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Health Care Services Document of The World Bank FOR OFFICIAL USE ONLY Public Disclosure Authorized Report No: PAD885 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON A PROPOSED GRANT Public Disclosure Authorized IN THE AMOUNT OF SDR 10.22 MILLION (US$15.79 MILLION EQUIVALENT) AND A PROPOSED GRANT IN THE AMOUNT OF US$5 MILLION FROM THE MULTI-DONOR TRUST FUND FOR HEALTH RESULTS INNOVATION Public Disclosure Authorized TO THE REPUBLIC OF CHAD FOR A MOTHER AND CHILD HEALTH SERVICES STRENGTHENING PROJECT May 6, 2014 Health, Nutrition and Population (AFTHW) Country Department West Africa (AFCW3) 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 March 31, 2014) Currency Unit = Franc CFA (FCFA) XAF 475.38 = US$1 US$1.55 = SDR 1 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AF Additional Financing AIDS Acquired Immuno-Deficiency Syndrome AFTEM Africa Region Financial Management Unit ANC Ante-Natal Care ARI Acute Respiratory Infection CAS Country Assistance Strategy CBO Community-based Organizations CFAF Central African Franc CHW Community Health Worker CPA Central Pharmaceutical Purchasing Agency CPA Complementary Package of Actions CPAR Country Procurement Assessment Report CPIA Country Policy and Institutional Assessment CPS Country Partnership Strategy CSO Civil Society Organization DALY Disability-Adjusted Life Year DHS Demographic and Health Survey DGRP General Directorate for Resources and Planning DOSS Directorate for Health Services Organization DPT Diphteria, pertussis (whooping cough), and tetanus vaccine DRF Division of Resources and Training (Ministry of Health) EA Environmental Assessment EEA External Evaluation Agency ECOSIT Enquête sur la consommation des ménages et le secteur informel au Tchad EA Environmental Assessment EU European Union FM Financial Management FMA Fiduciary Management Agency FMR Financial Management Report ii GDP Gross Domestic Product HDI Human Development Index HIPC Highly Indebted Poor Country HIV Human Immunodeficiency Virus HMIS Health Management Information System HPI Human Poverty Index HRITF Health Results Innovation Trust Fund IBRD International Bank for Reconstruction and Development ICB International Competitive Bidding ICT Information Communication Technologies IDA International Development Association IE Impact Evaluation IFAC International Federation of Accountants IFR Interim Financial Report IMF International Monetary Fund INSEED National Institute of Statistics, Economic and Demographic Studies IOI Intermediate Outcome Indicator ITN`` Insecticide Treated Net IPTM Intermittent Preventative Treatment of Malaria IPF Investment Project Financing ISN Interim Strategy Note IUD Intrauterine Device LLIN Long-Lasting Insecticide Treated Net MCH Maternal and Child Health MDG Millennium Development Goals M&E Monitoring and Evaluation MICS Multi-indicator cluster study (UNICEF) MoH Ministry of Public Health MoU Memorandum of Understanding MSP Ministry of Public Health MTR Mid-term Review MWMP Medical Waste Management Plan NCB National Competitive Bidding NDP National Development Plan NGO Non-Governmental Organization NPRS National Poverty Reduction Strategy NPV Net Present Value OI Outcome Indicator PACP Population and AIDS Control Project PAD Project Appraisal Document PBF Performance-based Financing PCT Project Coordination Team PDO Project Development Objective PETS Public Expenditure Tracking Survey PIM Project Implementation Manual PIU Project Implementation Unit PNDS National Heath Development Plan PPA Performance Purchasing Agency QEA Quality at Entry Assessment RBF Results-based Financing RZ Responsibility Zone iii SDR Standard Drawing Rights SECPO Board Operations SOE Statement of Expenditure SP Sulfadoxine-pyrimethamine THE Total Health Expenditure TFR Total Fertility Rate TOMPRO Dedicated accounting system UN United Nations UNDP United Nations Development Program UNFPA United Nations Population Fund UNICEF United Nations Children's Fund USD/US$ US Dollar WHO World Health Organization Regional Vice President: Makhtar Diop Country Director: Paul Noumba Um Acting Sector Director: Tawhid Nawaz Sector Manager: Trina S. Haque Task Team Leader: Aissatou Diack iv REPUBLIC OF CHAD Mother and Child Health Services Strengthening Project (P148052) TABLE OF CONTENTS Page I. STRATEGIC CONTEXT .................................................................................................1 A. Country Context ............................................................................................................ 1 B. Sectoral and Institutional Context ................................................................................. 1 C. Higher Level Objectives to which the Project Contributes .......................................... 5 II. PROJECT DEVELOPMENT OBJECTIVE ..................................................................6 A. PDO............................................................................................................................... 6 B. Project Beneficiaries ..................................................................................................... 7 C. PDO Level Results Indicators ....................................................................................... 7 III. PROJECT DESCRIPTION ..............................................................................................7 A. Project Components ...................................................................................................... 7 B. Project Financing ........................................................................................................ 11 C. Project Cost and Financing ......................................................................................... 12 D. Lessons Learned and Reflected in the Project Design ................................................ 12 IV. IMPLEMENTATION .....................................................................................................13 A. Institutional and Implementation Arrangements ........................................................ 13 B. Results Monitoring and Evaluation ............................................................................ 15 C. Sustainability............................................................................................................... 15 V. KEY RISKS AND MITIGATION MEASURES ..........................................................17 A. Risk Ratings Summary Table ..................................................................................... 17 B. Overall Risk Rating Explanation ................................................................................ 17 VI. APPRAISAL SUMMARY ..............................................................................................18 A. Economic and Financial Analysis ............................................................................... 18 B. Technical ..................................................................................................................... 19 C. Financial Management ................................................................................................ 20 D. Procurement ................................................................................................................ 22 v E. Social (including Safeguards) ..................................................................................... 23 F. Environment (including Safeguards) .......................................................................... 23 Annex 1: Results Framework and Monitoring...............................................................................25 Annex 2: Detailed Project Description ..........................................................................................30 Annex 3: Implementation Arrangements .......................................................................................44 Annex 4: Operational Risk Assessment Framework (ORAF) .......................................................60 Annex 5: Implementation Support Plan .........................................................................................64 Annex 6: Key Theories and Design Elements of Performance-based Financing ..........................68 Annex 7: 2011-2013 Chad Performance-based Financing Pilot Indicator List .............................71 Annex 8: Economic and financial analysis ....................................................................................74 Annex 9: Country Map ..................................................................................................................81 LIST OF DIAGRAMS Diagram 1: Funds flow diagram for IDA Grant ............................................................................50 LIST OF FIGURES Figure 1: Chadian women are exposed to the highest maternal mortality risk ................................2 Figure 2: Child mortality, Chad vs. sub-Saharan Africa .................................................................2 Figure 3: Coverage for assisted deliveries through PBF, October 2011 – March 2014 ................30 Figure 4: Chadian women are exposed to the highest maternal mortality risk amongst central African countries ...........................................................................................................31 Figure 5: Coverage for
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