Child/Maternal Nutrition. • RTUF and SAM) to OTP/SFP for follow-up and • Weighing scale (secca). 70 complicated malnourished child to TFC. • Iodine test kit. • Vitamin A for children. • Pre--recorded messages by • Screen pregnant and lactating women on MUAC < megaphone and posters in 71 230mm and refer to SFP. waiting area. • Cold Chain • Vaccines (BCG, Immunization. • Vaccinator 1 Support outreach immunization and campaigns. Penta, measles and pneumococcal. Symptomatic • Praziquantal • Provision of praziquantal. HW 1 Schistosomiasis & Malaria (adults) in • Anti-malaria • endemic areas. Provision of anti-malaria.
Administration & Registration • Recording and registering, logistics management, Folders, registers, Cards, N/A setting up the site of Outreach Services. screens and stationary
70 Map of functioning OTPs and TFCs should be prepared by governorate for adequate referral 71 To be implemented once resources are available for SFP for malnourished pregnant women
58
Community-Based Services72 Type of No. Facility Interventions/Conditions Treated Equipment Required Drugs Required General IEC Staff of Staff Required • Family planning counseling and method dispensing, Midwifery Kit (including but not • Oxytocin • Manage normal delivery and triage of complicated maternal limited to: • Lignocaine and neonatal cases. • Measuring tape, • Iron /Folate • Antenatal care ; Administer tetanus toxoid, iron and folic acid • Episiotomy Scissors, Needle holder • OCP combined and POC, injectables Home- supplement, educate to raise awareness on danger signs of • Toothed dissecting forceps based CMW 1 Home- and condoms) pregnancy, importance of safe delivery with a skilled birth • Mucus extractor, Foetoscope • MNH based. Vitamin A attendant(SBA), breast feeding, postpartum care and • Sphygmomanometer • interventi Anti-acids contraception. • Baby weighing scale, Stethoscope • Anti emetics ons • Advise high risk women of importance of follow-up with • Disposable apron
nearest capable health facility • Disposable polyethylene bags • Referral : before delivery, danger signs during delivery, • Cotton, Disposable Syringes antenatal care • Cord ligature/ tie • Maternal & Neonatal Health Education • Scalpels , Catgut • Case management of Cough & Fast breathing, Diarrhea • IMCI drugs e.g. Malaria, and Malnutrition • IMCI Package ( Timer, Counseling, Amoxicillin, • Identify danger signs and refer severely ill child: Education Mother Cards, and ORS, Zinc and • Home care: Recording Forms) anti Malaria Preparation of commercial ORS • Hanging Weighing (Salter) scale • De-worming and Child Help mother to drain the ear • MUAC Vitamin A for Health Help mother to clean eye discharge and ointment use CHV 1 Home- • Growth Charts Follow-up, reporting defaulters, Services Teach & assist mother to give cold compressors based. and referral forms Follow-up, • Micronutrients (IMCI, Help mother to keep the newborn warm reporting and referral forms sprinkles Immuniza Educate on hygiene, household indoor safety, and harmful • Iodine salt kit tion and traditional • Rapid Test for Malaria (RDT) Nutrition) • Active case finding (SAM &MAM) • Stationary, Box folders • Counseling/IYCF including feeding the ill child • Growth Monitoring and Promotion • Promotion of iodized salt • Educate the mother on balanced diet, food safety and maternal nutrition practices. • Track and refer defaults and late children on vaccination • Social mobilization during campaigns or outreach activities.
72 Community Midwife serves 5,000 population; Community Health Worker serves 25-30 household. 59
First Referral Facility (Health Center and/or District Hospital)73
Interventions/Conditions Treated Type of Referral Facility Facility Required
• Normal Delivery B-EMoC • Health Center/District • MNH/RH High Risk Case Follow-up C-EMoC Hospital • Major Obstetric Complication requiring surgery or blood • Comprehensive Hospital transfusion • Ward Admission • Referral Hospital IMCI & • Child with severe classification • Outpatient Admission • Health Center Malaria • Child with severe dehydration
Child • Uncomplicated: Management of U5 Malnourished SAM • Nutrition Out Patient Clinic (OTP • Health Center Nutrition & MAM and SFP) • Referral Hospital • Complicated: Malnourished U5 SAM and MAM • Therapeutic Feeding Centers TFC
73 Catchment area: 10,000-30,000 population (1-2 Districts)
60
Integration Strategy 24. A package of MNCH services is planned to be provided gradually in a phased and incremental approach. The package will be provided initially in priority rural/urban slum areas where most of the population is not reached with health services, i.e., in catchment areas defined as zones 2 and 3. 25. Service Package Integration. The incremental integration of services is planned to be implemented at four stages as follows: • Service Package-I: The package will be provided at two levels: (i) at the outreach level, the package will provide immunization, administration of praziquantel for schistosomiasis (in endemic districts), and IMCI including treatment of malaria; and (ii) at the community level, the package will provide a basic package of community child health services. • Service Package-II: The package continues to be provided at two levels: outreach and community. In addition, to Service Package-I, one addition will be introduced at outreach level as the package will provide a basic package of reproductive health services. • Service Package-III: The package will be provided at the three levels: outreach, community, and referral. In addition, to Service Package-II, three additions will be introduced: (i) at the outreach level, the package will integrate nutrition services within IMCI, and provide an advanced package of RH services; (ii) at the referral level, the package will include referral to EmONC referral centres (basic and comprehensive) for RH and referral to SFPs, OTPs and TFCs for nutrition; and (iii) at the community level, the package will provide an expanded package of community health services. • Service Package-IV: In addition to Service Package-III, the package will include home-based delivery at the community level.
26. Geographic Expansion. The project would target governorates classified in two separate groups to introduce the package of services gradually as follows: (i) Group A, the governorates with better capacity to implement an advanced package. These governorates are Ibb and Sana’a; and (ii) Group B, the governorates with lesser capacity to implement an expanded package of integrated services. These governorates will start to implement a basic package. These governorates are Al Dahla’a, Reimah, and Al Baydah. 27. The package of services will be expanded gradually by governorates as follows: (i) in year 1, Service Package-I (outreach) will be implemented in Group B, and Service Package-II (outreach) will be implemented in Group A; (ii) in year 2, Service Package-I (outreach) will continue to be implemented in Group B, Service package-III (outreach and referral) will be implemented in Group A. Service Package-I (community) will be implemented in both Groups A & B; (iii) in year 3, Service Package-II (outreach) will be implemented in Group B, while Service Package-III (outreach and referral) will continue to be implemented in Group A; (iv) in year 4, Service package-III (outreach and referral) will be implemented in Group B, and Service Package-IV (outreach, community, and referral) will be implemented in Group A; and (v) in years 5 and 6, Service Package-IV (outreach, community, and referral) will be implemented in both Groups A & B. For detailed description please refer to the table below. 28. Frequency of Outreach Rounds. Throughout the duration of the project, the intervals and number of outreach rounds will vary according to the readiness of governorates to implement the different service packages and availability of resources. The number of outreach rounds is planned to be implemented to increase gradually as follows: (i) three rounds in the first year of the project; (ii) four rounds in year 2; (iii) five rounds in year 3; and (iv) six rounds in each year for the remaining period of the Project ( years 4, 5, and 6).
61
Outreach Programs Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Rounds /year 3 4 5 6 6 6 Immunization Service Package Outreach Schisto (in endemic districts) Group B Group B I IMCI Community Community Basic Services Immunization Schisto (in endemic districts) Service Package Outreach Group A IMCI Group B II Basic Reproductive Health Community Community Basic Services Immunization Schisto (in endemic districts) Outreach IMCI and Child Nutrition Group A Service Package Advanced Reproductive Health Group A Group B III Community Basic Services Community Community Advance Services EMOC Centers Referral Group A OTP &TFC Immunization Schisto (in endemic districts) Outreach IMCI and Child Nutrition Service Package Reproductive Health II Group A Group A & B IV Home Based Delivery Community Community Advanced Services EMOC Centers Referral OTP &TFC Group A: Ibb and Sana'a Governorates Group B: Al Dahla'a, Reimah, and Al Baydah
62
Annex 4B: Strategic Development Communication Strategy
1. The service delivery would be complemented with demand side activities through the design and implementation of a communication and social mobilization strategy and detailed action plan. The overall goal of this strategy will contribute to the Project’s objectives of improving access to MNCH services in geographic areas with poor MNCH indicators as well as the delivery of Outreach Services and upgraded first level referral facilities. The impact of the communication interventions will contribute to reduction of morbidity and mortality and improvements in health status.
2. By the end of the Project, the strategic development communication component would be expected to have achieved improvements towards the following outcomes with specific targets that will be defined as part of the communication strategy:
(a) Populations in the served areas are aware of the new integrated service delivery model and the availability of the Outreach Services interventions as well as the routine-based preventive services through fixed facilities and community based services. (b) Increase in the willingness of the target population in the served areas to utilize the services. (c) Utilization of the services increased. (d) Referral of complicated cases increased. (e) Identified areas of community health empowerment and individual behavioral change, such as family planning and nutrition are improved to contribute to a level of service utilization and overall improvement of health and population indicators. (f) Ministry of Health community outreach system is strengthened with planning, monitoring and reporting tools in place for an improved evidenced-based program implementation. This will entail that program elements are fully reviewed and improved and that the capacity of the teams undertaking the Outreach Services is fully developed.
3. To achieve the above outcomes a number of strategies will be used including the following:
(a) Multi-layered advocacy interventions with decision makers and key stakeholders on the national, governorate and community levels. (b) Targeted mass media campaign. (c) Community mobilization campaign. (d) IEC materials. (e) Community outreach system strengthening and capacity building. (f) Partnership (with community organizations, NGOs and influencing groups such as religious’ leaders).
4. The project implementation plan will be guided by two main strategic elements:
(a) The communication strategy that will need to be developed as an immediate priority to lay out the communicating vision, different detailed communication objectives linked to specific benchmarks and mechanisms for reaching these objectives while detailing the specific communication activities over the period of the life project.
63
(b) Communication research, monitoring and evaluation: will be an important corner stone in guiding the entire effort from start to finish. A number of research activities are envisioned including a baseline, qualitative and quantitative community research assessment, annual brief snap shot survey to show the progress made and the bottlenecks as well as a final post intervention survey to compare the before and after effect of the program. Finally, the specific community outreach monitoring tools that will be developed as part of the program strengthening will be also an important component to guide the refinement of the implemented communication activities in light of the actual progress made on the short term.
Potential Communication Challenges and Opportunities
5. It is critical for the communication activities to be well aligned with other activities of the Project as well as the Yemeni context. The communication activities and key interventions will be designed with some degree of flexibility to accommodate the community feedback and extent of acceptance of the promoted services. The partnership and linkages with other sectors like policy and community leaders, religious leaders, youth groups and NGOs will be instrumental in preempting some of the possible challenges. Meanwhile, a number of opportunities for success are quite evident including internal and external factors. On the internal level, the MoPHP commitment and political will for implementation is quite positive and will create an important momentum. Additionally, the availability and access to mass media will provide a platform for reaching the target population in a cost effective way in addition to the local network of NGOs which can be a supporting element.
64
Annex 5: Project Costs Project Cost by Component and Category (US$ million)
Component 1: Component 2: Improving Access Results-Based to Maternal, M&E and Neonatal and Child Project Total IDA Health Services Administration (US$ M) (US$ M) (US$30.5 M, (US$4.5 M, funded by IDA) funded by IDA) I. Investment Cost Goods A. Drugs, Contraceptives, and Medical Equipment 38.64 0.00 38.64 12.60 Other Goods 0.45 0.20 0.65 0.65 Sub Total goods 39.09 0.20 39.29 13.25 B. Consultant Services and Training and Workshops 3.11 3.80 6.91 6.91 C. Incremental Operating Costs 0.00 1.30 1.30 0.40 D. Outreach Services/Campaign Operating Costs 15.16 0 15.16 13.75 Total Baseline Costs 57.35 5.30 62.66 34.31 Physical Contingencies 0.29 0.05 0.34 0.34 Price Contingencies 0.29 0.05 0.34 0.34 Total Project Costs 57.94 5.41 63.34 35.00
Notes: Numbers may not add due to rounding. • The term “Incremental Operating Costs” means the expenditures incurred by PAU for the purpose of Project implementation on account of office rental, utility charges, transportation, maintenance of vehicles, office supplies, operation and maintenance of office equipment, printing, advertisements, banking charges, communication services, translation services, fuel, vehicle rental, local travel costs and per diem, and support staff excluding salaries of officials of the Recipient’s civil service and the purchase of vehicles. • The term “Outreach and Campaign Costs” means expenditures incurred by MoPHP for the purpose of carrying out Component 1 of the Project on account of travel costs of MoPHP staff, car rental costs, local transport costs of drugs, stationary, fuel, outreach and campaign launching workshop costs, microphone rental costs, and communications.
Project Cost by Local and Foreign Expenditures (US$ million)
Local Foreign Total US$ Million Component 1: Improving Access to Maternal, Neonatal and Child Health 17.91 39.44 57.35 Services (US$30.5 M, funded by IDA) Component 2: Results-Based M&E and Project Administration (US$4.5 M, 3.30 2.69 5.99 funded by IDA) Total Project Costs 21.21 42.13 63.34
65
Project Cost by Activity and Financiers ((US$ million)
Total IDA GoY Activity ------US$ million ------Implementation Component 1: Improving Access to Maternal, Neonatal and Child Health Services US$30.5M Sub-component 1.1: Delivery of Outreach Services US$17.5M 1 Outreach Services program operating costs 9.16 7.75 1.41* 2 Planning training for health workers at district level 0.15 0.15 3 TOT training of trainers for Outreach Services at governorate level 0.01 0.01 4 Training for physicians (neonatal 2 weeks; EmONC 4 weeks) for Rayma, Bayda, Sanaa, and Aden 0.06 0.06 5 Integrated PHC training for health workers (16 days training) 0.65 0.65 6 Service package (I) training for physicians (9 days training) 0.08 0.08 7 Governorate planning workshops (6 workshops) 0.06 0.06 8 Training for drug distribution systems in project governorates 0.02 0.02 9 Training to apply HMI for Outreach Services in project governorates 0.02 0.02 10 Communication consulting services (part time) 0.05 0.05 11 WHO service agreement for technical assistance 0.15 0.15 12 Health advisor (part time) 0.05 0.05 13 Assessment and development of QA systems for Outreach Services in project governorates 0.10 0.10 14 Cost of printing of comm.+training materials, prod..of TV spots, registries, and capacity-building materials 0.35 0.35 15 Procurement of goods to apply HMIS for Outreach Services in project governorates 0.10 0.10 16 Procurement of essential drugs for outreach and UN administrative cost 2.50 2.50 17 Procurement of contraceptives for outreach and first level of referral, and UN administrative cost 3.50 3.50 18 Procurement of diagnostics, kits, and equipment for outreach and UN administrative cost 1.60 1.60 19 Procurement of vaccines and related consumables for outreach and UN administrative cost 26.04 0.00 26.04* Sub-component 1.2: Upgrade of First Level Referral Facilities and Provision of Community-Based Health Services US$7.0M 1 Long term training for midwives (2 years) 0.40 0.40 2 Trainings for midwives (1month) including kits and printing material for home-based delivery 0.75 0.75 3 Trainings for midwives (1 week for implanon) 0.06 0.06 4 Training for community volunteers in the 6 governorates 0.50 0.50 5 Nationwide supply of contraceptives (IUDs and implanon) and UN administrative cost 1.00 1.00 6 Drugs for referral centers and UN administrative cost 2.00 2.00 7 Equipment for referral centers and UN administrative cost 2.00 2.00 Sub-component 1.3: Support National Public Health Campaigns US$6.0M 1 Support for national polio, measles, tetanus toxoid and nutrition campaigns (operating cost) 6.00 6.00 Component 2: Results-Based Monitoring and Evaluation and Project Administration US$4.5M 1 Base line, mid-term, and end of project evaluation, DHS (two rounds) 2.00 2.00 2 Independent Technical and Financial Firm (ITFF) 1.00 1.00 3 Independent Technical Auditor (ITA) to verify outreach rounds and campaigns 0.05 0.05 4 Environmental safeguards consulting services 0.10 0.10 5 Financial audit of the project 0.05 0.05 6 PAU staff costs 0.60 0.60 7 Outreach program management staff costs 0.23 0.00 0.9** 8 PAU operating costs 0.40 0.40 9 TA, equipment, software, and supplies to support PAU 0.20 0.20 Subtotal 61.99 34.31 28.57 Physical Contingencies US$0.69 0.34 0.34 0.00 Price Contingencies 0.34 0.34 0.00 Total 63.34 35.00 28.34 * Government local contribution in the form of purchase of vaccines and outreach operating cost that is already part of the regular government budget. ** Government local contribution to cover incentives for government employees, stores rental, office rental and utility charges, costs of custom clearances, transportation allowances for governmental staff, and allowances for participation in different committees.
66
Annex 6: Implementation Arrangements 1. The MoPHP will have overall responsibility for implementing the HPP. The Project activities will be implemented by the MoPHP's GDFH, together with the Outreach Services Team and PAU under the supervision of the MoPHP Deputy Minister of Primary Health Care (PHC). In order to manage the project in an integrated and coordinated manner, and to expedite decisions and actions, the MoPHP structure will provide: (i) oversight (ii) management; and (iii) implementation functions. 2. Project Oversight - Steering Committee (SC). The SC would be chaired by the Minister of Public Health and Population, and it would comprise: the Deputy Minister of PHC, the Head of the GDFH, the Technical Officer of the Outreach Team, one representative of the MoPIC, and one representative of the MoF. The Project Administrator of the PAU will serve as the Secretary for the Committee. The SC will meet at least every three months, and its main tasks are to: (i) review policy issues relevant to the achievement of Project development objectives; (ii) approve annual work-plans and budgets including the Recipient’s financial contribution; (iii) review Project progress reports and take appropriate actions in support of implementation; and (iv) review and approve the design and budget of the second phase of implementation at the project midterm review as well as the end of project evaluation. 3. Project Management - General Directorate for Family Health. The GDFH will be responsible for: (i) day-to-day project management activities; and (ii) facilitating coordination between the Outreach Team and the PAU. The Head of the GDFH will act as the Project Manager of the PAU and will be responsible for the overall coordination and management of the Project. 4. Project Implementation - Outreach Services Team. The Outreach Services Team will be responsible for implementing the project activities with the administrative support from the PAU. Detailed outreach implementation arrangements have been prepared which define core responsibilities and team composition at the central, governorate and district levels (see Annex 4A). The Outreach Services Team will be responsible for preparing the technical sections of the Quarterly Progress Reports. To fulfill the program objectives, the Outreach Team will be supported by experts in the following fields: (i) Public Health (Public Health Advisor); (ii) Planning and M&E (Health Planner); and (iii) Communication (Communication Specialist). 5. Project Implementation (Fiduciary Management Responsibility) - Project Administration Unit. The PAU reports directly to the Deputy Minister of Health of PHC and is led by the General Director of Family Health who is also the Project Manager of the PAU. It is to be attached to the GDFH to administer the Grant funds and to provide full time administrative and technical support with close administrative proximity to the Outreach Services Team to support their efforts to implement the Project. The PAU will consist of: (i) Project Administrator; (ii) Procurement Officer; (iii) Financial Manager; (iv) Accountant; and (v) Secretary. The PAU will be complemented with the services of an Independent Technical and Financial Firm (ITFF) for the whole life of the Project, except for the first year when the Project will engage an individual Independent Technical Auditor (ITA). 6. The PAU will have the following key functions: project M&E, financial management, and procurement management. The PAU will: (i) assist the Outreach Team in project implementation and manage the resources of the project; (ii) facilitate efforts to conduct the mapping and baseline surveys, monitor and evaluate the project targets, and evaluate the project results in coordination with the Outreach Team; (iii) handle procurement, financial, and disbursement managements, including the preparation of withdrawal applications under the Project; (iv) ensure that an independent audit of the Project is carried out on an annual basis; (v) prepare the financial and procurement sections of the quarterly Progress Reports and consolidate with the technical sections prepared by the Outreach Team for submission to the SC and IDA; (vi) act as liaison between the Outreach Team/GDFH and IDA; (vii) ensure that all reporting requirements for IDA are met in accordance with the Financing Agreement; and (viii) provide secretarial services to facilitate the activities of the SC.
67
Chart 1: Project Implementation Organizational Structure
Minister of Hea lth Steering Committee Oversight
Key Role: Program Oversight Deputy Minister of Health Members: - Minister of Health - Deputy Minister of PHC - MoPIC - MoF General Directorate of Project Technical Assistance Fa mily Hea lth Management WHO, UNICEF, UNFPA, Independent Technical and Financial Firm (ITFF) Outreach Services Teams National Institutes Project Administration Unit (PAU) Governorate/District Health Offices
Project Implementation Referra l Hea lth Fa cilities
Outreach Mobile Teams
Chart 2: Organizational Structure of the Project Administration Unit (PAU)
Head of GDFH and Project Manager
Key Roles of the ITFF: • Independent verification of Independent Technical compliance to planning and and Financial Firm financial management (ITFF) guidelines, and availability of drugs. • Independent verification of project coverage. • Verification of invoices for disbursements. • Project Reporting: semi- Financial Procurement Administrative annual and annual progress Management Management Team Support reports, MTR and end of project reports. Financial Officer, Procurement Officer, Accountant Procurement Advisor Bi-Lingual Secretary
68
Annex 7: Financial Management and Disbursement Arrangements
A. General
1. Project activities will be implemented by the MoPHP's GDFH, together with the Outreach Team and PAU under the supervision of the Deputy Minister of PHC. The FM activities under this Project will be carried out by a Financial Management (FM) Team under the PAU structure which will be established and reside in the MoPHP in Sana'a and will be supported by accountants at the MoPHP’s governorates offices.
B. Risk Assessment
2. Country Financial Management Risks. As reported and outlined in the CAS of 2009, poor governance remains a critical issue faced in Yemen. The Country Public Expenditure and Financial Accountability Report (PEFA, 2008) indicated that there had been some progress in the fiscal area, particularly in terms of budget expenditure classification and consolidation of investments. However, a lack of progress was observed on achieving budget comprehensiveness and implementing a broader fiscal framework based on a multi-year expenditures framework. Efforts to move forward in reforming budget comprehensiveness, implementation, and cash management, accounting and reporting have been pinned on the design and implementation of the Accounting & Financial Management Information System (AFMIS) Project, which is experiencing significant delays. These factors, as well as the poor quality of education and training in accounting, have contributed to the generally observed insufficiencies of the financial reporting and auditing systems in the country. The above Country Risks result in having higher potential exposure to corruption, which is mitigated through the Project's design.
3. The PAU will contract with an Independent Technical Auditor (ITA) in year 1 of the Project and Independent Technical Financial Firm (ITFF) during the remaining life of the Project, to independently verify and certify for IDA that the planning and implementation of the outreach rounds have been conducted at an acceptable level and constitute a reliable base for the disbursement of IDA funds. Additionally, the PAU will contract with an independent external Financial Auditor selected by COCA and acceptable to IDA to perform quarterly reviews on the Project's Interim Financial Reports (IFRs) and annual audits of the Project's Financial Statements (PFS).
Inherent Risks
Risk Risk Issue / Risk Before Mitigating Measures (MM) After MM MM The findings of the various Country systems need to be enhanced, thus, country assessments High the project design follows the ring fencing Substantial conducted recently indicated method based on the PAU structure and use lack of progress on achieving of an ITFF for expenditures with high risk sufficient public financial nature (outreach rounds operating cost and management reforms inventory) and use of an independent including governance, external financial audit firm to review the accounting and auditing Project’s quarterly financial reports and audit systems in the country. the annual financial statements.
69
4. As detailed above, the inherent risk in the Country is High. The successful implementation of the Project's design, which follows the ring fencing method and uses the technical and financial firm and an independent external financial audit firm will eventually reduce the project FM risk to Substantial.
5. The Project’s FM arrangements are based on a PAU structure rather than the use of country systems. This is a result of the delay in the country’s implementation of a number of earlier FM reform interventions which had created the basis for systems/structures in Yemen. GoY staff capacity in this area remains low for several reasons, including poor compensation and incentives and the country’s accounting system remains under development. However, the Project’s design includes supporting the financial management capacity of the MoPHP’s health offices in the governorates within the project’s scope by involving one qualified accountant from each of the governorate offices to be responsible for implementing the financial management arrangements of the campaigns’ operation costs. The Project will support these accountants by providing them with training on the Bank’s financial management and disbursement guidelines, training on the Project’s financial management manual, and the automated accounting system.
Project Financial Management Risks
Risk Comments/ Risk Issue/Risk Before MM Mitigating Measures (MM) After MM
Implementing Entity Flow of funds and financial reporting are designed The Project activities High to be simplified and managed centrally by the Substantial will be implemented PAU, which will utilize accounting system that is by the Outreach capable of recording and reporting funds by source Team of MoPHP and and uses of funds by category and activity. administered by the Training on Bank guidelines will be provided to PAU. the PAU through the Bank’s regular training workshops and continuous support through the Bank’s field office will be provided especially during the first year of implementation.
Staffing Staff capacity to The FM implementation is ring-fenced and the FM manage the FM High Team has been recruited on competitive basis, Substantial activities of the including the selection of a qualified Financial project. Manager and an Accountant. The FM Team will be responsible for managing the FM aspects of the project and will receive regular training.
Information Systems Lack of an The PAU has procured and installed an automated accounting system Substantial accounting system acceptable to IDA which Moderate capable of recording follows cash basis accounting and capable of and generated recording all project activities, generating required required reports. reports such as the quarterly financial reports (IFRs).
70
Risk Comments/ Risk Issue/Risk Before MM Mitigating Measures (MM) After MM
Internal Controls & Accounting Policies and Procedures
The PAU will apply internal controls (e.g. segregation of duties, ex-ante reviews, controls Lack of appropriate Substantial over inventory and fixed assets, and use of an Moderate and comprehensive ITFF) to ensure proper use of funds including accounting policies maintenance of original supporting documents. and procedures These internal controls are documented in the manual. Project's FMM.
The FMM details the policies and procedures covering FM aspects such as: (i) Project accounting policies, including those related to treatment of expenditures, including their classification, treatment of petty cash and advances, inventory and fixed assets management, authorization and payments system, conversion from foreign currency to the local currency; (ii) eligibility of expenditures to be reimbursed from IDA; (iii) project flow of funds including the funds from the DA to the sub-account supporting the operating cost of the campaigns; (iv) PAU staff job descriptions; and (v) internal control systems including the role of the ITFF.
Inventory Management (Specific FM risk of Component 1)
The policies and procedures over inventory Lack of appropriate High management are properly recorded in the Project’s Substantial policies and Operational and FMM including control procedures over procedures over receipt and release of inventory management of and recording of such transactions and the role of inventory. the PAU. Such controls will ensure proper receipt of goods by the MoPHP as evidenced by signed receipt documents confirming the quantity received and signed by authorized officials validating the order received is acceptable.
The PAU is a newly The ITFF will verify that control procedures over established unit and inventory management with emphasis on receipt may not have in and release of drugs are properly implemented and place, the systems in compliance with the Project’s Operational and and policies to FMM. The MoPHP will arrange for a secured safeguard and warehouse for maintaining the drugs. manage the assets during project implementation.
71
Risk Comments/ Risk Issue/Risk Before MM Mitigating Measures (MM) After MM
Also, lack of a safe Specific controls will be applied over inventory and secured such as inventory register; an individual assigned warehouse for the the responsibility for inventory management (e.g., storage of the drugs. inventory custodian). Additionally, there will be a The drugs are regular (at least annually) physical check over expected to be stored inventory to be conducted by the PAU and verified in advance of starting by the ITFF and the external Auditor. the rounds, which creates risk of proper management.
Flow of Funds Flow of funds and financial reporting are designed The Project funds will High to be simplified and managed centrally by the Substantial be made available PAU, which will utilize an automated accounting through IDA to the system that is capable of recording and reporting PAU. A large portion funds by source & use of funds by category and of the funds will be activity. IDA funds will be deposited into a US$ made for the DA at the CBY. operation cost of the outreach rounds. IDA proceeds will be disbursed in accordance with the traditional disbursement method in accordance with the Bank's disbursements guidelines, noting that disbursement for operation cost of the outreach rounds will require the verification and certification of the ITFF.
FM procedures for expenditures related to drug distribution (Specific FM risk of Component 1) Drug distribution campaigns will be planned for As the High properly to ensure proper control over Substantial implementation of disbursement. Before the implementation of each delivering drugs to outreach round, the ITFF will review these plans the beneficiaries is and verify their compliance to the project’s done in a guidelines. decentralized way, there is inherent risk The ITFF will also review the budgets proposed as of managing the part of these plans and verify their compliance to related expenditures. the FM guidelines and to the budgets planned as part of the Project Implementation Plan (PIP).
Such planning and controls will be done in an organized manner based on documented procedures, controls and safeguards for control of funds including the role of the ITFF, to be applied during the project implementation.
72
Risk Comments/ Risk Issue/Risk Before MM Mitigating Measures (MM) After MM
Flow of funds will be managed by the PAU through the use of bank transfers from the project’s DA to the project’s sub-account and then checks will be issued by the PAU from the sub-account. The checks will be issued to assigned individuals with responsibility to settle the advances with the PAU. The individuals will be identified and the required supporting documents are documented in the Project’s FMM and the documents will be maintained by the PAU. In addition, the Project’s design includes a vision for progressive approach of decentralizing a portion of the financial management arrangements to the governorate offices upon satisfactory assessments. The assessment will ensure that each of the health offices has established financial management arrangements acceptable to the Association. The first governorate expected to be ready for assessment as a pilot is Sana’a governorate. Internal Audit The PAU will appoint an ITFF responsible for Limited capacity of Substantial conducting reviews of ongoing outreach rounds Moderate the internal audit and providing additional internal control layer for functions in Yemen. reviews of compliance with internal control procedures. External Audit An independent qualified private external financial Audit profession in Substantial auditor acceptable to IDA will be hired to audit the Moderate Yemen requires project accounts according to TOR upon which enhancement. IDA would grant its No-Objection. Overall Project FM High Overall Project FM Risk after MM Substantial Risk Before MM
6. Overall Project FM Risk Assessment. As detailed above, the Project’s FM risk assessment identified under the project is High. The successful implementation of the mitigation measures, which have been agreed upon with the GoY, will eventually reduce the Project’s FM risk to Substantial. C. Financial Management Arrangements 7. Organization & Staff. The FM activities under the HPP will be managed by an FM Team under the PAU structure and will be supported by accountants at the MoPHP’s governorate offices. The FM unit is to be staffed with a Financial Manager and an Accountant based on TORs reviewed and cleared by IDA.
73
8. Additionally, the PAU will contract with an ITFF to independently verify and certify for IDA that the planning and implementation of the national campaigns have been conducted at an acceptable level and constitute a reliable base for the disbursement of IDA funds. The ITFF’s TOR will be acceptable by IDA. An individual ITA will be considered to independently verify and certify for IDA that the planning and implementation of the pilot campaigns during the first year of the Project have been conducted at an acceptable level and constitute a reliable base for the disbursement of IDA funds.
9. Accounting Software and Financial Manual. The PAU has procured and installed an automated accounting system which follows cash basis accounting and is capable of recording all project activities and generating required reports, such as the quarterly IFRs. The Project's FMM has been prepared by the PAU’s Financial Manager with the assistance of the MoPHP Outreach Team and documents the FM aspects of the project including the internal controls, FM system, chart of accounts designed to capture and classify the project's sources of funds, and expenditures by component and category.
10. Reporting Requirements. In line with the Bank guidelines, the PAU will issue the following reports reflecting the project activities.
11. Quarterly. IFRs prepared by the PAU and reviewed by an independent external Auditor, selected by COCA, under acceptable TOR. The PAU will be responsible for submitting the reviewed IFRs to IDA no later than 45 days after the end of each quarter. These reports will include the following: • Statement of sources and uses of funds showing uses of funds by component, activity and category of expenditures, quarterly cash forecast for the following two quarters, an expenditure report comparing quarter actual and planned expenditures by category, and the Project's DA's reconciliation statement.
12. Annually. Audited Project Financial Statements (PFS) to be remitted to IDA by six months after the end of the project fiscal year. The PFS will include: • Statement of sources and uses of funds, indicating sources of funds received and project expenditures. • Appropriate schedules classifying project expenditures by component and by category, showing yearly and cumulative balances. • DA's reconciliation statement reconciling opening and year-end balances.
13. In addition to the above, the PAU shall furnish to IDA, Independent Technical and Financial Auditors’ reports not later than 60 days after the end of each outreach round or public health campaign.
14. An independent qualified private external financial auditor acceptable to IDA will be hired to audit the project accounts according to TORs upon which IDA would grant its No Objection. The Auditor will conduct quarterly reviews of the project’s quarterly IFRs and annual audits of the Project’s financial statements. The external Auditor report (in English) shall encompass all project components and activities and shall be in accordance with internationally accepted auditing standards e.g., International Standards on Auditing (ISA). The audit report and opinion will cover the Project’s financial statements, reconciliation and use of the DA, use of direct payments, and withdrawals from the grant funds. The Auditor is required to prepare a “management letter” indentifying any observations, comments and deficiencies, in the system and controls, that the Auditor considers pertinent, and shall provide recommendations for their improvements.
74
15. Additionally, the PAU will issue monthly reports reflecting the project commitments by category. This report will be submitted to the World Bank within the first 7 days of the following month.
16. Flow of Funds and Disbursement Arrangements. To ensure that funds are readily available for project implementation, the MoPHP through the PAU would open, maintain and operate a segregated USD DA at the CBY. Deposits into and payments from the DA will be made in accordance with the provisions stated in the grant agreement. Disbursements under this grant will be transaction-based and include withdrawal applications for advances, direct payments, reimbursements and special commitments. Withdrawal applications will be prepared by the PAU and signed by authorized signatories, as designated by the representative of the recipient. The name of each of the authorized signatories and their corresponding specimen of signature will be submitted to IDA before the first disbursement is claimed. Additionally, the PAU will open a sub-account in the CBY. The sub-account will be used to receive transfers from the DA and disburse payments for eligible expenditures for costs related to outreach activities and campaigns (excluding procurement of drugs which will be paid from the Project's DA or through Direct Payments). In addition, the Project’s design includes a vision for progressive approach of decentralizing a portion of the financial management arrangements to the governorate offices upon satisfactory assessments. The assessment will ensure that each of the health offices has established financial management arrangements acceptable to the Association. The first governorate expected to be ready for assessment as a pilot is Sana’a governorate. Upon satisfactory assessments, the PAU will request the Bank to approve opening sub-accounts with proper ceiling at the governorates’ health offices which will be used mainly for managing payments related to campaigns’ incremental operating cost under Component 1 of the Project.
17. IDA Designated Account. The PAU will be responsible for maintaining and operating IDA's DA in US dollars in CBY under conditions acceptable to IDA. The authorized ceiling of the Designated Account would be US$3,000,000. The amount to be advanced under the first application would be determined based on initial project needs. The PAU would claim the remainder of the advance when the project has reached an advanced stage of implementation. The DA would be replenished monthly based on withdrawal applications supported by appropriate documentation, or when half of the advance to the DA has been utilized, whichever occurs first. The DA will be audited annually by external auditors acceptable to IDA as part of the overall project audit.
18. Use of Statement of Expenditures (SOEs): All applications for withdrawal of proceeds from the grant account will include attaching the supporting documentation. The following will be claimed on the basis of SOEs: (i) expenditures under contracts with an estimated value of US$100,000 or less for goods; (ii) US$50,000 or less for individual consultants, and (iii) US$100,000 or less for consulting firms, and for all operating cost (except for operating cost under Parts A1 and A3 of the Project) and training. The documentation supporting all expenditures will be retained at the PAU of MoPHP and will be readily accessible for review by the external auditor and periodic Bank supervision missions. All disbursements will be subject to the conditions of the Financing Agreement and the procedures defined in the Disbursement Letter. Additionally, withdrawal applications for documentation and reimbursements of operating cost expenditures under Parts A1 and A3 of the Project related to the cost of the outreach activities and campaigns operating costs will be accompanied by certification by the ITTF and/or the ITA.
19. Government’s Financial Contribution. The Project has two types of government financial contributions:
(1) A portion of the MoPHP’s existing budget from MOF is part of the Project’s overall finance plan and such funds will be used for: (i) the procurement of vaccines and related consumables and equipment for outreach and UN administrative cost; (ii) outreach services program operating costs designed for the sustainability of the Project; thus, Government’s funding to outreach 75
services will only take place after IDA’s project has completed its intervention in a specific area; and (iii) outreach program management staff costs. These funds will be implemented following the MoPHP’s own arrangements.
(2) Additional funds for operating cost will be sought from the MOF for the purpose of financing operating cost related to this project but for expenditures not eligible for IDA financing. This contribution will be maintained at a YR account at the CBY to be managed by the PAU with MoF representative.
20. Specific FM Risks of Component 1. Component 1 of the Project entails purchasing and delivering drugs and equipment. These activities introduce additional FM risks mitigated through a number of measures including controls over flow of funds and inventory and fixed assets management. The design of flow of funds as shown in the charts below shows separately [Project Expend (b)] disbursement for the expenditures related to the cost of outreach rounds. This arrangement is special to these activities to manage the flow of funds from the Project’s DA to the sub-account and finally to the cash recipient. Additionally, more details on the FM arrangements for the expenditures related to the cost of outreach rounds are described below under Specific FM risks of Component 1.
21. Note: Outreach rounds are planned to take place four to five times a year and each round will last for a limited number of days (approximately four to six days). Therefore, the flow of funds from the Project’s DA to the sub-account and to the cash recipient will be limited to these periods. The Chart below, summarizes the flow of funds:
IDA
US$ DA – CBY Project Expenditures: (A)
YR Sub-account Project Expenditures: (B)
22. Project Expenditures (A) will be paid from IDA's DA and these represent all eligible expenditures. Project Expenditures (B) will be paid from IDA's sub account and these represent eligible expenditures related mainly to the cost of drug distribution campaigns.
Chart A: Illustrating Process for Requests of Payments from the Project’s DA
MoF PAU requests for FM & Director CBY Pmt expenditure (A) approval
76
23. Chart A above applies to eligible expenditures paid from the Project’s DA, noting that PAU salaries require an additional approval from the MoPIC before MoF.
Chart B: Illustrating Process for Requests of Payments from the Project’s DA to the Sub-Account
PAU req. for Transfer from DA FM & Director MoF Approval expenditure to sub-account (b) CBY
Checks signed by FM & Director from sub-acc.
24. Chart B above applies to eligible expenditures paid from the Project’s sub-account which is replenished from the Project’s DA. Each time the sub-account is replenished, the PAU will submit to IDA a request for replenishment based on the approved budget for operation cost of the upcoming round. The request will be accompanied by the ITFF certification of both the budget for the next round and the actual activities incurred in the last round.
25. Sub-Account Controls Procedures
(a) The PAU will create a separate cost center in its chart of account for the sub-account.
(b) The sub-account advance threshold will be agreed upon based on estimated cash flow for one round.
(c) For each advance request to the sub-account, the PAU will prepare a disbursement plan detailed by governorate and activity, illustrating how the funds will be used.
(d) The disbursement plan must be prepared by the PAU Financial Manager and approved by the Project Director (which is based on the budget approved by the SC) and submitted to IDA for approval and accompanied by the certification of the ITFF.
(e) Advance to the sub-account must be settled within a maximum period of 90 days and original supporting documents of disbursements from the sub-account must be maintained at the Project.
(f) No new advances to the sub-account are to be made unless the outstanding advance balance is settled.
(g) The Project can partially settle its advance to the sub-account and request replenishment equivalent to the settled amount providing that :
- The aggregate of the remaining advance balance in and the requested amount for replenishment do not exceed the sub-account's ceiling.
- An acceptable disbursement plan of the requested amount is prepared by the Project’s Finance Department and approved by the Project Director, the ITFF and IDA.
77
(h) The PAU's Financial Manager will be responsible for ensuring that advances are timely settled and original supporting documentations are maintained.
(i) The PAU's Financial Manager is responsible for ensuring that with each W/A submitted to IDA, the DA and the sub-account balances and relevant reconciliations are provided.
(j) The Project is not entitled to claim the advances made from the DA to the sub-account in its W/As to the Bank until settlements are made and original supporting documents are provided. The PAU's Financial Manager is responsible for ensuring no advances are claimed to IDA for replenishment.
(k) The sub-account will be part of the external auditor’s scope of work when performing the quarterly reviews and annual audits on the project accounts. Also, if sub-accounts are opened at the MoPHP’s governorate offices, such sub-accounts will also be subject to audits.
Specific FM Risks of Component 1
(i) Inventory Management
26. The PAU is a relatively newly established unit and may not have in place the systems and policies to safeguard and manage the assets during project implementation, including risk of a safe and secured warehouse for the storage of drugs. Drugs are expected to be stored in advance of starting the rounds, which creates risk of proper management of the inventory.
27. The policies and procedures over inventory management are properly recorded in the Project's FM Manual (FMM) including control procedures over receipt and release of inventory and recording of such transactions and will explain the role of the PAU. Such controls will ensure proper receipt of goods by the MoPHP as evidenced by signed receipt documents confirming the quantity received, and signed by authorized officials validating the order received is acceptable. The ITFF will verify that control procedures over inventory management with emphasis on receipt and release of drugs are properly implemented and in compliance with the FMM. The MoPHP will arrange for a secured warehouse for maintaining the drugs. Specific controls will be applied over inventory such as inventory register; an individual assigned the responsibility for inventory management (e.g., inventory custodian). Additionally, there will be a regular physical check (at least annually) of inventory to be conducted by the PAU and verified by the ITFF.
(ii) FM Procedures for Expenditures Related to Outreach Rounds
28. As the implementation of outreach rounds to the beneficiaries is done in a decentralized way, there is inherent risk of managing the related expenditures. Planning for outreach rounds will ensure a successful implementation and control over the payments for the related expenditures (e.g., transportation cost for individuals traveling to conduct training and/or delivery of drugs and daily allowance to the teams working on the rounds). Such planning and controls will be done in an organized manner based on documented procedures, controls and safeguards including the role of the ITFF, to be applied during the Project implementation as documented in the Project's FMM.
29. Responsibilities of the Ministry's Health Offices in Each Governorate. The governorates health offices of the MoPHP will be required to prepare a detailed budget for the planned round including the source of funding by activity. Such budget will be approved by the PAU and the World Bank based on the budget approved by the SC. The budget will specify the names of the individuals who will be
78
responsible for managing the implementation of the campaign. Identified and approved individuals may request advances from the PAU and will be responsible for settling the advances received with complete documentation consistent with the Project’s Manual, within 30 days from receipt of funds. In addition, once each of the health offices has established financial management arrangements acceptable to the Association, funds for campaigns’ operating cost will flow from the Project’s DA to sub-accounts at the MoPHP’s health offices at the governorates. The Project will start with Sana’a governorate as a pilot to establish the financial management arrangements through assigning a qualified Accountant from the health office at the governorate and equipping them with the requirement equipment and accounting software. Each of the health offices would then open a separate bank account for the Project which will be used to receive the allocated funds from the PAU and manage the payments for the campaigns’ operating cost. The health office and the assigned Accountant will be the authorized signatories to making payments from their sub-account.
30. Responsibilities of the PAU. Upon obtaining the required approvals of the budget and prior to the scheduled date for implementing the rounds, the PAU will disburse from the sub-account, an agreed upon percent of the requested campaign funds to the assigned individuals (as per the Project’s FMM). The remaining balance of the requested funds to the individuals will be disbursed upon proper settlement of the initial advance. The sub-account will be funded from the Project's DA and then disbursement from the sub-account in CBY via checks will be issued by the PAU to the assigned and approved individuals' names.
31. Corruption. Fraud and corruption may affect the project resources. The above fiduciary arrangements including ring-fencing, reporting and audit arrangements will reasonably reduce the risk of corruption from a technical perspective through the fiduciary arrangements but may not be effective in case of collusion.
32. IDA Supervision. The Project's FM arrangements will be supervised by IDA in conjunction with its overall supervision of the Project, which will be performed at least on a semi-annual basis, including field visits to selected governorates to assess the implementation of the outreach rounds and the FM capacity at the governorates’ level. IDA FM team will conduct more intensive supervisions during the first year of the Project.
79
Annex 8: Procurement Arrangements A. General
1. A Country Procurement Assessment Report (CPAR) for Yemen carried out in 2000 concluded that the procurement legislation, Law No. 3 of 1997 concerning Government Tenders, Auctions and Stores, and corresponding Regulations introduced by Decree No. 234 of 1997, was a significant improvement over previous legislation for public procurement but nonetheless not yet up to acceptable international standards. The GoY and the Bank agreed on a transition strategy until a revised procurement law is enacted, to address the gaps in the legal framework and to clarify areas which seem to conflict with donors’ guidelines, or which are still ambiguous in terms of contributing to a satisfactory legal framework. The CPAR recommended preparation of a comprehensive National Procurement Manual (NPM) to support capacity building of the GoY’s procurement management at all levels, together with a national Standard Bid Document (SBDs) for goods, works and services. The NPM and SBDs for works, goods and consultancy services were endorsed by the Cabinet in April 2006, and preparation and capacity building efforts led by the Technical Committee of the High Tender Board (HTB) have been underway since 2007 and intensifying for broad dissemination and capacity building in one pilot ministry. Enforcement on the use of these country procurement documents is ongoing.
2. In addition to the National Reform Agenda adopted by GoY in early 2006, a new reform-oriented public procurement law reflecting international best practice has been prepared with Bank and USAID support which was ratified by Parliament as Law No. 23 on July 24, 2007. The requirements of the new law have subsequently been reflected as implementing arrangements in the Executive Regulations/Bylaws drafted by an Inter-Ministerial drafting committee with the assistance of the same consultants appointed by USAID (Booz Allen). Implementation of the Bylaws subsequent to Cabinet approval is to start once consultations with key stakeholders including donors are concluded, as part of reforming the institutions handling government contracts.
B. Procurement Arrangements
3. Procurement under the Project will be carried out in accordance with the “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants” known as the ‘2006 Anti-Corruption Guidelines’, and the "Guidelines: Procurement under IBRD Loans and IDA Credits" dated May 2004, revised May 2010; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" dated May 2004, revised May 2010; the accompanying standard bidding documents for any new procurement; and the provisions stipulated in the Financing Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the grant, the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements, and time frame are agreed between the Recipient and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.
Advertisement
4. The General Procurement Notice (GPN) for procurement under HPP has been posted in dgMarket and UNDB.
Procurement of Works
5. The Project will not finance any works contracts. 80
Procurement of Goods
6. Goods procured under the project would include: procurement of drugs, equipment, and supplies for the Outreach Services and referral Health Centers, MoPHP Governorates, District Offices and the Project Administration Unit (PAU). The drugs and certain medical equipment will be procured through UN Organizations, namely UNICEF, UNFPA and WHO using Direct Contracting (DC) procedures. Other goods will be procured using ICB for contracts costing US$300,000 equivalent or above, NCB for contracts costing less than US$300,000 equivalent and shopping procedures with a minimum of three quotations for contracts costing below US$50,000 equivalent. Direct Contracting procedure may be used on an exceptional basis, with prior agreement of IDA, for procurement of goods that meet the requirements of Clause 3.6 of Procurement Guidelines. The Bank’s Standard Bidding Document (SBDs) for goods will be used for ICB procurement, although no ICB procurement is envisaged at present.
7. The procedures to be followed for NCB under this paragraph shall be those set forth in Law No. 23 for 2007 concerning Government Tenders, Auctions and Stores, and its Regulations, with the following additional procedures:
i) a Recipient-owned enterprise in the Republic of Yemen shall be eligible to bid only if it can establish that it is legally and financially autonomous, operates under commercial law, and is not a dependent agency of the Recipient; ii) bidding (or pre-qualification, if required) shall not be restricted to any particular class of contractors or suppliers, and non-registered contractors and suppliers shall also be eligible to participate; iii) tenders shall be advertised for at least two (2) consecutive days in two (2) local newspapers of wide circulation; iv) prospective bidders shall be allowed a minimum of thirty (30) days for the preparation and submission of bids, such thirty (30) days to begin with the availability of the bidding documents or the advertisement, whichever is later; v) until national standard bidding documents acceptable to the Association are available, bidding documents approved by the Association shall be used, and may be prepared in Arabic; vi) registration shall not be used to assess bidders’ qualifications; qualification criteria (in case pre- qualification was not carried out) and the method of evaluating the qualification of each bidder shall be stated in the bidding documents, and before contract award the bidder having submitted the lowest evaluated responsive bid shall be subject to post-qualification; vii) a foreign bidder shall not be required to register or to appoint an agent as a condition for submitting its bid and, if determined to be the lowest evaluated responsive bidder, shall be given reasonable opportunity to register, without let or hindrance; the registration process shall not be applicable to sub-contractors; viii) all bids shall be submitted in sealed envelopes and may be submitted, at the bidder’s option, in person or by courier service; ix) all bids shall be opened at the same time in a public bid opening which bidders shall be allowed to attend and which shall follow immediately after the deadline for submission of bids; x) evaluation of bids shall be carried out in strict adherence to the criteria declared in the bidding documents and contracts shall be awarded to the lowest evaluated responsive bidder, without resorting to the rejection of bids above or below a certain percentage of the pre-bid estimate (bid price bracketing);
81
xi) no bidder shall be requested or permitted to modify its bid after the bid closing date shall have elapsed and bids submitted after the deadline for submission of bids shall be returned to the bidder unopened; xii) post-bidding negotiations with the lowest or any other bidder shall not be permitted; xiii) under exceptional circumstances, the procuring entity may, before the expiration of bid validity, request all bidders in writing to extend the validity of their bids, in which case bidders shall not be requested nor permitted to amend the price or any other condition of their bids; a bidder shall have the right to refuse to grant such an extension without forfeiting its bid security, but any bidder granting such extension shall be required to provide a corresponding extension of its bid security; xiv) price adjustment provisions may be included in contracts for works with a duration of more than eighteen months; xv) rejection of all bids is justified when there is lack of effective competition, or bids are not substantially responsive, however, lack of competition shall not be determined solely on the basis of the number o f bidders; and xvi) each contract financed from the proceeds of the Grant shall provide that the contractor or supplier shall permit the Association, at its request, to inspect their accounts and records relating to the performance of the contract and to have such accounts and records audited by auditors appointed by the Association.
Procurement through UN Organizations
8. The GoY has requested to procure drugs and certain medical equipment through UNICEF, UNFPA and WHO which is consistent with the MoPHP’s current policy to procure all principal health sector goods through UN organizations due to weak capacity in procurement management at both central and decentralized levels as well as the weak capacity to handle procurement of International Competitive Biddings (ICBs) following the World Bank procurement guidelines. While GoY has initiated efforts to strengthen its public procurement system, this is likely to take time and will not be in place to meet the needs of this project.
Procurement of Non-consulting Services
9. Non-consulting services under the project would include: various training events, workshops, seminars, etc., communication services, hotel services, advertising services, printing services, translation services etc. The procurement will be done using the Bank’s SBD for all ICB and National SBD agreed with or satisfactory to the Bank.
Selection of Consultants
10. Consulting services under the project to be provided by consulting firms and individuals would include: surveys (baseline, mid-term, and end of project) and independent monitoring and technical audit, technical assistance to develop and implement communications strategy, technical assistance to design Outreach Services and its tools. The selection of local and international consulting firms will be carried out using IDA’s standard Request for Proposals (RFP) and appropriate form of contract based on the scope of services to be procured. Short lists of consultants for services estimated to cost less than US$200,000 equivalent per contract may be composed entirely of national consultants although foreign firms may express interest for consideration in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines.
82
11. For consulting firms, all contracts would be procured using Quality- and Cost-Based Selection (QCBS) procedures except for small contracts for assignment of standard or routine nature and estimated to cost less than US$100,000 equivalent which may be procured using selection based on Consultants’ Qualifications (CQ) and Least-Cost Selection (LCS) methods. Selection under a Fixed Budget (FBS) may be used for hiring services that meet the requirements of paragraph 3.5 of the Guidelines for Selection of Consultants. Single-source selection (SSS) procedures may be used on an exceptional basis, with prior agreement of IDA, for hiring services that meet the requirements of paragraph 3.10 of the Guidelines for Selection of Consultants, for assignments when only one consulting firm or individual consultant is qualified or has experience of exceptional worth. All consultants assignments estimated to cost more than US$200,000 will be advertised in the UNDB online and dgMarket. All individual consulting assignments would be on the basis of comparison of qualifications in accordance with Section V of IDA’s Guidelines for Selection of Consultants. Individual consultants may be selected on a sole-source basis in exceptional cases that meet the requirements of paragraph 5.4 of the Guidelines for Selection of Consultants, with prior approval of IDA. Operating Costs 12. Operating costs as outlined below would be financed by the Project and procured according to procedures acceptable to IDA and listed in FM manual.
(a) Operating costs incurred by the PAU for project implementation activities include: office rental, utility charges, transportation, maintenance of vehicles, office supplies, operation and maintenance of office equipment, printing, advertisements, banking charges, communication services, translation services, fuel, vehicle rental, local travel costs and per diem, and support staff excluding salaries of officials of the Recipient’s civil service and the purchase of vehicles. (b) Operating costs incurred by the MoPHP for Outreach Services and campaigns include: travel costs of MoPHP staff, car rental costs, local transport costs of drugs, stationary, fuel, outreach and campaign launching workshop costs, microphone rental costs, and communications. 13. The procurement procedures and SBDs to be used for each procurement method, as well as model contracts for goods procured, are presented in the Project Implementation Manual. C. Assessment of the Agency’s Capacity to Implement Procurement 14. Procurement activities will be carried out by the new PAU and attached to the GDFH under the supervision of the Head of GDFH. The PAU staff, including the Procurement Officer, is being recruited to establish a robust procurement management system in the GDFH which can serve as a model for other sectors in the MoPHP. As the upcoming activities under the project are mainly procurement of goods (drugs and equipment) and managing TA consultant contracts, the procurement capacity in this area will be developed on a fast track basis as a precursor to satisfactory project implementation results. 15. To strengthen the procurement management at the PAU, the Project would (i) exercise quality control for project procurement documents and process and contract management particularly for the technical services contracts; (ii) ensure adequate training of the Procurement Officer; (iii) prepare and establish procurement guidelines and procedures; and (iv) maintain a sound procurement filing system. In terms of lessons learned from Independent Procurement Reviews (IPRs) carried out in Yemen, it is often a weak link in good practice project management. The Project would hire a short term Qualified Procurement Advisor during implementation, if procurement capacity proves to be weak.
16. To mitigate the risk of inadequate handling of ICB procedures for procurement of drugs and medical equipment in Yemen, it is recommended that they be procured through United Nations Organizations, mainly UNICEF, UNFPA and WHO using the UN Global Agreements which have just been approved by the Bank. 83
17. A preliminary Procurement Capacity Assessment in February 2009 taking into account the transfer of responsibility for preparing the proposed HPP from the GMU to the sector the overall base line project risk for procurement is considered High which would be reduced to Substantial, when the following already agreed upon mitigation measures to be implemented as prerequisites for project fiduciary readiness are in place. These risks relative to procurement aspects would be mitigated by: (i) strengthening procurement management capacity through recruitment of competent Procurement Officer; (ii) a short-term qualified Procurement Advisor, if procurement capacity is not adequate; (iii) procuring drugs and medical equipment through UN organizations; and (iv) providing descriptive procurement procedures in the project operational manual taking into consideration the procurement implementation experience in the Health Sector Reform Project which was closed on August 31, 2009.
Table 1: Procurement Management Action Plan
Risk Mitigation Measures By When Recruit a competent Procurement Officer. Complete
Inadequate capacity to efficiently Recruit a short-term qualified Procurement manage procurement. Advisor, if procurement capacity is not Implementation adequate. Stipulate descriptive procurement section in the Complete project operational manual. Procure drugs and medical equipment through Inadequate capacity to handle UNICEF, UNFPA and WHO using UN Implementation ICB. approved Global Agreements.
D. Procurement Plan
18. The MoPHP has developed a draft procurement plan for the first 18 months of project implementation which provides the basis for the procurement methods (attached in this Annex). This plan has been agreed between the MoPHP and the Project Team on December 14, 2010 and it will be available in the Project’s database and in IDA’s external website. The procurement plan will be updated in agreement with the Project’s Team annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.
E. Frequency of Procurement Supervision
19. In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment of the PAU has recommended two annual supervision missions to visit the field to carry out post review of procurement actions.
84
F. Details of the Procurement Arrangements Involving International Competition 1. Goods and Non Consulting Services
(a) List of contract packages to be procured following ICB and direct contracting. 1 2 3 4 6 7 Ref. Contract Estimated Procurement Review Expected No. (Description) Cost Method by Bank Bid-Opening (US$ M) (Prior/Post) Date Essential drugs for Outreach Program (OP) 2.50 DC [UN] Prior Jan. 2011 Contraceptives for OP 3.50 DC [UN] Prior Jan. 2011 Diagnostic kits and equipment for OP 1.60 DC [UN] Prior Jan. 2011 Medical kits for training midwives 0.10 DC [UN] Prior Jan. 2012 Nationwide supply of contraceptives 1.00 DC [UN] Prior Jan. 2012 Drugs for referral centers 2.00 DC [UN] Prior Jan. 2012 Medical equipment for referral centers 2.00 DC [UN] Prior Jan. 2012
2. Consulting Services
(a) List of consulting assignments with short-list of international firms. 1 2 3 4 5 6 Ref. Description of Assignment Estimated Selection Review Expected No. Cost Method by Bank Proposals Submission (US$ M) (Prior/Post) Date TA to conducting surveys US$2.00 QCBS Prior March 2011 (Baseline, mid-term, end of project) Independent Technical and US$1.00 QCBS Prior Nov. 2011 Financial Firm (ITFF) External Financial Audit US$0.05 LCS Post Review
The prior review thresholds are as follows:
Goods and Non-consultant All ICB, all contracts above US$200,000, all DC and the first contract. Services Consultant Services Above US$50,000 for individual and US$200,000 for firms plus the first three contracts, TORs, EOI, short-list, and all single source selection.
G. Post Review
20. Monitoring and evaluation of the PAU’s procurement performance under the proposed HPP would be carried out under the prior review thresholds indicated in the procurement plan during supervision mission and through ex-post procurement reviews as deemed necessary during the project implementation. During implementation, post reviews of in-country training would also be conducted from time to time to review the selection of institutions, course content, nominated trainees and justifications thereof, and costs incurred.
85
General Procurement Plan
I. General Project Information Project Name: Health And Population Project 1. Country: Republic of Yemen Project ID: P094755 Loan/Credit Numbers: Original: 14/12/2010
2. Bank's approval date of Procurement Plan Revision 1: * Add new revisions 10/20/2010 (dgMarket), 10/21/2010 (UNDB online), and 3. Date of General Procurement Notice 11/26/2010 (UNDB, Issue no. 786)
II. Goods, Work and Non-Consulting Services Thresholds
Prior Review Threshold. Procurement Decisions subject to Prior Review by the Bank as stated in Appendix 1 to the Guidelines for Procurement: [Thresholds for applicable procurement methods (not limited to the list 1. below) will be determined by the Procurement Specialist /Procurement Accredited Staff based on the assessment of the implementing agency’s capacity.]
1a. Procurement Category Prior Review Threshold (USD) Comments
All ICB, All Contracts Above 200,000 Goods + the first Contract + All Direct Contracts
All ICB, All Contracts Above 200,000 Non-Consultant Services + the first Contract + All Direct Contracts Include all categories authorized by the loan agreement
1b. Procurement Method Procurement Method Threshold Comments (USD) ICB (Goods) >=300,000 NCB (Goods) <300,000 Shopping (Goods) <50,000 Only with Clearance from DC (Goods) Bank Include all methods authorized by the loan agreemen
Prequalification. Bidders for ______shall be prequlified in accordance with the provisions of paragraphs 2. 2.9 and 2.10 of the Guidelines. NA
Proposed Procedures for CDD Components (as per paragraph 3.17 of the Guidelines): Refer to the relevant 3. CDD project implementation document approved by the Bank . NA
4. Reference to (if any) Project Operational/Procurement Manual: Procurement Manual
Any Other Special Procurement Arrangements: [ncluding advance procurement and retroactive financing, 5. if applicable. Some advance procurement will be carried out under a PPA]. Drugs and Medical Supplies and Equipment shall be procure through UN Agencies
6. Procurement Packages with Methods and Time Schedule: As attached
86
III. Selection of Consultants
Prior Review Threshold: Selection decisions subject to Prior Review by Bank as stated in Appendix 1 to the 1. Guidelines Selection and Employment of Consultants:
1a. Procurement Category Prior Review Threshold (USD) Comments
Consulting Firms (Competitive) >200,000 + First Three Contracts Consulting Firms (Sole Source) All Individual Consultants (Competitive) > 50,000 Individual Consultants (Sole Source) All Include all categories authorized by the loan agreement
1b. Procurement Method Procurement Method Threshold Comments (USD) QCBS Any Value FCS ------LCS <100,000 CQS <100,000 Consulting Firms (Competitive) Consulting Firms (Sole Source) Individual Consultants (Competitive) Individual Consultants (Sole Source) ICB (Non-Consultant Services) Include all methods authorized by the loan agreement Short list comprising entirely of national consultants: Short list of consultants for services, estimated to 2. cost less than $ 200,000 equivalent per contract, may comprise entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. Note: OPCPR list of ceilings can be found here: http://go.worldbank.org/MKXO98RY40 Any Other Special Selection Arrangements: [including advance procurement and retroactive financing, if 3. applicable]
4. Consultancy Assignments with Selection Methods and Time Schedule: As attached
IV. Implementing Agency Capacity Building Activities with Time Schedule: As attached
* After the Bank's approval date of Procurement Plan
87
Republic of Yemen Ministry of Public Health and Population Health and Population Project (HPP) Initial Procurement Plan for the First 18 Months As of December 14, 2010 Individual Consultant and UN Agencies
Plan Proc. Contract Estimated Selection Bank TOR Start Adv. EOI end Short Listing Contract Contract Start Completion vs. SN. # System Location/ Description of Assignment TOR end Date NOL Date NOL Date negotiation/Aw NOL Date Cost (US$) Method Rev. Date Date Report Date signature Date Date Date (original) Actual Ref. # ard- Draft
COMPONENT 1: IMPROVING ACCESS TO TO MATERNAL, NEONATAL AND CHILD HEALTH SERVICES
P 14-Aug-11 28-Aug-11 4-Sep-11 24-Sep-11 1-Oct-11 8-Oct-11 15-Oct-11 22-Oct-11 29-Oct-11 31-Oct-11 31-Oct-12 R 1 IC001 Health advisor (part time) 50,000 IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 18-Mar-00 19-Mar-01 A 0-Jan-00 P 14-Aug-11 28-Aug-11 4-Sep-11 24-Sep-11 1-Oct-11 8-Oct-11 15-Oct-11 22-Oct-11 29-Oct-11 31-Oct-11 29-Jan-12 Communication consulting services R 2 IC002 50,000 IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 18-Mar-00 16-Jun-00 (part time) A 0-Jan-00 P 28-Aug-11 11-Sep-11 18-Sep-11 8-Oct-11 15-Oct-11 22-Oct-11 29-Oct-11 5-Nov-11 12-Nov-11 14-Nov-11 14-Nov-12 WHO service agrrement for technical R 3 IC003 150,000 UN PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 18-Mar-00 19-Mar-01 assistance A 0-Jan-00 P 31-Aug-11 14-Sep-11 21-Sep-11 11-Oct-11 18-Oct-11 25-Oct-11 1-Nov-11 8-Nov-11 15-Nov-11 17-Nov-11 15-Feb-12 Assessment and development of QA R 4 IC004 100,000 IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 18-Mar-00 16-Jun-00 systems for outreach services A 0-Jan-00 COMPONENT 1.2: UPGRADE OF FIRST LEVEL REFERRAL FACILITIES AND PROVISION OF COMMNUNITY-BASED SERVICES
P 15-Jul-11 29-Jul-11 5-Aug-11 25-Aug-11 1-Sep-11 8-Sep-11 15-Sep-11 22-Sep-11 29-Sep-11 1-Oct-11 30-Dec-11 R 1 IC001 Assessment of Referal Facilities 30,000 IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 18-Mar-00 16-Jun-00 A 0-Jan-00 COMPONENT 2: PROJECT ADMINISTRATION UNIT (PAU)
P 19-May-10 2-Jun-10 9-Jun-10 29-Jun-10 6-Jul-10 13-Jul-10 20-Jul-10 27-Jul-10 3-Aug-10 5-Aug-10 6-Aug-11 R 1 IC001 Project Administration Unit Staff 600,000 IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 18-Mar-00 19-Mar-01 A 0-Jan-00 P 17-Jul-10 31-Jul-10 7-Aug-10 27-Aug-10 3-Sep-10 10-Sep-10 17-Sep-10 24-Sep-10 1-Oct-10 1-Oct-10 1-Oct-11 R 1.1 IC001.1 Project Administration IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 16-Mar-00 16-Mar-01 A 0-Jan-00 P 19-May-10 2-Jun-10 9-Jun-10 29-Jun-10 6-Jul-10 13-Jul-10 20-Jul-10 27-Jul-10 3-Aug-10 3-Aug-10 3-Aug-11 R 1.2 IC001.2 Procurement Officer IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 16-Mar-00 16-Mar-01 A 0-Jan-00 P 17-Jul-10 31-Jul-10 7-Aug-10 27-Aug-10 3-Sep-10 10-Sep-10 17-Sep-10 24-Sep-10 1-Oct-10 1-Oct-10 2-Oct-11 R 1.3 IC001.3 Financial Officer IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 16-Mar-00 17-Mar-01 A 0-Jan-00 P 17-Jul-10 31-Jul-10 7-Aug-10 27-Aug-10 3-Sep-10 10-Sep-10 17-Sep-10 24-Sep-10 1-Oct-10 1-Oct-10 2-Oct-11 R 1.4 IC001.1 Accountant IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 16-Mar-00 17-Mar-01 A 0-Jan-00 P 19-May-10 2-Jun-10 9-Jun-10 29-Jun-10 6-Jul-10 13-Jul-10 20-Jul-10 27-Jul-10 3-Aug-10 3-Aug-10 4-Aug-11 R 1.5 IC001.2 Executive Secretary IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 16-Mar-00 17-Mar-01 A 0-Jan-00 P Independent Technical Auditor to 28-Oct-11 11-Nov-11 18-Nov-11 8-Dec-11 15-Dec-11 22-Dec-11 29-Dec-11 5-Jan-12 12-Jan-12 14-Jan-12 14-Jan-13 R 2 IC002 Verify and Certify the Outreach & 50,000 IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 18-Mar-00 19-Mar-01 A Public Health Campaigns 0-Jan-00 P 15-Jun-11 29-Jun-11 6-Jul-11 26-Jul-11 2-Aug-11 9-Aug-11 16-Aug-11 23-Aug-11 30-Aug-11 1-Sep-11 30-Nov-11 Environmental Safeguards R 3 IC003 100,000 IC PR 14-Jan-00 21-Jan-00 10-Feb-00 17-Feb-00 24-Feb-00 2-Mar-00 9-Mar-00 16-Mar-00 18-Mar-00 16-Jun-00 Consulting Services A 0-Jan-00 Total Estimates 1,130,000
88
Republic of Yemen Ministry of Public Health and Population Health and Population Project (HPP) Initial Procurement Plan for the First 18 Months As of December 14, 2010
Consulting Firms
Short Financial Contract Location/ RFP Technical Final Contract Completion Est. Cost Bank TOR Start TOR end Adv. EOI Listing Public negotiation/ Contract Description of NOL Date NOL Date RFP prep. NOL Date Submission Evaluation NOL Date Evaluation NOL Date Signature Date
SN. # (US$) Rev. Date Date End Date Report Opening Award- Start Date Assignment Date Report Date Report Date Date (original) Date Date Draft Plan vs. Actual Plan vs. Selection Method Proc. System Ref. #
COMPONENT 2: RESULTS-BASED MONITORING & EVALUATION AND PROJECT ADMINISTRATION
P 11-Nov-10 25-Nov-10 2-Dec-10 1-Jan-11 22-Jan-11 29-Jan-11 5-Feb-11 12-Feb-11 29-Mar-11 19-Apr-11 26-Apr-11 3-May-11 13-May-11 27-May-11 3-Jun-11 10-Jun-11 17-Jun-11 16-Jun-12
Base line R 1 FC001 1,000,000 QCBS PR 14-Jan-00 21-Jan-00 20-Feb-00 12-Mar-00 19-Mar-00 26-Mar-00 2-Apr-00 17-May-00 7-Jun-00 14-Jun-00 21-Jun-00 1-Jul-00 15-Jul-00 22-Jul-00 29-Jul-00 5-Aug-00 5-Aug-01 evaluation
A 0-Jan-00
P 21-Jun-11 5-Jul-11 12-Jul-11 11-Aug-11 1-Sep-11 8-Sep-11 11-Sep-11 18-Sep-11 17-Nov-11 8-Dec-11 15-Dec-11 22-Dec-11 1-Jan-12 15-Jan-12 22-Jan-12 29-Jan-12 5-Feb-12 4-Feb-13 Independent Technical and R 2 FC002 1,000,000 QCBS PR 14-Jan-00 21-Jan-00 20-Feb-00 12-Mar-00 19-Mar-00 22-Mar-00 29-Mar-00 28-May-00 18-Jun-00 25-Jun-00 2-Jul-00 12-Jul-00 26-Jul-00 2-Aug-00 9-Aug-00 16-Aug-00 16-Aug-01 Financial Firm (ITFF) A 0-Jan-00
P 22-Jul-11 5-Aug-11 12-Aug-11 11-Sep-11 2-Oct-11 9-Oct-11 12-Oct-11 19-Oct-11 18-Dec-11 8-Jan-12 15-Jan-12 22-Jan-12 1-Feb-12 15-Feb-12 22-Feb-12 29-Feb-12 7-Mar-12 7-Mar-13
Financail audit of R 3 FC003 50,000 LCS Post R 14-Jan-00 21-Jan-00 20-Feb-00 12-Mar-00 19-Mar-00 22-Mar-00 29-Mar-00 28-May-00 18-Jun-00 25-Jun-00 2-Jul-00 12-Jul-00 26-Jul-00 2-Aug-00 9-Aug-00 16-Aug-00 16-Aug-01 the project
A 0-Jan-00 Total estimates: 2,050,000
89
Republic of Yemen Ministry of Public Health and Population Health and Population Project (HPP) Initial Procurement Plan for the First 18 Months As of December 14, 2010
Goods – Direct Contracting and NCB
Bid. Bid. Proc. Bid Contract Completion Plan vs. SN. Estimated Selection Bank Doc/Specs Doc/Specs Invitation Evaluation System Comp Sub-Comp Location/ Description of Assignment NOL Date Opening NOL Date Signature Start Date Date Actual # Cost (US$) Method Rev. prep. prep. Date & Recomm. Ref. # Date Date (original) Start Date End Date
Component 1: Improving Access to Maternal, Neonatal, and Child Health Services
Sub-component 1.1: Delivery of Outreach Services 7,700,000
P 21-Feb-11 23-Mar-11 30-Mar-11 29-Apr-11 29-Apr-11 29-May-11 5-Jun-11 15-Jun-11 29-Jun-11 5-Jan-12 Supply of essential drugs for R 1 PG001 1 1.1 2,500,000 DC/ UN PR 30-Jan-00 6-Feb-00 7-Mar-00 7-Mar-00 6-Apr-00 13-Apr-00 23-Apr-00 7-May-00 13-Nov-00 the Outreach Program (OP). A 0-Jan-00 P 21-Feb-11 23-Mar-11 30-Mar-11 29-Apr-11 29-Apr-11 29-May-11 5-Jun-11 15-Jun-11 29-Jun-11 5-Jan-12 Supply of contraceptives for the R 2 PG002 1 1.1 3,500,000 DC/ UN PR 30-Jan-00 6-Feb-00 7-Mar-00 7-Mar-00 6-Apr-00 13-Apr-00 23-Apr-00 7-May-00 13-Nov-00 OP A 0-Jan-00 P 21-Feb-11 23-Mar-11 30-Mar-11 29-Apr-11 29-Apr-11 29-May-11 5-Jun-11 15-Jun-11 29-Jun-11 5-Jan-12 Supply of diagnostics, kits and R 3 PG003 1 1.1 1,600,000 DC/ UN PR 30-Jan-00 6-Feb-00 7-Mar-00 7-Mar-00 6-Apr-00 13-Apr-00 23-Apr-00 7-May-00 13-Nov-00 equipment for the OP A 0-Jan-00
P Supply of goods for the HMIS or 21-Feb-11 23-Mar-11 30-Mar-11 29-Apr-11 29-Apr-11 29-May-11 5-Jun-11 15-Jun-11 29-Jun-11 5-Jan-12 R 4 PG004 1 1.1 outreach services in project 100,000 NCB PR 30-Jan-00 6-Feb-00 7-Mar-00 7-Mar-00 6-Apr-00 13-Apr-00 23-Apr-00 7-May-00 13-Nov-00 governorates A 0-Jan-00
Sub-component 1.2: Upgrade of First Level Referral Facilties and Provision 5,400,000 of Community-Based Services
P 22-Feb-12 23-Mar-12 30-Mar-12 29-Apr-12 29-Apr-12 29-May-12 5-Jun-12 15-Jun-12 29-Jun-12 5-Jan-13 R 1 PG005 1 1.2 Medical kits for training of midwives 200,000 DC/ UN PR 30-Jan-00 6-Feb-00 7-Mar-00 7-Mar-00 6-Apr-00 13-Apr-00 23-Apr-00 7-May-00 13-Nov-00 A 0-Jan-00 P 22-Nov-11 22-Dec-11 29-Dec-11 28-Jan-12 28-Jan-12 27-Feb-12 5-Mar-12 15-Mar-12 29-Mar-12 5-Oct-12 Printing materials for training of R 2 PG006 1 1.2 200,000 NCB PR 30-Jan-00 6-Feb-00 7-Mar-00 7-Mar-00 6-Apr-00 13-Apr-00 23-Apr-00 7-May-00 13-Nov-00 midwives A 0-Jan-00 P Nationwide supply of contraceptives 22-Feb-12 23-Mar-12 30-Mar-12 29-Apr-12 29-Apr-12 29-May-12 5-Jun-12 15-Jun-12 29-Jun-12 5-Jan-13 R 3 PG007 1 1.2 (IUDs and implanon) and UN 1,000,000 DC/ UN PR 30-Jan-00 6-Feb-00 7-Mar-00 7-Mar-00 6-Apr-00 13-Apr-00 23-Apr-00 7-May-00 13-Nov-00 A administrative cost; 0-Jan-00 P 22-Feb-12 23-Mar-12 30-Mar-12 29-Apr-12 29-Apr-12 29-May-12 5-Jun-12 15-Jun-12 29-Jun-12 5-Jan-13 Drugs for Referral Centers and UN R 4 PG008 1 1.2 2,000,000 DC/ UN PR 30-Jan-00 6-Feb-00 7-Mar-00 7-Mar-00 6-Apr-00 13-Apr-00 23-Apr-00 7-May-00 13-Nov-00 administrative cost A 0-Jan-00 P Supply of medical equipment for 22-Feb-12 23-Mar-12 30-Mar-12 29-Apr-12 29-Apr-12 29-May-12 5-Jun-12 15-Jun-12 29-Jun-12 5-Jan-13 R 5 PG009 1 1.2 referral centers and UN administrative 2,000,000 DC/ UN PR 30-Jan-00 6-Feb-00 7-Mar-00 7-Mar-00 6-Apr-00 13-Apr-00 23-Apr-00 7-May-00 13-Nov-00 A cost 0-Jan-00 Total Estimates 13,100,000
90
Republic of Yemen Ministry of Public Health and Population Health and Population Project (HPP) Initial Procurement Plan for the First 18 Months As of December 14, 2010
Goods – National Shopping
Plan Proc. Revised Quotations Contract Completion SN. Sub- Location/ Description of Est. Cost Selection Bank Specs prep. Specs prep. Comparison Contract Contract vs. System Comp Est. Cost Submission Signature Date # Comp Assignment (US$) Method Rev. Start Date End Date of Quotations Draft Start Date Actual Ref. # (US$) Date Date (original)
Component 1: Improving Access to Maternal, Neonatal, and Child Health Services
P 5-Jul-11 19-Jul-11 26-Jul-11 16-Aug-11 6-Sep-11 16-Sep-11 19-Sep-11 18-Nov-11 Printing of communication R 1 PG-S001 1 1.1 and training materials (Multi- 100,000 SH PR 14-Jan-00 21-Jan-00 11-Feb-00 3-Mar-00 13-Mar-00 16-Mar-00 15-May-00 Contracts) A 0-Jan-00
P 5-Jul-11 19-Jul-11 26-Jul-11 16-Aug-11 6-Sep-11 16-Sep-11 19-Sep-11 18-Nov-11 Production of TV spots (Multi- R 2 PG-S002 1 1.1 80,000 SH PR 14-Jan-00 21-Jan-00 11-Feb-00 3-Mar-00 13-Mar-00 16-Mar-00 15-May-00 Contracts) A 0-Jan-00
P 5-Jul-11 19-Jul-11 26-Jul-11 16-Aug-11 6-Sep-11 16-Sep-11 19-Sep-11 18-Nov-11
R 3 PG-S003 1 1.1 Registeries (Multi-Contracts) 100,000 SH PR 14-Jan-00 21-Jan-00 11-Feb-00 3-Mar-00 13-Mar-00 16-Mar-00 15-May-00
A 0-Jan-00
P 5-Jul-11 19-Jul-11 26-Jul-11 16-Aug-11 6-Sep-11 16-Sep-11 19-Sep-11 18-Nov-11 Printing of capacity building R 4 PG-S004 1 1.1 70,000 SH PR 14-Jan-00 21-Jan-00 11-Feb-00 3-Mar-00 13-Mar-00 16-Mar-00 15-May-00 materials. (Multi-Contracts) A 0-Jan-00
Component 2: Project Administration Unit (PAU)
P 4-Sep-10 18-Sep-10 25-Sep-10 16-Oct-10 6-Nov-10 16-Nov-10 19-Nov-10 29-Dec-10 TA, equipment, software, and R 1 PG-S005 1 supplies to support PAU 200,000 SH PR 14-Jan-00 21-Jan-00 11-Feb-00 3-Mar-00 13-Mar-00 16-Mar-00 25-Apr-00 (Multi Contracts) A 0-Jan-00 Total Estimates 550,000
Note: If any Contract is of value >50,000 USD it will be Procured following NCB.
91
Republic of Yemen Ministry of Public Health and Population Health and Population Project (HPP) Initial Procurement Plan for the First 18 Months As of December 14, 2010
Training and Workshops
Estimated Estimated Completion Ref SL NO. Expected Outcome/ Activity Description Duration Start Date Comments Cost Date (days)
Sub-component 1.1: Delivery of Outreach Services
Planning training for health workers at 2 1 150,000 14 6-Feb-11 20-Feb-11 For 6 Governorate district levels
Training of Trainers (TOT) for outreach 3 2 10,000 14 13-Apr-11 27-Apr-11 For 6 Governorate services at governorate level Training for physicians (neonatal 2 weeks 4 3 and EMoC 4 weeks) for Raima, Albaida, 60,000 42 4-Jun-11 16-Jul-11 For 6 Governorate Sana'a Integrated PHC training for health workers 5 4 650,000 16 26-Feb-11 14-Mar-11 For 6 Governorate (16-day training)
Service package (1) training for 6 5 80,000 9 16-May-11 25-May-11 For 6 Governorate physicians (9 days training)
Governorate planning workshop (1 of 6 7 6 60,000 6 1-Aug-11 7-Aug-11 For 6 Governorate workshops conducted every 1 1/2 years)
Training for drug distribution system in 14 days for each 8 7 20,000 14 4-Jun-11 18-Jun-11 project governorate Governorate
Training to apply health management 9 8 information of outreach services in project 20,000 14 11-Jun-11 25-Jun-11 For 6 Governorate governorates
Sub-component 1.2: Upgrade of First Level Referral Facilities and Provision of Community-Based Services
1 1 Long term training for midwives (2 years) 400,000 2 Years 5-Mar-11 5-May-13 For 6 Governorate
2 2 Training for midwives for one month 350,000 30 2-Apr-11 2-May-11 For 6 Governorate
Trainings for midwives (1 week for 3 3 60,000 7 2-Apr-11 9-Apr-11 For 6 Governorate implanon)
Training for community volanteers in the 6 4 4 500,000 14 2-Apr-11 16-Apr-11 For 6 Governorate governorates
Grand-total 2,360,000
Procurement of goods, non-consultanting services required for capacity building will be identified, procurement plan updated and shall Note: be procured as per agreed procurement procedures
92
Annex 9: Economic and Financial Analysis
I. Introduction
1. In an effort of improving health care service delivery in Yemen, the MoPHP has initiated the Health Sector Reform Strategy in 1998 which attempted to address an improvement of the management system through decentralization. Although the strategy was to promote efficiency, equity, and access to health care, the country has been facing political and administrative challenges in its implementation process in the last ten years. In spite of the continuous efforts made by the government as well as international donors, access and utilization of health care service in Yemen remains low.
2. According to Household Budget Survey conducted in 2005/6, percentage of individuals who received medical care one month prior to the survey is approximately 70 percent among those who were sick or injured. There is a regional disparity, and utilization is lower in rural areas than urban areas in most of the governorates. It is estimated that per capita annual utilization rate in 2005/6 is 0.91 in urban areas while the rate goes down to 0.56 in rural areas. The main reasons for not receiving the medical treatment when ill or injured one month prior to the survey are: (i) it was a minor illness; (ii) can’t afford; (iii) travel is difficult; and (iv) service is not available. Approximately 30 percent of individuals could not afford medical treatment when they were sick, 3.8 percent reported that travelling to the health facility was too difficult, and 3.7 percent were unable to receive the care because the service was not available.
Figure 9.1: Reasons not to Receive Medical Treatment
0.6 cannot affored 0.6 travel is too difficult 5.6 29.8 no female/male doctor or nurse available services not available
illness was minor 55.3 3.8 bad services 0.7 social reasons 3.7 other
Source: using Yemen HBS 2005/6.
3. Figures below show number of physicians, nurses and midwifes per 1,000 populations. With respect to the income level, Yemen is one of countries with the smallest number of health workers among countries in the Middle East and North Africa. Especially, the number of nurses and midwives is below global average of countries with equivalent income level.
93
Figure 9.2: Number of Health Workers vs. Income Level
Physicians vs income for MENA countries, 2004/5 Nurses/midwives vs income for MENA countries, 2004/5 8 15 6 10 4 Bahrain Egypt Jordan Lebanon Bahrain 2 Oman Kuwait 5 Libya Tunisia Saudi Arabia Libya Oman Kuwait Egypt Jordan Iran Tunisia Saudi Arabia
Morocco Yemen Iran Lebanon Djibouti
Yemen Morocco
Djibouti physiciansper 1,000 population nurses/midwives per1,000 population
250 1000 5000 25000 250 1000 5000 25000 GNI per capita, US$ GNI per capita, US$
IDA IBRD GCC IDA IBRD GCC
Source: Using WDI, the World Bank Source: Using WDI, the World Bank
4. Most of Yemeni visit health facility only when they are ill, and preventive care is not yet a common practice in Yemen. Individuals who regularly see health professional at least once every 6 months is less than 1 percent in 2006. Birth attended by skilled health professional remains low. According to the most recent World Development Indicator, only 35.7 percent of deliveries are assisted by skilled professional in 2007. It is estimated that 32.6 percent of married women age between 10-49 received medical treatment during deliver, and there is a noticeable disparity between urban (55.5 percent) and rural (23.4 percent) according to HBS in 2006.
5. Evidently, lack of access and utilization of health care service when patients are in need reflects health outcomes of Yemen. Although health performance indicators: under 5 mortality rate and infant mortality rate in Yemen have shown slow improvements, under 5, infant, as well as maternal mortality rates are highest among the countries in MENA. As figures below show, both under 5 mortality and maternal mortality in Yemen are higher than global average with respect to the health spending among the similar level of per capita expenditure. All these trends are severely off track to be able to achieve the MDG goals by the year 2015. Prevalence of underweight children less than 5 years has been even increasing in the past few decades, and child malnutrition continues to be the serious issue in Yemen.
Figure 9.3: Health Outcomes vs. Health Spending
Under-five mortality vs health expenditure for MENA countries, 2006 Maternal mortality vs health expenditure for MENA countries, 2005 250
Djibouti Djibouti
Yemen 500 YemenIraq 100
SyriaMoroccoAlgeria Egypt Iran Lebanon TunisiaLibya Algeria 100 Egypt Jordan Oman Morocco Lebanon JordanIran Saudi Arabia 25 United Arab Emirates Qatar Bahrain Libya 25 Syria Tunisia Saudi Arabia Qatar Oman KuwaitBahrain
United Arab Emirates 5 Kuwait 5
Maternalmortality ratio(per 100,000 live births) 10 50 250 1000 5000 10 50 250 1000 5000 Health expenditure per capita, US$ Under-five mortality rate(deaths per 1,000 live births) Health expenditure per capita, US$ IDA IBRD GCC IDA IBRD GCC Source: Using WDI, the World Bank Source: Using WDI, the World Bank Note: maternal mortality rates are WHO modeled estimate.
94
6. In order to support the reform strategy that has been executed by the government of Yemen, the Health Population Project (HPP) financed by an IDA credit will be implemented upholding the objective that is to increase access to and utilization of health care service especially among women and children. The main activity of the proposed Project is routine mobile outreach health care services. The effectiveness of Outreach Services in Central American countries, El Salvador and Guatemala, and in Africa is well documented. 74 Utilizing existing fixed facilities in six selected governorates, mobile outreach service will offer extensive health care, reaching out to the vulnerable population who are in need to receive medical treatments and preventive care in remote areas.
7. A detailed economic and financial assessment of the proposed project was undertaken during the project preparation. The results from the economic analysis show that the proposed Project is economically viable, and provision of extensive outreach mobile services attached to the fixed facilities is more cost effective than the service deliveries taken place only at fixed facilities. From a financial point of view, results indicate that the project is financially feasible in the country’s economy. The purpose of this section is to present summary results of the cost benefit/effectiveness analysis of the HPP in Yemen.
II. Methodology
8. Applying the Bank’s standard approach to economic evaluation, cost benefit methodology was used. The cost benefit analysis for the Project was conducted for the following three scenarios to evaluate which alternative would be the most cost effective option: (i) Fixed facility only; (ii) Fixed facility + outreach mobile service for immunization; and (iii) Fixed facility + outreach mobile service for immunization and maternal care. 75 Then effectiveness of the project was estimated for the above- mentioned scenarios and for scenario (iv) Fixed facility + outreach mobile service for immunization, maternal care and nutrition.
9. The cost benefit analysis calculates the net benefits generated by each activity component on an incremental basis within the project period. The benefits of the project are equal to the difference between the incremental benefits and the incremental costs of three scenarios: “with” and “without” outreach service. The “without” outreach scenario considers the health care service would continue unchanged ; i.e., hours of service, and associated operation costs, and would deliver only through fixed facilities. The social discount rate of 3 percent was used in the analysis. In the with outreach scenarios, the assumption of 30 percent efficiency rate of utilization among target population was applied. Then, sensitivity analysis was conducted to measure impact on the project effectiveness when assumed value (30 percent of outreach utilization) changes while all others remain constant.
Costs
10. Project costs include estimated training cost for physicians and midwives, drug and medical equipment, communication and mobilization cost for Outreach Services, staff salaries and operation and maintenance (O&M) costs based on the previous years of operation of the respected facilities. The table below is a summary table of the annual estimated costs.
74 See Fundacion Salvadorena para el Desarollo economic y Social 2009; and Fox-Rushby & Ford, 1995. 75 Analysis does not include benefits from health care service for family planning due to data limitation which might underestimate the net benefit of the HPP. 95
Table 9.1: Estimated Annual Cost (in 1,000 Yrls)
2010 2011 2012 2013 2014 2015 2016 Program operating costs 7,668.58 8,065.91 8,115.06 8,115.06 8,798.65 8,798.65 8,798.65 Equipment and other medical supplies 726.00 4,099.42 4,099.42 4,099.42 4,099.42 4,099.42 4,099.42 Drugs 1,584.00 1,259.27 1,259.27 1,259.27 1,288.31 1,288.31 1,288.31 Communication and mobilization cost for outreach rounds 15.00 30.00 35.00 35.00 40.00 40.00 40.00 Training workshops for health workers including midwives 229.50 571.62 596.86 624.63 655.18 688.78 725.74 Staff salaries 11,721.60 11,721.60 12,307.68 12,923.06 13,569.22 14,247.68 14,960.06 Total 21,944.68 25,747.82 26,413.30 27,056.45 28,450.78 29,162.84 29,912.19
Benefits
11. Poverty in Yemen is highly concentrated in rural areas. According to HBS 2006, 84 percent of poor people are in rural settings. The figure below shows poverty incidence among six targeted governorates. Beneficiaries of HPP are vulnerable women and children who are imporished living in remote rural areas in Sana’a, Ibb, Reimah, Al Dahla’a and Al Baydah, and urban slums in Aden.
Figure 9.4: Incidence of Poverty by Location in Six Selected Governorates
100 Incidence of Poverty by Location 90 Urban Rural 80 70 59.8 60 50 46.4 % 40 32.8 35.3 28.1 28.2 30 20 16.4 16.7 16.9 10 5.4 0 Sana'a Ibb Reimah Al Dahla'a Al Baydah Aden
Source: Poverty Assessment in Yemen, 2007
12. Benefits come from saving for the cost of medical treatment due to reduced morbidity of childhood disease and avoided delivery complications by receiving periodical consultation of trained health professionals and birth attended trained midwives. Without outreach mobile service, patients especially in rural areas have to pay large amount of transportation fee to reach the health facility. The amount saved for transportation to get the fixed health facility will be included in the benefit for scenario 2-4. According to Yemen Family Health Survey conducted in 2005, the average waiting time at the health facility is 1.5 hours, and average time to reach the facility is one hour. The opportunity 96
cost to visit the facility for pregnant wife and her husband is be estimated using average time to reach the facility plus waiting time multiplied by estimated average wage rate using HBS 2006. The transportation cost to reach the health facility is another portion of the opportunity cost to visit the fixed facility. The saving of these opportunity costs is included in benefits of all scenarios with outreach mobile services. Table 9.2 presents descriptions of parameters used to compute monetary value of benefits.
Table 9.2: Descriptions of Key Parameters
Value used Plausible Descriptions for Notes range computation
Cost of medical treatment including consultation and medicines for childhood 2500 - 3700 2,500 Data from hospitals in Ibb and Taiz: diseases (in Yrls) Consultation: 1,000 Yrls Drug: 1,500 Yrls Cost of medical treatment including Hospitalization for 6 days: 1,200 Yrls consultation and medicines for birth 1000 - 40000 2,500 complication (in Yrls)
% of married women who have .. 19.1% Calculation using Yemen HBS 2005/6 experienced delivery complication
Vaccine efficacy 85% - 98% 85% National Center for Biotechnology Information WHO EMRO Country Profile 2008, calculation Incidence rate child disease (measles) .. 23% based on reported case in 2008. Probability of mother who did not receive prenatal care from skilled midwives 23.9% Study conducted in the US, 2008 having c-section
% pregnant women who had utilized 1.96% Calculation using Yemen HBS 2005/6 prenatal care in 2005/6 Average transportation cost to get a 0 - 20000 592.50 Calculation using Yemen HBS 2005/6 health facility (in Yrls) Wage rate (hourly earnings in Yrls) 0 - 1847.58 37.35 Calculation using Yemen HBS 2005/7 Average waiting hours at the facility (in 2.5 Calculation using Yemen HBS 2005/8 hours) Average time to reach the facility (in 1 Calculation using Yemen HBS 2005/9 hours)
III. Result of Economic Analysis
13. The results of cost benefit analysis presented in the Table 9.3 show scenarios with outreach components have higher positive net gains and lower cost-benefit ratio. Scenario 9 with both immunization and maternal care outreach activities has maximum social welfare. As Figure 9.4 shows a project scenario with two outreach activities immediately gains large net benefit reaching out a greater number of beneficiaries if it will be implemented and carry on successfully.
97
Table 9.3: Summary Results of the Economic Analysis (in 1,000 Yrls)
Scenario 1: Scenario 2: Fixed Scenario 3: Fixed Fixed facility facility + immuni- facility + immunization only zation outreach & maternal care outreach Net Present Value 8,507.84 89,508.71 209,094.97 Economic Rate of Return (%) 9.6% 53.0% 78.7%
14. The results of cost benefit analysis presented in the Table 9.4 show scenarios with outreach components have higher positive net gains and lower cost-benefit ratio. Scenario 9 with both immunization and maternal care outreach activities has maximum social welfare. As Figure 9.4 shows a project scenario with two outreach activities immediately gains large net benefit reaching out a greater number of beneficiaries if it will be implemented and carry on successfully.
Table 9.4: Summary Results of Cost Benefit Analysis (in 1,000 Yrls)
Cost-Benefit Costs Benefits Net Gains Ratio Scenario 1: Fixed facility only 149,424.51 163,407.57 14,616.99 0.91
Scenario 2: Fixed facility + immunization outreach 153,980.26 323,271.72 169,291.46 0.48 Scenario 3: Fixed facility + immunization & 192,504.65 441,298.75 248,794.10 0.44 maternal care outreach
Figure 9.4: Estimated Net Benefit of HPP
Estimated net benefits of HPP 170000000
120000000
fixed facility + 70000000 immunization & maternal outreach service in Yrlsin 20000000 fixed facility + immunization outreach -300000002010 2011 2012 2013 2014 2015 2016 service
-80000000 Year
IV. Cost Effectiveness/Sensitivity
15. Cost effectiveness of the proposed Project in four alternative scenarios was computed using estimated target population who will possibly utilize the health care service. Table 9.5 shows the result of cost effective analysis. The project maximizes cost effectiveness if all 3 proposed outreach activities are included in the fixed facility service. Per capita cost of scenario 4 is as low as 735.17 Yrls which is 98
equivalent to US$3.62 while per capita cost of scenario 1: fixed facility only is 3285.97 Yrls (US$16.2) if 10 percent of estimated target population, in fact, utilize the health care service. Per capita cost for scenario 4 goes down to less than US$1.00 if 50 percent or more expected targets receive the service. The analysis concluded the project is more cost effective with three outreach components: immunization; maternal care; and nutrition, and efficiency of HPP thoroughly depend on the number of beneficiaries. Larger the number individuals reached by outreach mobile services, greater the efficiency of HPP.
Table 9.5: Cost Effectiveness of HPP
Per capita Cost of Activities Number of Beneficiaries by Utilization Rates (in 1,000 Yrls) Costs by Utilization Rates 10% 30% 50% 80% 10% 30% 50% 80% Scenario 1: Fixed facility 149,424.51 45,473 136,420 227,367 363,788 3.29 1.10 0.66 0.41 only Scenario 2: Fixed facility 153,980.26 113,192 339,577 565,961 905,538 1.36 0.45 0.27 0.17 + immunization outreach
Scenario 3: Fixed facility + immunization & 192,504.65 248,780 746,341 1,243,901 1,990,242 0.77 0.26 0.15 0.10 maternal care outreach Scenario 4: fixed facility + immunization, maternal 193,690.35 263,465 790,395 1,317,325 2,107,719 0.74 0.25 0.15 0.09 care & nutrition outreach
V. Fiscal Sustainability
16. HPP will be financed mainly by the IDA credit (US$35 million equivalent), and the Government of Yemen (US$28.34 million). Calculations of the project sustainability are based on an analysis of the recurrent costs of the project, plus the annual maintenance costs, training fees and outreach health care coverage of immunization, maternal care and nutrition. Public health expenditure as percentage of government spending, and public health expenditure as percentage of GDP has been remaining constant since 2003 up until 2007 that is the most current available data point for Yemen; therefore, we assume that public expenditure as percentage of GDP in the next 5 years continue to be constant for the purpose of this analysis. GDP projected by IMF for available year 2010-2014, and public health expenditure data in 2006 were used for the computation. The results of the analysis are summarized in the table presented below. The cost of the project is expected to be gradually absorbed into the national budget; and thus, it is anticipated that there will be no affect on fiscal policy sustainability in the country of Yemen.
Table 9.6: Expected Fiscal Impact and Project Sustainability
2010 2011 2012 2013 2014 2015 Predicted GDP 31,980 34,645 37,153 40,003 42,687 .. Public health expenditure (% of GDP) 2.000 2.000 2.000 2.000 2.000 .. Public health expenditure (% of Government spending) 6.000 6.000 6.000 6.000 6.000 .. Cost of project (% of GDP) 0.009 0.014 0.013 0.012 0.012 .. Total cost of project (% of GDP) 0.027 0.031 0.029 0.026 0.025 .. Source: International Monetary Fund, World Economic Outlook Database, October 2009; price in US$, current price in billions.
99
Annex 10: Safeguard Policy Issues
Safeguard Policy Issues
1. The proposed Project has been classified as a Category “B” for environmental screening purposes given the risks associated with the handling and disposal of medical wastes generated from the procurement of drugs and equipment under Component 1. An Environment and Social Impact Assessment (ESIA) has been prepared that includes a Health Care Waste Management Plan. The ESIA adequately discusses management issues and mitigation measures associated with Health Care Waste.
2. The major issues envisaged during project operation are the following:
(a) Improper handling and storage of chemicals and drugs. (b) Improper management of Hazardous Health Care Waste generated by the project health facilities. (c) Inappropriate disposal of HCW generated during outreach activities.
Handling and Storage of Chemicals and Drugs
3. Improper handling of chemicals and drugs can cause a number of health affects. These include:
(a) The deterioration and/or corruption of chemicals and drugs due to improper conditions of usage and storage. This affects the patients' health and weakens the quality of healthcare services provided. (b) Easy uncontrolled access of the population, especially those untrained and unaware, to these chemicals and drugs. (c) Soil contamination due to direct contact with spilled and dropped products. (d) Surface and ground water contamination in case of direct contact. (e) Increase of expenses of drugs and chemicals which can present a burden on the Project's budget.
4. Guidelines will be developed for the project to avoid any significant impacts through some mitigation measures that include the design and implementation of a simple and low-cost management system for handling and storage of chemicals and drugs, as mentioned in the ESIA.
Waste Management
5. Waste segregation and identification: A key effective management tool is the identification and proper segregation of wastes. The waste consists of mainly the following: regular domestic waste, non hazardous waste, health care waste and hazardous or infectious waste. Wastes will be segregated at the point of generation.
6. Observance of sound on-site waste management practices: Wastes will be properly sealed and packed to avoid spillage or leakage and cross contamination with other materials and media. Collection will be done regularly. A waste storage area will be required where there is none.
7. Treatment and disposal: A number of options will be made available to the facilities for the treatment of hazardous wastes. On-site treatment may be required, where off-site treatment is unavailable. Only those treated or disinfected wastes will be downgraded and considered general waste for disposal in municipal dumpsites. General waste will be disposed of in municipal dumpsites.
8. Wastewater: Participating health care facilities will be required to conduct a compulsory separation for medical waste from domestic waste. This is in addition to the establishment of primary 100
sedimentation tanks if possible, especially isolated or fully insulated tanks, for the wastewater generated from medical laboratories and small or large operating rooms.
9. Capacity building: The capacity of the participating facilities in terms of environmental and waste management will be built and enhanced through training and workshops. The project will support establishment of systems for waste storage, disposal of general wastes, installation of onsite capability for treatment and containment, infectious waste sterilization and treatment capability, and materials and acquisition management in project facilities.
Social Safeguards
10. Involuntary physical resettlement and/or involuntary land acquisition are not foreseen in the context of the implementation of the Project’s proposed components. Therefore OP 4.12 has not been triggered.
Implementation Arrangements
11. The PAU under the supervision of the Deputy Minister of the Primary Health Care will include a focal point from MoPHP who will work closely with the Ministry of Water and Environment (MoWE) to ensure that the participating health care facilities will adhere to the Project’s environment and health care waste management guidelines and comply with the relevant environmental requirements and standards in coordination with the relevant agencies. The FP will carry out routine M&E of the outreach sites with the MoWE to ensure proper handling of the medical waste generated from the project activities during implementation. Training of health care workers on handling of medical waste will be developed and incorporated into the training modules as part of the capacity building activities in the Project. Financing for the above activities will be incorporated in the operating costs of the Project.
12. In addition, an Environmental Consultant will be hired under the project to implement the ESMP which includes carrying out monitoring of the Outreach Services in the six governorates twice a year during project operation, reporting on the implementation of the ESMP and developing training modules and guidelines for a proper system for managing hazardous healthcare waste at the project health facilities.
Findings from the Public Consultation on Environmental and Social Safeguards
13. A public consultation event was organized on June 6, 2010 at MoPHP in Sana'a, Yemen, inviting stakeholders of relevance to the project both on the central and Governorates level to share the draft of the ESIA. The group of invitees included Governmental personnel, NGOs, civil society, press and the public in general. Annex 3 of the ESIA presents a full report of the public consultation, including a list of participants and the agenda. The event had the primary interest of engaging a wider range of relevant stakeholders and disclosing the EIA preliminary results to a wider audience. The objective of the public consultation was also to review the findings of the EIA including the identified impacts and the proposed mitigation measures under the ESMP. The participants' feedback was meant to inform the final version of the ESIA report through full consideration of the relevant comments.
14. The Public Consultation was divided into two main sessions (agenda attached in Annex 3-D of the ESIA). The first involved welcome speeches and a presentation of the HPP and its relevance to the national strategy in addressing health challenges. The same session included a presentation of the social part of the ESIA. The presentation included the following main key components:
101
(a) Baseline information and general indicators related to the health of the mother and child. (b) Predicted social impacts during the preparation and implementation phases. (c) Project alternatives. (d) Social mitigation and monitoring plan.
15. The second session included the presentation of the findings of the environmental aspects related to the ESIA including:
(a) Baseline information and general indicators related to biodiversity and the environment in the targeted governorates. (b) Predicted environmental impacts during the preparation and implementation phases. (c) Environmental mitigation and monitoring plan.
16. This presentation was followed, in the same second session, by an open discussion where all participants were invited to present their comments and feedback on the presented information. During this session, the concerned stakeholders from governmental authorities (including the MoPHP and the Environmental Protection Agency) as well as the team of consultants provided replies to the issues raised. In order to ensure efficient documentation of the participants' feedback, several tools were employed. This mainly include direct note taking by the EcoConServ consulting team and their local partner. In addition, comment sheets were distributed to the Public Consultation participants to ensure that comments of the widest portion possible of participants would be taken into account. (A sample of the written feedback sheet is attached in Annex 3-E of the ESIA). Participants' questions were replied to by the consultants. Several of the issues raised were already included in the full ESIA draft report while other relevant comments and feedback have been incorporated into the final version of the report. Participants were invited to access the full ESIA report by contacting the Family Health Sector in MoPHP. A table summarizing most of the received environmental comments is also attached to the report in Annex 3-E of the ESIA.
17. From the social perspective, the project agreed to tackle one of the main challenges in the health sector in Yemen, namely the issue of women and children's access to health facilities and the various topographic, cultural and demographic challenges associated with this subject. The Project was agreed to be designed to handle several root causes of the problem. Participants, generally, received the social impact analysis very well and appreciated, in particular, the discussion around the potential risks related to project sustainability. The discussion around cost sharing was also very informative.
Findings from the Stakeholder Consultation on Project Design
18. A Health and Population Project stakeholders’ workshop was launched by MoPHP on June 30, 2010. The workshop demonstrated considerable participation from civil society representing NGOs especially those working in the health sector and human rights, central government as well as local government in project target areas, and other parastatal organizations interested in the health sector such the National Council for Childhood and Motherhood and the Social Fund for Development.
19. The participants expressed their concurrence and strong support to the objectives and design of both the HPP and SCP. The discussions included an emphasis on the nature of their roles to enhance community participation and social mobilization interventions including service delivery and facilitating the work of MoPHP at the community level.
102
Annex 11: Project Preparation and Supervision
Planned Actual PCN review 06/11/2008 06/11/2008 Initial PID to PIC 08/01/2008 Initial ISDS to PIC 08/01/2008 Appraisal 07/24/2010 08/08/2010 Negotiations 12/12/2010 12/14/2010 Board/RVP approval 02/22/2011 Planned date of effectiveness 08/12/2011 Planned date of mid-term review 07/15/2014 Planned closing date 09/30/2017 Key institutions responsible for preparation of the Project: Ministry of Public Health and Population. Bank staff and staff from partner institutions who worked on the project included: Name Title Unit World Bank Team Alaa Hamed Sr. Health Specialist MNSHH E. Gail Richardson Sr. Health Specialist OPCRX Dhekra Amin Annuzaili Health Operations Officer MNSHH Mira Hong Operations Officer MNSSP Nehad Kamel Health Planner (Consultant) Consultant Arine Valstar Nutrition Specialist (Consultant) Consultant Maggie Mohei Reproductive Health Specialist (Consultant) Consultant Wendy Ravano Public Health Specialist Consultant Irene Jilson Integration Expert Consultant David Freese Sr. Finance Officer CTRFC Renee M. Desclaux Sr. Finance Officer CTRFC Hyacinth Brown Sr. Finance Officer CTRFC Danielle Malek Roosa Sr. Counsel LEGEM Moad Alrubaidi Financial Management Specialist MNAFM Mikael Mengesha Senior Procurement Specialist MNAPR Shivendra Kumar Procurement Specialist (Consultant) MNAPR Kimie Tanabe Economist MNSHD Samia Al-Duaij Operations Officer MNSEN Fatou Fall Social Development Specialist MNSSO Afifa Alia Achsien Sr. Program Assistant MNSHD Safa’a Al-Sharif Program Assistant MNCYE Maha Assabalani Program Assistant MNCYE Renata Lukasiewicz Program Assistant MNSHD
Bank funds expended to date on project preparation Estimated approval and supervision costs: 1. Bank resources: US$421,382 1. Remaining costs to approval: US$60,000 2. Trust funds: US$83,194 2. Est. annual supervision cost: US$110,000 3. Total: US$504,576
103
Annex 12: References
Chandler, Rudolph. (2009), Yemen Immunization Tracking Study. Health Management Associates. (2007) Midwifery Licensure and Discipline Program in Washington State-Economic Costs and Benefits. Thuriau, M. C. (1971), Notes on the Epidemiology of Malaria in the Yemen Republic, Ann.Soc. Belg. Med. Trop., 51(2), 229-238. Suleman, M. (1999), Entomological Situation Related to Epidemiology of Malaria in Yemen. Assignment Report, 17 February - 15March, Who/EMRO. Ministry of Public Health and Population in Yemen. Public Health Expenditure Review, 2004-2007. Ministry of Public Health and Population in Yemen. PAPFAM Summary Report of the Yemen Family Health Survey 2003. The World Bank. (2007), Yemen Poverty Assessment vol.II: Annexes. The World Bank. (2009), Yemen Health Sector Review: Conceptual Framework and Strategy Options The World Bank (2009), Health Financing Modalities in Yemen. Possibilities for Results-Based Financing and Social Health Insurance The World Bank. (2010), Public Expenditure Review for the Health Sector 2009/10. (Draft under review) National Center for Biotechnology Information. http://www.ncbi.nlm.nih.gov. WHO EMRO. (2008) Country Profile. http://www.emro.who.int/emrinfo/index.asp?Ctry=yem. Al Serouri A.W. (2207). Development of M&E for Integrated Management of Childhood Illnesses (IMCI) in Yemen. PHCS, MoPHP. MOPHP (2000) Health Sector Reform in the Republic of Yemen: Strategy for Reform. Ministry of Public Health, Sana'a, Republic of Yemen. Ashworth A. and E. Ferguson 2009, Dietary Counseling in the Management of Moderate Malnourishment in Children. Food and Nutrition Bulletin, vol. 30, no. 3 © 2009 (supplement), The United Nations University. Briend A. and Z.W. Prinzo, 2009, Dietary Management of Moderate Malnutrition: Time for a Change. Food and Nutrition Bulletin, vol. 30, no. 3 © 2009 (supplement), The United Nations University. ENN, CIHD and ACF, 2010, MAMI Project Technical Review: Current Evidence, Policies, Practices & Programme Outcomes, January 2010 IFE Core Group, 2008, Discussion Paper on Infant and Young Child Feeding in Context of Moderate Malnutrition MOPHP, 2008, Guidelines for the Management of the Severely Malnourished in Yemen, Version 1, Oct. 2008 in Collaboration with UNICEF and WHO. Pee S.de and M.W. Bloem 2009, Current and Potential Role of Specially Formulated Foods and Food Supplements for Preventing Malnutrition among 6- to 23-month-old Children and for Treating Moderate Malnutrition among 6- to 59-month-old Children. Food and Nutrition Bulletin, vol. 30, no. 3 © 2009 (supplement), The United Nations University. Shoham J. and A. Duffield 2009, Proceedings of the World Health Organization/UNICEF/World Food Programme/United Nations High Commissioner for Refugees Consultation on the Management of Moderate Malnutrition in Children under 5 Years of Age. Food and Nutrition Bulletin, vol. 30, no. 3 © 2009 (supplement), The United Nations University. UNHCR/WFP, 2009, Guidelines for Selective Feeding, the Management of Malnutrition in Emergencies, May 2009 in Collaboration with SCN WHO, 2001 Iron Deficiency Anaemia Assessment, Prevention and Control, a Guide for Programme Managers.
104
Annex 13: Credits and Grants Yemen: Health and Population Project (Status as of November 8, 2010)
Expected and Actual Original Amount in US$ Million Project ID FY Project Name Disbursements a/ IDA Grant Cancel. Undisb. Orig. Frm Rev'd P005906 2001 Rural Water Supply & Sanitation 40 0.05 1.33 -21.22 -5.17 P070092 2002 Taiz Municipal Dev & Flood Protec 100.2 31.91 -30.41 2.84 P057602 2003 Urban Wtr Supply & Sanitation APL 130 4.74 34.83 18.92 6.74 P074413 2004 Groundwater & Soil Conserv Proj 55 7.78 -7.65 2.37 P082976 2004 Third Public Works 74.84 4.99 -26.05 -5.72 P076185 2005 Basic Education Development Program 65 14.71 11.70 5.41 P085231 2006 Second Rural Access 80 50.28 9.32 0.32 P086886 2006 Fisheries Res. Mngmnt & Conservation 25 18.18 10.51 P086865 2006 Power Sector 50 49.00 45.51 P089259 2007 Rainfed Agriculture And Livestock 20 11.41 6.50 2.34 P086308 2007 Second Vocational Training Project 15 14.62 7.31 5.67 P089761 2008 Sec. Educ. Dev. and Girls Access 20 18.97 6.24 6.24 P101453 2008 Institutional Reform Grant (DPL) 50.93 24.62 -1.53 P092211 2009 Rural Energy Access 25 26.16 1.57 P107037 2009 Water Sector Support 90 82.54 15.10 P110733 2010 Higher Education Quality Improvement 13 11.83 -1.37 P117608 2010 SWF Institutional Support Project 10 10.35 0.42 P107050 2010 Integrated Urban Development 22 21.96 P088435 2010 Port Cities Development II 35 35.37 1.18 P113102 2010 Schistosomiasis Control Project 25 19.13 -5.29 P103922 2010 GEF Agrobiodiversity and Adaptation 4 4.00 P117949 2010 Social Fund For Development IV 60 57.09 3.33 Total 1,005.97 4 4.79 551.06 44.09 21.02 a/ Intended disbursements to date minus actual disbursements to date as projected at appraisal
STATEMENT OF IFC’s Held and Disbursed Portfolio Country: Republic of Yemen (Status as of October 30, 2010)
COMMITTED (US $ M) OUTSTANDING (US$ M) Commitment Institution (FY) Loan Equity Quasi Guarantee ALL ALL Loan Equity Quasi Guarantee RM ALL ALL Cmtd-IFC Cmtd-IFC Cmtd-IFC Cmtd-IFC Cmtd-IFC Cmtd-Part Out-IFC Out-IFC Out-IFC Out-IFC Out-IFC Out-IFC Out-Part 1999 ACSM 0.95 0 0 0 0.95 0 0.95 0 0 0 0 0.95 0.00 2003 Ahlia Water 1.36 0 0 0 1.36 0 1.36 0 0 0 0 1.36 0.00 2007/ 2008 A YCC 66.20 0 0 0 66.20 46.44 66.20 0 0 0 0 66.20 46.44 2006 NCC Yemen 35.00 0 0 0 35.00 0 0 0 0 0 0 0 0.00 2007 S Y Healthcare 17.89 0 0 0 17.89 0 17.89 0 0 0 0 17.89 0.00 2007/2008/2009/ Saba Islamic Bank 0 0 0 0.96 0.96 0 0 0 0 0.96 0 0.96 0.00 2010/2011 2008 Al-Mawarid 8.00 0 0 0 8.00 0 8.00 0 0 0 0 8.00 0.00 2008 Magrabi Yemen 10.00 0 0 0 10.00 0 0 0 0 0 0 0 0.00 Total Portfolio 139.40 0.00 0 0.96 140.35 46.44 94.40 0.00 0 0.96 0 95.35 46.44
105
Annex 14: Country at a Glance
Yemen, Rep. at a glance 2/25/10
M. East Key Development Indicators & North Low Yemen Africa income Age distribution, 2008 (2008) Male Female
Population, mid-year (millions) 23.1 325 973 75-79 Surface area (thousand sq. km) 528 8,778 19,310 60-64 Population growth (%) 3.0 1.8 2.1 Urban population (% of total population) 31 57 29 45-49 30-34 GNI (Atlas method, US$ billions) 21.9 1,053 510 15-19 GNI per capita (Atlas method, US$) 950 3,242 524 GNI per capita (PPP, international $) 2,210 7,308 1,407 0-4
10 5 0 5 10 GDP growth (%) 3.9 5.8 6.4 percent of total population GDP per capita growth (%) 0.9 3.8 4.2
(most recent estimate, 2003–2008)
Poverty headcount ratio at $1.25 a day (PPP, %) 18 4 .. Under-5 mortality rate (per 1,000) Poverty headcount ratio at $2.00 a day (PPP, %) 47 17 .. Life expectancy at birth (years) 63 70 59 Infant mortality (per 1,000 live births) 55 32 78 150 Child malnutrition (% of children under 5) .. .. 28 120
Adult literacy, male (% of ages 15 and older) 77 82 72 90 Adult literacy, female (% of ages 15 and older) 40 65 55 60 Gross primary enrollment, male (% of age group) 100 109 102 Gross primary enrollment, female (% of age group) 74 104 95 30
Access to an improved water source (% of population) 66 88 67 0 Access to improved sanitation facilities (% of population) 46 74 38 1990 1995 2000 2007
Yemen, Rep. Middle East & North Africa
Net Aid Flows 1980 1990 2000 2008 a
(US$ millions) Net ODA and official aid 571 400 263 225 Growth of GDP and GDP per capita (%) Top 3 donors (in 2007): Germany 20 38 32 61 15
Netherlands 20 30 34 32 12 United Kingdom 9 10 5 25 9
Aid (% of GNI) .. 8.3 3.0 1.0 6 Aid per capita (US$) 68 32 14 10 3 0 Long-Term Economic Trends -3 95 05 Consumer prices (annual % change) .. 44.9 8.1 5.5 GDP implicit deflator (annual % change) .. 17.1 25.8 18.6 GDP GDP per capita
Exchange rate (annual average, local per US$) 4.6 26.2 161.7 199.7 Terms of trade index (2000 = 100) .. 80 100 157 1980–90 1990–2000 2000–08 (average annual growth %) Population, mid-year (millions) 8.4 12.3 18.2 23.1 3.8 3.9 3.0 GDP (US$ millions) .. 4,828 9,441 26,576 .. 6.0 3.9 (% of GDP) Agriculture .. 24.2 10.3 14.3 .. 5.6 .. Industry .. 26.8 46.5 40.3 .. 8.2 .. Manufacturing .. 9.3 5.2 4.7 .. 5.7 .. Services .. 49.0 43.2 45.4 .. 5.0 ..
Household final consumption expenditure .. 73.8 60.7 62.4 .. 2.8 .. General gov't final consumption expenditure .. 17.5 14.1 16.7 .. 1.7 .. Gross capital formation .. 14.6 19.5 24.4 .. 11.4 ..
Exports of goods and services .. 14.3 42.3 38.0 .. 16.6 .. Imports of goods and services .. 20.1 36.6 41.4 .. 8.3 .. Gross savings .. 45.1 33.6 21.9
Note: Figures in italics are for years other than those specified. 2008 data are preliminary. .. indicates data are not available. a. Aid data are for 2007. Development Economics, Development Data Group (DECDG).
106
Yemen, Rep.
Balance of Payments and Trade 2000 2008 Governance indicators, 2000 and 2008 (US$ millions) Total merchandise exports (fob) 3,797 6,624 Total merchandise imports (cif) 2,484 4,538 Voice and accountability Net trade in goods and services 540 1,214 Political stability Current account balance 1,266 709 as a % of GDP 13.4 4.2 Regulatory quality
Rule of law Workers' remittances and compensation of employees (receipts) 1,288 1,420 Control of corruption
Reserves, including gold 2,822 6,198 0 25 50 75 100
2008 Country's percentile rank (0-100) Central Government Finance higher values imply better ratings 2000 (% of GDP) Current revenue (including grants) 39.2 34.5 Source: Kaufmann-Kraay-Mastruzzi, World Bank Tax revenue 7.7 6.7 Current expenditure 25.8 28.3 Technology and Infrastructure 2000 2008 Overall surplus/deficit 8.0 -2.2 Paved roads (% of total) 15.5 8.7 Highest marginal tax rate (%) Fixed line and mobile phone Individual .. .. subscribers (per 100 people) 2 18 Corporate .. .. High technology exports (% of manufactured exports) 0.9 1.4 External Debt and Resource Flows Environment (US$ millions) Total debt outstanding and disbursed 5,125 6,258 Agricultural land (% of land area) 34 34 Total debt service 243 283 Forest area (% of land area) 1.0 1.0 Debt relief (HIPC, MDRI) – – Nationally protected areas (% of land area) .. 0.0
Total debt (% of GDP) 54.3 23.5 Freshwater resources per capita (cu. meters) 109 94 Total debt service (% of exports) 4.5 2.6 Freshwater withdrawal (billion cubic meters) 3.4 ..
Foreign direct investment (net inflows) 6 1,555 CO2 emissions per capita (mt) 0.80 0.96 Portfolio equity (net inflows) 0 0 GDP per unit of energy use (2005 PPP $ per kg of oil equivalent) 7.7 6.7 Composition of total external debt, 2008 Energy use per capita (kg of oil equivalent) 269 326 Short-term, 483 IBRD, 0 Private, 6
IDA, 2,113 World Bank Group portfolio 2000 2008
(US$ millions)
Bilateral, 2,637 IBRD IMF, 95 Total debt outstanding and disbursed 0 0 Disbursements 0 0 Other multi- Principal repayments 0 0 lateral, 924 Interest payments 0 0
US$ millions IDA Total debt outstanding and disbursed 1,216 2,113 Disbursements 65 108 Private Sector Development 2000 2008 Total debt service 23 55
Time required to start a business (days) – 13 IFC (fiscal year) Cost to start a business (% of GNI per capita) – 93.0 Total disbursed and outstanding portfolio 12 49 Time required to register property (days) – 19 of which IFC own account 12 49 Disbursements for IFC own account 8 21 Ranked as a major constraint to business 2000 2008 Portfolio sales, prepayments and (% of managers surveyed who agreed) repayments for IFC own account 0 1 n.a. .. .. n.a. .. .. MIGA Gross exposure – – Stock market capitalization (% of GDP) .. .. New guarantees – – Bank capital to asset ratio (%) .. ..
Note: Figures in italics are for years other than those specified. 2008 data are preliminary. 2/25/10 .. indicates data are not available. – indicates observation is not applicable. Development Economics, Development Data Group (DECDG).
107
46ºE 48ºE 50ºE 52ºE 54ºE This map was produced by the Map Design Unit of The World Bank. REPUBLIC OF The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any YEMEN endorsement or acceptance of such boundaries. 20ºN SELECTED CITIES AND TOWNS 20ºN GOVERNORATE CAPITALS REP. OF SAUDI ARABIA NATIONAL CAPITAL YEMEN RIVERS MAIN ROADS GOVERNORATE BOUNDARIES INTERNATIONAL BOUNDARIES OMAN 18ºN 42ºETo Abha 44ºE
SanawSanaw To Thamarit
HabarutHabarut ThamudThamud M SAADAHS A A D A H a h r To Mirbat SaadahSaadah n a t hu M k AL-A L - t a n s i M . ad AL-JOWFA L - J O W F W MAHRATM A H R AT ZamakhZamakh HADRAMOUTH A D R A M O U T Damqawt - adi Al Jiz Maydi HuthH¸ uth W AlAl HazmHazm ert es Wa Mar’aytMar’ayt Al Ghaydah W D di 16ºN HAJJAHHAJJAH AMRANAMRAN ad n Deser Ha 16ºN i Ja y dr wf ta AlAl GhurafGhuraf am 'a o Nishtun Al Luhayyah HajjahHajjah aab'atab ut S AmranAmran as HawraHawra llatat MARIBM A R I B am Salif AlAl MahwitMahwit MaribMarib R ShabwahShabwah AL- SANAASANAA t Qishn ao u MAHWIT SANA'ASANA'A SHABWAS H A B WA m Sayhut Red Sea a Al Hodeidah NuqubNuqub r Al Gabain HaribHarib d DHAMARDHAMAR a Shihr HODEIDAHDAHDAH (3199(3199 mm)) NisabNisab AtaqAtaq H RAIMHRAIMH DhamarDhamar RRidaida Al Mukalla
W bid AL-BEIDAAL-BEIDA adi Za 14ºN IBBI B B AL-AL- AlAl BeidaBeida AlAl HuwaymiHuwaymi 14ºN IbbIbb DHALE'EDHALE'E Bir Ali (3227(3227 mm)) AlAl Dhale'eDhale'e W TaizTaizTaiz a ABYANA B YA N d i B a
n Ahwar Mocha a TAIZTA I Z Shaqra AtAt TurbahTurbah ERITREA LahejLahej Zinjibar Gulf of Aden At LAHEJLAHEJ Turbah Aden Qalansiyah Qadub ETH. ADEN Socotra 'Abd al Kuri
) IBRD 33513R Samha Darsa E 0 50 100 150 Kilometers AT 12ºN DJIBOUTI R 12ºN ( The Brothers N O MAY 2009 H A D E R R A M O U T G O V 0 50 100 Miles SOMALIA 42ºE 44ºE 46ºE 48ºE 50ºE 52ºE 54ºE