Document of The World Bank Report No: 17399 GM PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 13.4 MILLION TO THE REPUBLIC OF THE GAMBIA FOR A PARTICIPATORY HEALTH, POPULATION AND NUTRITION PROJECT MARCH 2, 1998 Human Development 2 Country Department 14 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective as of March 2, 1998) Currency Unit = Dalasi DI = US$0.094 US$1 = D10.58 FISCAL YEAR January I to December 31 ABBREVIATIONS AND ACRONYMS ADB African Development Bank BHF Basic Health Facility BI Bamako Initiative CHN Community Health Nurse CPR Contraceptive Prevalence Rate DALY Disability Adjusted Life Year DHS Directorate of Health Services DSH Department of State for Health, Social Welfare and Women's Affairs EPI Expanded Program of Immunization FGM Female Genital Mutilation GRIPA Getting Research into Policy and Action IDB Islamic Development Bank IEC Information, Education and Communication IMCI Integrated Management of Childhood Illnesses IMR Infant Mortality Rate LIF Local Initiative Fund MCH Maternal Child Health MMR Maternal Mortality Ratio NHDP National Health Development Project PER Public Expenditure Review PHC Primary Health Care PIP Project Implementation Plan PIU Project Implementation Unit POM Project Operations Manual SEN State Enrolled Nurse SRN State Registered Nurse STI Sexually Transmitted Infection TBA Traditional Birth Attendant TFR Total Fertility Rate UNFPA United Nations Population Fund VHW Village Health Worker WFP World Food Program WHO World Health Organization Vice President: ............ Jean-Louis Sarbib Country Director: ............ Mahmood A. Ayub Sector Manager: ............ Nicholas Burnett Task Team Leader: .... ........ Richard Seifman Republic of The Gambia Participatory Health, Population and Nutrition Project TABLE OF CONTENTS Project Financing Data ...........................................................i A. Project Development Objective ...........................................................1 1. Project development objective and key performance indicators ......................................I B. Strategic Context ..........................................................l1 1. Sector-related CAS goal supported by the project ...........................................................1 2. Main sector issues and Government strategy ........................................................... 1 3. Sector issues to be addressed by the project and strategic choices ..................................2 C. Project Description Summary ...........................................................6 1. Project components ...........................................................6 2. Key policy and institutional reforms supported by the project ........................................7 3. Benefits and target population ...........................................................8 4. Institutional and implementation arrangements ........................................................... 8 D. Project Rationale .......................................................... 11 1. Project alternatives considered and reasons for rejection ................................... ............. I 1 2. Major related projects financed by the Bank and/or other development agencies .......................................................... 12 3. Lessons learned and reflected in the project design ......................................................... 14 4. Indications of borrower commitment and ownership ...................................................... 15 5. Value added of Bank support in this project ............................................. ............. l 6 E. Summary Project Analyses .......................................................... 16 1. Economic .......................................................... 16 2. Financial .......................................................... 17 3. Technical .......................................................... 18 4. Institutional .......................................................... 18 5. Social .......................................................... 19 6. Environmental assessment .......................................................... 19 7. Participatory approach .......................................................... 19 F. Sustainability and Risks ............................ 20 1. Sustainability ...................... 20 2. Critical risks ...................... 20 3. Possible controversial aspects ...................... 21 G. Main Credit Conditions ............................ 22 1. Negotiation conditions ...................... 22 2. Board condition .................. 22 3. Effectiveness conditions .................. 22 4. Other .................. 22 H. Readiness for Implementation ........................ 22 I. Compliance with Bank Policies ........................ 23 Annexes Annex 1 Project Design Summary Annex 2 Project Description Annex 3 Estimated Project Costs Annex 4 Economic Analysis Annex 5 Financial Summary Annex 6 Procurement and Disbursement Arrangements Table A Project Costs by Procurement Arrangements Table Al Consultant Selection Arrangements Table B Thresholds for Procurement Methods and Prior Review Table C Allocation of Credit Proceeds Annex 7 Project Processing Budget and Schedule Annex 8 Documents in the Project File Annex 9 Statement of Loans and Credits Annex 10 The Gambia at a Glance Annex 11 Detailed Project Design Summary Map of the Republic of The Gambia (IBRD - 22203) The Republic of The Gambia Participatory Health, Population and Nutrition Project Project Appraisal Document Africa Region Country Department 14 Date: March 2, 1998 Task Team Leader: Richard Seifman Country Director: Mahmood A. Ayub Sector Manager: Nicholas Burnett Project ID: GM-PE-825 Sector: Pop. Health & Nutrition Program Objective Category: Poverty Reduction Lending Instrument: Specific Investment Credit Program of Targeted Intervention: [X] Yes [ ] No Project Financing Data [] Loan [X] Credit [] Guarantee [] Other [Specify] For Loans/Credits/Others: Amount: (US$m/SDRm): 18.0/13.4 Proposed terms: [X] Multicurrency [ ] Single currency, specify Grace period (years): 10 [] Standard Variable [ ] Fixed [ LIBOR-based Years to maturity: 40 Commitment fee: 0.5% (presently waived) Service charge: 0.75% Financing Plan (US$m): Source Local Foreign Total Govermnent 1.6 0.3 1.9 IDA 7.6 10.4 18.0 Total 9.2 10.7 19.9 Borrower: The Republic of The Gambia Guarantor: NA Responsible agency(ies): Department of State for Health, Social Welfare and Women's Affairs Estimated disbursements (Calendar Year/US$M): 1998 1999 2000 2001 2002 2003 Annual 4.4 5.4 3.8 2.4 1.4 0.6 Cumulative 4.4 9.8 13.6 16.0 17.4 18.0 For Guarantees: [] Partial credit [ Partial risk Proposed coverage: Project sponsor: Nature of underlying financing: Terms of financing: Principal amount (US$) Final maturity Amortization profile Financing available without guarantee?: [ Yes [ No If yes, estimated cost or maturity: Estimated financing cost or maturity with guarantee: Project implementation period: 5 years Expected effectiveness date: June 30, 1998 Expected closing date: December 31, 2003 I Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 1 A: Project Development Objective 1. Project development objective and key performance indicators (see Annex 1): The overall project development objective is to improve family health in The Gambia. This is defined in The Gambia as a combination of reproductive health, infantlchild health and good nutritional status. Specific project objectives are improved quality of: (a) reproductive health services; (b) infant and child health services; (c) nutrition services for women of reproductive age, infants and children; and (d) management and implementation of a family health program. Progress toward these objectives would be principally measured through indicators on access to, and use and quality of family health services. B:: Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project (see Annex 1): Date of latest CAS discussion: January 1993 A CAS was presented to the Board in 1993, but was not fully implemented following the July 1994 military coup. The current interim Bank strategy for The Gambia was formulated upon the return to constitutional rule in January 1997, and preparation of a new CAS has begun in early 1998. The interim strategy supports continued emphasis on poverty alleviation through investments in the health and education sectors. The Participatory Health, Population and Nutrition Project will contribute to the strategy's objective of improving the quality of life for the Gambian population as an end in itself and as a means to the country's development of human resources. These are minimum requirements if The Gambia is to break out of a pattern of low-level economic equilibrium and achieve faster economic growth. Reduction of infant and maternal morbidity and mortality, along with primary education, are the principal means to achieve the goal of human resource development. 2. Main sector issues and Government strategy: The main sector issues include (a) the key health problems facing the Gambian population, (b) lirnited capacity of the health care sector, and (c) issues in other sectors. (A) The key health issues are (i) high maternal, infant, and child morbidity and mortality; (ii) high fertility rate; (iii) high prevalence of endemic diseases, particularly malaria, diarrheal diseases, acute respiratory infections, leprosy, tuberculosis, and sexually transmitted infections (STIs); and (iv) high prevalence of malnutrition among women of reproductive age and infants/children. The infant mortality rate was 80/1000 in 1995; under-five mortality rate 110/1000 in 1995; and maternal mortality ratio 1,050/100,000 in 1993. The total fertility rate (TFR) was 6.0 in 1993, while the contraceptive prevalence rate (CPR) among women is only 19.3% for all methods, and 14.3% for modern methods (latest provisional estimates). 20-30% of young children are chronically malnourished while the incidence of low birth weight is as high as 25% in rural areas. These figures represent, however, a substantial improvement compared to the period before the introduction of a Primary Health Care (PHC) program in 1978. Mortality had been as high as 213/1000 for infants in 1960 and 159/1000 in 1980, 375/1000 for under-five's in 1960 and 250/1000 in 1980. The maternal mortality ratio had been 2000/100,000 before the introduction of PHC, and the TFR was 6.5 in 1980. Low birthweight had been at 35% in 1980-82. The EPI program brought child immunization rates up to a high 88% for measles and 93% for DPT. Despite this progress, maternal and infant/child mortality and morbidity and fertility rates remain unacceptably high. Project Appraisal Document Project Title: Participatory Heafth, Population and Nutrition Project Country: The Gambia Page 2 (B) Further progress in reducing morbidity and mortality could be produced by better health care. However, the health care sector is constrained from substantially contributing to health status improvement because of the low quality of health services, and insufficient access provided to them. The access and quality problems of reproductive health, infant/child health and nutrition services are particularly harmful for women and infants/children. A major cause of these limitations is the underfunding of the health sector, particularly of the non-hospital sector, due to stagnating or declining public sector resources. This is exacerbated by less than optimal use of the limited financial, human, and technical resources in many key areas of health support services. The sub-optimal use of resources is caused by the limited capacity of the DSH to adequately plan, manage, coordinate, monitor, and evaluate services. An insufficient number of trained health providers further reduces the quality of health services. Public recurrent budget spending on health is $6.5 per capita, which - although better than in many countries in the region - is half the required resources for the essential package of health services estimated in the 1993 World Development Report for low income countries. The underfunding of recurrent expenditures for pharmaceuticals, supervision, training, transport and maintenance severely affects access to and quality of services. Public resource allocation is biased towards urban, tertiary care with nearly 50% of public resources provided to the two hospitals. Although the hospitals also provide important referral functions for primary and secondary health care, much of the resources is allocated to specialist services, which have less impact on national health outcomes. (C) The low health status of the Gambian population is strongly affected by factors outside the health care sector, predominantly by (i) limited access to safe drinking water and sanitation; (ii) low educational levels, especially among girls and women, which contributes to poor health-maintaining behavior; (iii) low income levels; (iv) lack of food security; (v) poorly developed and maintained roads, coupled with difficult terrain and lack of transport which impair access to health facilities; and(vi) poor environmental hygiene. Government Strategy: The Gambian Government strategies to address these issues are described in the following policy documents: "Health Policy 1994-2000: Improving Quality and Access", "The National Population Policy", "The Gambian National Drug Policy", "The Strategy for Poverty Alleviation", "National Poverty Alleviation Program", "Vision 2020 - The Gambia Incorporated". These policy documents aim to promote policies and programs which will lead to improved health status for all Gambians, primarily through the reduction of maternal, infant and child morbidity and mortality. To achieve improved access to and quality of health services, the Gambian Health Policy 1994-2000 envisages: (i) Integration of health delivery programs under the umbrella of family health (reproductive health, infant and child health, and nutrition); (ii) control of endemic diseases; (iii) health promotion and protection from chronic diseases; (iv) decentralization of health services management; (v) strengthening of the primary, secondary and tertiary levels of the health care pyramid; (vi) community participation in health promotion and disease prevention, as well as financing and management of health services; (vii) strengthening of cost-sharing mechanisms, i.e. the Bamako Initiative and Drug Revolving Fund; (viii) collaboration with the private sector; and (ix) human resource development. The Gambian health policy also recognizes the vital importance of cooperation with other sectors such as education, water, sanitation, agriculture, roads and other infrastructure. 3. Sector issues to be addressed by the project and strategic choices: Out of the many sector issues identified, the project will address reproductive health issues, child health, and nutrition issues as well as key implementation issues of public health care relevant for these areas. Health-impeding factors outside the health sector were excluded, as they fall within the domain of other Departments of State, will be addressed through other means, and would overstretch the project. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 3 The importance of individual health-maintaining behavior is, however, recognized by the project and reflected in the IEC support included in every component. The selection of these project components was driven by the desire to avoid duplication and to achieve complementarity with other ongoing or planned eflforts in the health sector. The specific selection is supported by worldwide research which shows strong and mutually reinforcing relationships between reproductive health, infant/child health and nutritional status. Poor health of pregnant women compromises the health of newborns, and a major contributing factor to poor maternal and infant health is lack of adequate nutrition and health care for mothers. The World Development Report 1993, "Investing in Health", found that family health services, as reflected in the strategic choice of this project, were among the most cost-effective interventions in terms of cost per disability-adjusted life year (DALY) gained. The reproductive health issues the project will address include: (i) high maternal mortality; (ii) low contraceptive prevalence rate, particularly for modern methods, high fertility rates and the presumed high number of unwanted pregnancies; and (iii) high rates of STIs and high potential for an increasing incidence of HIV. Although the data on maternal mortality in The Gambia are limited, a 1990 survey suggests that the leading causes of maternal deaths are eclampsia, sepsis, hemorrhage and anemia. Only 44 percent of births are attended by a health provider with midwifery skills. In addition, the rate of maternal mortality among women whose deliveries are attended by untrained TBAs or relatives is double that of women attended by trained TBAs. Almost half of all maternal deaths occur between one day to six weeks postpartum. Prenatal care attendance is inadequate with the majority of women having less than four prenatal visits. Most referral-level facilities lack the capacity for blood transfusions. Female genital mutilation (FGM), by which a significant number of Gambian women are affected, increases the risk of complications during childbirth. Anemia and malnutrition among women of reproductive age heavily contribute to maternal morbidity and mortality. These data underline the importance of improving the coverage, quality and utilization of prenatal, delivery and postpartum care as well as the need to reduce risk factors. Currently however, the number of midwives and trained TBAs is insufficient to provide full coverage of the rural population. The midwife and TBA training curricula are in need of revision to include life saving skills. In addition, pregnant women, their families and communities need to be educated about the importance of prenatal, delivery and postpartum care, proper nutrition, signs of complications, and appropriate actions to take. While ambulances are available at health facilities, appropriate means for communicating with them need to be identified and implemented. A substantial nuimber of women report dissatisfaction with maternal health services. The PHPNP will address these needs by improving the coverage and quality of obstetric services through revising pre- and in-service training curricula for relevant health workers, providing training, including for additional TBAs, implementing improved clinical practice and supervision guidelines, improving interpersonal communication skills of health staff, providing needed equipment and supplies, rehlabilitating dilapidated health facilities, introducing a blood supply system, strengthening postpartum care, and facilitating prompt identification, transport and treatment of emergencies. The demand for maternal health services will be increased through IEC to encourage women, their families and communities to seek care, and to educate them about danger signs of complications and actions which should be taken. User satisfaction will be measured in regular surveys, and their findings will be used to improve service quality. The project will address risk factors by supporting IEC of local NGOs on the hatmful effects of FGM and by providing iron supplements to health facilities and TBAs. The data situation on maternal mortality will be improved by support to maternal death audits. Despite 80 percent reporting knowledge of modern contraceptive methods, preliminary 1996 data indicate that only 14.3 percent of women of reproductive age use them. This indicates that the existing IEC strategies have been very successful in increasing knowledge, but not as successful in changing attitudes and practices. While contraceptive prevalence is increasing, research indicates that preference Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Page 4 for large families, religious beliefs, societal attitudes, health concerns, and male disapproval are barriers to use. Among women not wanting to become pregnant, partner disapproval is a leading reason for non- use. Data from the Royal Victoria Hospital show that incomplete abortion accounted for 34 percent of in- patient admissions to the gynecology ward (1995), suggesting that this may be a significant reproductive health problem. The low contraceptive prevalence is linked to the high fertility with a TFR of 6.0 in 1993 which constitutes a serious risk for women's reproductive health. The project will support efforts to improve women's health by reducing fertility through an increase in contraceptive use. To this end, the project will support IEC designed to increase the demand for modern contraceptives by affecting attitudes and motivating behavior change. Men and religious leaders will be included as target groups. Demand for as well as supply of contraceptives will also be increased through the introduction of a social marketing program. A 1994 rapid assessment of sexually transmitted infections (STI) found that 41 percent of women who attended prenatal clinics showed evidence of having had an STI, 25% had an active STI, and an HIV seroprevalence rate of about 2 percent (primarily transmitted through heterosexual contact). Knowledge of AIDS and condom use are lowest in the areas with highest STI prevalence. The high prevalence of STIs increases susceptibility to HIV and suggests high rates of sexual activity, which together with poor knowledge of AIDS and low condom use, set the stage for a rapid spread of HIV in the near future. In addition, both men and women tend to conceal their symptoms because of societal attitudes. The PHPNP will support community and facility-based IEC activities aimed at affecting knowledge, attitudes and behavior towards STIs and HIV, the development of pre- and in-service training curricula for the syndromic management of STIs, training for health providers and pharmacists as well as the development and implementation of protocols for syndromic management, prenatal screening for women and contact tracing of STI-positive clients. About 60% of childhood deaths are caused by malaria, acute respiratory infections and diarrhea. Malnutrition is a complicating factor for all childhood diseases, and many children have two or more diseases at the same time. Yet, diagnosis and treatment in health facilities is undertaken along the lines of vertical programs which take care of only one disease at a time. Moreover, there are hardly any systematic diagnostic assessment guidelines, and treatment protocols are unclear, if at all existent. This leads to an underrating of severe cases and often lethal delays in referrals by both VHWs and BHF staff. In cases of correct diagnosis, the absence of clear treatment protocols often results in an overprescription of drugs, leading, in turn, to drug shortages. These weaknesses are exacerbated by poor monitoring and supervision of staff, and clinical skills which in many cases require strengthening. Infants and children's health is also put at risk by lack of knowledge on behalf of their parents. They often do not know how important it is to give ORS during diarrhea, do not know the danger signs of diseases and when it is time to ask for professional help. If they decide to do so, they often lack the money for transport to the nearest health facility. Lack of knowledge also leads to wrong feeding practices as the majority of mothers do not exclusively breastfeed their infants during the first four months, but supplement with water, and thereafter give weaning foods which are too low in energy density. Things get worse during the busy rainy season when mothers work in the fields and leave their infants at home with older siblings who know even less about the right treatment of infants. The rainy season therefore sees an increase in malnutrition and diarrhea cases. The project will alleviate these problems through the introduction and implementation of the Integrated Management for Childhood Illnesses (IMCI) approach which will develop comprehensive diagnostic guidelines and treatment protocols for all childhood diseases of relevance in The Gambia, train health workers and VHWs in correct and integrated case management, and strengthen their monitoring and supervision. An IEC campaign will promote early help-seeking behavior of parents and educate them about danger signs. Other project components will complement these efforts through IEC on Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Count: The Gambia Page 5 conrect feeding practices, the social marketing of ORS and impregnated bednets against malaria, the opportunity, through the Local Initiative Fund, to organize and finance emergency transport and the construction of baby-friendly resthouses for working mothers, and the introduction of a blood supply system for severe cases of anemia. The poor nutritional status of women and of infants/children is a severe contributing factor to both poor reproductive health of women and poor infant/child health. Severe malnutrition is over 2 percent. Levels of moderate malnutrition, manifested in high rates of underweight, are high, particularly during the rainy season, as well as stunting among infants and young children, due to chronic malnutrition and frequent infections. There are acute protein malnutrition and several micro-nutrient defiiciencies. Malnutrition rates are highest in the rural areas, and girls and women are most vulnerable. Low birthweight is as high as 25% in rural areas. Food insecurity is an important factor for malnutrition in The Gambia, but most important is the low awareness of people about the correct nutrition. Many attempts to remedy the situation have had limited success which is due to capacity gaps and lack of coordination among the many initiatives undertaken. The project has, therefore, made several strategic choices. First, the project will promote an intersectoral approach to combat malnutrition. It will provide the policy basis for establishing inter-sectoral nutrition programs and the institutional coordination mechanisms and capacity to make them work. Second, it will focus on strategies and initiatives which raise awareness and the ability to address the determinants of malnutrition, including micronutrient deficiencies. A nutrition education approach for behavioral change in the improvement of matemal and chil]d nutrition related practices will be developed and promoted, along with community-based intervention programs. Third, it will utilize non-governmental as well as governmental expertise in carnying out nutrition programs. Fourth, it will invest in developing the basic data tools to permit sound judgments to be made in selecting interventions for the reduction of micronutrient deficiencies. In its first three components, the project will thus focus on quality enhancing investments in reproductive health services, infant/child health services and nutrition services. In order to make these investments effective, a number of cross-cutting and coordination issues need to be addressed. These issues will be dealt with under the project's fourth component. The cross-cutting issues concern the undlerfunding of the health sector and related issues, the shortage of trained staff, and the need for community participation to complement the supply of services. With a view to a long-tern solution to the underfunding of the health care sector, the project will support the development of a national health care financing policy which will be based on the ongoing Public Expenditure Review (PER), and which should define the roles of the public, private, and NGO sectors. In addition, the financing of phairmaceuticals and medical supplies will be addressed through the expansion of the Bamako Initiative, the up-dating of a national drug action program and the elaboration of programs for the rational use of drugs to avoid wastage. The performance of health budget allocations will be monitored through a financial management system which will be developed and installed under the project. This will be part of a comprehensive Health Management Information System (HMIS) which will strengthen the DSH's planning and management capacities leading to a more efficient allocation and use of scarce resources. This will also be supported by the definition of norms and standards and the definition of "minimum packages of services" under a health mapping exercise. Support to an initiative to make research more relevant to health programs will also lead to improvements in effectiveness and efficiency. The development and implementation of a maintenance policy will define the increase of resources allocated to maintenance, and improve the efficiency of maintenance expenditures by out-contracting the execution of imaintenance activities to the private sector. To increase efficiency, the management of the project's civil works will also be delegated to a non-Government entity. The lack of trained personnel will be addressed through the development and implementation of training programs in all family health areas supported by the project. Further, a long-term strategy for Project Appraisal Document Project Title: Participatory Health, Population and Nutriton Project Country: The Gambia Page 6 staff retention will be elaborated to address the problems of low staff motivation and retention, and poor coaching and supervision of staff. All these measures will improve the quality of health services, yet to be translated into better health status, the supply of quality services needs to be complemented by appropriate support from individuals and communities. A paramount factor is the adoption of behavior patterns which are conducive to avoiding the contraction of diseases, to apply simple measures to remedy diseases, and to seek professional help for the treatment of severe diseases in a timely manner. The required behavior change is supported through extensive IEC activities in all components. Often, however, external factors like lack of transportation or lack of access to key nutrients are barriers to effective behavior change. The project will therefore support communities in overcoming such obstacles by providing micro-funding of supplemental mini-projects at the grassroots level through a Local Initiative Fund (LIF). The expansion of the Bamako Initiative will further empower communities to participate in the management of health services and to generate funds for the replenishment of drugs. Finally, the implementation of the project requires effective project management and coordination of activities. Training, monitoring and evaluation, IEC and operational research are activities which are a crucial element to all of the first three project components. They require careful coordination to avoid duplication and contradictions. This coordination and project management will be supported in the project's fourth component. C: Project Description Summary 1. Project components (see Annex 2for a detailed description and Annex 3for a detailed cost breakdown): Component Category Cost Incl. % of Bank- % of Contingencies Total financing Bank- (US$M) (US$M) financing A. Reproductive Health Services: Institution 4.7 23.7 4.4 24.5 This component supports (i) the Building / improvement of maternal health Other services; (ii) the prevention of unwanted pregnancies; and (iii) STIAIIV prevention and control. B. Integrated Management of Institution 0.9 4.5 0.8 4.4 Childhood Illnesses: Building/ This component supports the Other integration of vertical programs to combat childhood diseases through the introduction and implementation of the "Integrated Management of Childhood Illnesses" (IMCI) approach. C. Nutrition Policy and Services for Institution 2.3 11.5 2.1 11.7 Women, Infants and Children: Building / This component supports (i) Other nutrition policy formulation and institutional strengthening; as well as (ii) community and micronutrient approaches to improve the Projiact Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 7 nutritional status of women and young children. D. Management and Institution 10.7 53.8 9.4 52.3 Implementation of a Family Health Building / Program: Policy / This component supports: (i) Physical/ capacity building and policy Project development; (ii) up-grading and Management maintaining health infrastructure; (iii) a Local Initiative Fund; and (iv) project management. Under (i) capacity will be built, inter alia, in the areas of (a) cost recovery through the expansion of the Bamako Initiative, (b) IEC (information, education and communication), (c) monitoring and evaluation through the establishment of financial and health information systems, and (d) research application. The upgrading and maintaining of health infrastructure under (ii) includes the rehabilitation of selected PHC facilities, the establishment of a blood supply system, procurement of equipment and maintenance support. PPF 0.8 4.0 0.8 4.4 Unalllocated 0.5 2.5 0.5 2.7 Total 19.9 100 18.0 100 2. Key policy and institutional reforms supported by the project: The project includes support to on-going health reform efforts aiming at higher quality of service delivery and at increasing the participation of individuals and communities in health maintaining efforts. In order to create an enabling environment for the achievement of these reform objectives, the project will support key policy reforms in the areas of health financing, health mapping for the definition of "minimum packages of services", integration of health services, staff retention, maintenance, nutrition, dnrg management, and application of research. Given the status of, and wide range of policy matters to be addressed, it was determined that progress would be reviewed annually, with benchmarks established initially at the first annual review. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 8 Support to institutional reforms that will result in higher service delivery and a more active participation of the population includes: the development of a comprehensive health management information system, the revision of training curricula, the development of new clinical practice guidelines, the extensive technical and communication skills training for health sector staff and community health workers, staff and client surveys, the extensive IEC program, the expansion of the Bamako Initiative and support to the Local Initiative Fund - both initiatives which involve grassroots communities -, and a strong involvement of the private sector. Institutional reforms in the latter area include strengthening the cooperation between the Government and NGOs as well as private non-profit research institutes in the areas of nutrition, research and blood supply. A further institutional novelty is that the capacities of the private sector will be tapped for the management of civil works contracts, for the execution of maintenance activities and for the implementation of the social marketing program. 3. Benefits and target population: The following benefits are expected from the project: (a) Improved quality of life for women of reproductive age, infants and children through better health; (b) improved quality of and access to health services in the areas of reproductive health, infant and child health, and nutrition; (c) reduction in the total fertility rate; (d) decreased prevalence of STIs; (e) increased institutional capacity for more effective and efficient management and implementation of family health programs; (f) long-term policies in the areas of health sector financing, drugs, maintenance, nutrition and staff development; (g) sector-wide financial management and health information systems; (h) greater sustainability of investments through improved maintenance; (i) greater participation of the population in health care through IEC and their involvement in the Bamako Initiative and a Local Initiative Fund; and (k) stronger linkages to the private sector. The project is targeted to the 84 percent of the Gambian population living in rural and peri-urban areas, with particular emphasis being placed on women of reproductive age and children under 5. A recently completed analysis of the 1993 Household Economic Survey prepared by the Gambian Central Statistics Department found that about 33 percent of the population is poor. Poverty increases with distance from the Greater Banjul Area, and is most prevalent in rural areas. However, migration of the rural population to peri-urban areas in recent years, particularly to the Greater Banjul area, has increased poverty there and placed increasing demands on existing health services. By focusing investments on health and nutrition services for women and children, the project will contribute to poverty reduction by improving women's health, and consequently, their energy which is available for productive work. It will also contribute to increasing women's control over their lives by providing them with greater means for choosing when and how many children to have. As this project focuses on the rural and peri-urban population and on women, who represent a disproportionate share of the poor, it meets the criteria for inclusion in the Program of Targeted Interventions (PTI). 4. Institutional and implementation arrangements: Implementation Period: 5 years; FY99-2003 Institutional Arrangements: The Department of State for Health (DSH) will be the lead agency heading project execution. While the DSH will have overall responsibility for the entire project, it will look to appropriate entities, both within the Government and outside, to implement components. The Central Management Committee (CMC) which is the top coordination mechanism of the DSH is the main instrument for overall donor coordination in the health sector. Implementation Arrangements: The implementation mechanism will consist of (i) a Project Coordination Committee (PCC) to provide overall guidance to the project, (ii) a Project Implementation Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 9 Unit (PIU) responsible for the day-to-day management of the project, (iii) the implementors of project components, and (iv) a PHPNP Action Group comprised of those most directly involved in the implementation of project components. The responsibilities of each of these actors will be spelt out in detail in the Project Operations Manual (POM). The following shall serve as an overview. (i) Senior inter-sectoral guidance to the project and to family health in general will be provided by the PCC in which the Office of the President (National Population Commission Secretariat) and the Departments of State for Health (DSH), Local Government and Lands (DSLGL), and Finance and Economic Affairs (DSFE) will be represented. On behalf of the CMC, the PCC will ensure donor coordination and give direction to all family health programs in The Gambia by setting priorities and appraising and deciding on any new initiatives like major research, workshop or program proposals. The PCC and IDA will conduct annual IDA project reviews, to the extent possible together with other donors in the family health field. These annual reviews will analyze the progress of project activities in light of the performance indicators, and agree on forthcoming annual work plans and budgets. It will approve the Project Operations Manual (POM) and the Project Implementation Plan (PIP), to be submitted to IDA as credit conditions, as well as their possible revisions during the annual reviews. Once approved, the PIU, which will also act as Secretariat to the PCC, will manage the actual implementation process thereafter. (ii) The PIU will be the implementing unit for the PHPNP, the ADB and IDB health projects. It will be headed by a project manager, supported by two deputy project managers (one supported under the project, the other by the ADB), a financial controller, a procurement officer (financed by the project), two accountants (shared by the project and the ADB) and an architect (financed by the ADB). A senior health, population and nutrition advisor will ensure program content quality for the PHPNP. The PIU will have necessary support staff and offices to carry out its functions, financed by the Government. The IDB will contribute to the operating costs of the PIU. The PIU will supervise (a) aNutrition Coordinator located in the Office of the Director of Health Services until such time as the national nutrition policy determines her/his permanent location, (b) an IEC Coordinator located in the DSH Health Education Unit, and (c) a Bamako Initiative Coordinator located in the Directorate of Planning and Information. PIU management will be physically located in the DSH and will be in regular and frequent contact with the DSH Directorates and DSH line units. The PIU will be responsible for the management and coordination of project implementation, including: (i) the management of projects funds (Government's counterpart account and IDA and ADB Special Accounts); (ii) installation and maintenance of sound financing and accounting procedures for all funds; (iii) providing audit reports about PHPNP funds to the Government and IDA; (iv) all procurement activities including convention with GAMWORKS for IDA financed civil-works, and procurement of goods and services in accordance with World Bank procedures for IDA financed contracts, and other donors' procedures for their respective funds; (v) reporting on project activities to the Government and IDA for PHPNP activities (as well as to other donors for related activities); (vi) organizing the annual reviews (as well as review of other projects managed by the PIU); (vii) ensuring the coordination of all training activities; and (viii) coordinating all monitoring and evaluation activities, and compiling all results in comprehensive progress reports with indicators to be revised during the annual reviews. The PIU will look to the DSH Directorate of Planning and Information for the overall planning of health facilities, human resource information, health information, financial information and monitoring and evaluation related to health indicator performance, and to the DSH Directorate of Support Services for maintenance management. (iii) The actual implementation of project components will be the responsibility of DSH line unit managers, with the exception of the Local Initiative Fund (LIF) which will be managed by the Directorate of Community Development (DCD) within the DSLGL, and of the civil works component. The Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Page 10 management of construction, rehabilitation and maintenance activities of civil works will be delegated by the DSH to GAMWORKS, a local AGETIP-like Construction Management Agency, under an agreement to be signed by both parties. Under the project, the DSH will shift from undertaking maintenance activities itself, and move towards out-contracting maintenance to the private sector. Divisional Health Teams (DHTs), which are the DSH's representation at the divisional level responsible for managing the delivery of rural health services, will be key in the implementation of the project. The latter will be regularly reviewed during by-monthly DHT/Action Group meetings. DHTs will also be part to the development of the Health Management Information System and in the monitoring and evaluation of project activities. Project implementation will also involve cooperation with local NGOs. In the nutrition component, the Gambia Food and Nutrition Association (GAFNA) will be contracted for food supplementation programs. The Gambia Blood Association (GAMBLOOD) will be used for blood donor mobilization. The Medical Research Council (MRC), a private non-profit research institute will cooperate with the Government in performing family health relevant research. (iv) The interface between this implementation level and the PIU is the PHPNP Action Group, chaired by the PIU manager. The Action Group will be comprised of the key players implementing the project, including the Director of Health Services (DHS) and designated unit heads, the Director of Planning and Information (DPI), the Director of Support Services (DSS), the Chief Nursing Officer, the Nutrition Coordinator, the IEC Coordinator, the Bamako Initiative Coordinator, and the Director of Community Development. The Group will ensure the operational effectiveness of the project, including component coordination and collaboration, identifying problems and solutions, information sharing, providing progress reports and monitoring information, and preparing draft work plans and budgets. Financial Management Arrangements. The PIU in the DSH will implement and maintain adequate financial management systems - including accounting, financial reporting and auditing - to ensure that adequate and timely information with respect to project resources and expenditures is available. Financial management arrangements will include: (i) accounting based on project Chart of Accounts to group/classify expenditures by project components/activities, disbursement categories and sources of funds, and appropriate reporting formats; (ii) arrangements for recording monitorable physical and other indicators for comparison with related costs; (iii) procurement contract management information; and (iv) internal control arrangements to ensure proper segregation of duties, documented procedures for authorizations, levels of supervision, etc. Accounting. The PIU will be responsible for the preparation of the financial statements every year including the Special Account (SA) and Statements of Expenditures (SOEs). The existing accounting capacity of the PIU will be reinforced by the recruitment of a financial controller who will be assisted by two accountants (one for IDA funds, one for other donors' funds). A Special Account (SA) for the IDA credit will be opened and maintained at the Central Bank of The Gambia, managed by the project manager and the financial controller. The appointment of the financial controller and accountant, the installation and operation (including training) of a computerized accounting software, and the submission of an Accounting Procedure Manual acceptable to IDA will be conditions of effectiveness of the IDA credit. Auditing. A review of IDA financed projects carried out in the country in 1997 revealed a widespread project weakness to timely submit audit reports. An independent auditor acceptable to IDA will be recruited with an annual contract tacitly renewable on a yearly basis. Auditors will audit the use of IDA funds applied in financing the project including the IDA special account and SOEs. As the PIU is also managing other donors' funds, the audit will cover the management of all funds. During negotiations, the Standard IDA auditor's terms of reference, modified to reflect the need for the auditor to review overall internal PIU financial management, were agreed upon with IDA, and the Government Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 1I gave assurances that the PIU will submit audit reports no later than six months after the end of the fiscal year. The appointment of the auditor will be a condition of effectiveness of the IDA credit. Reporting. The PIU will be responsible to submit: (i) a half-yearly project progress report; (ii) a yearly progress report, workplan and budget for the following year, 4 weeks before the annual joint project review, and at the latest before each September 30; (iii) a detailed progress report including technical and financial aspects, 4 weeks before the joint mid-term review of the project; and (iv) a project completion report 3 months before the project closing date. Monitoring and Evaluation. Under the overall guidance of the PCC, the monitoring and evaluation of the project will be the shared responsibility of the DSH directorates, with the particular involvement of the DPI and the PIU. M&E activities will extensively use the integrated computerized monitoring and information systems (for health, financial, and maintenance data) to be set up under the project and will provide information to all DSH managers including the PIU. Key data produced by this integrated MIS will be included by the PIU in the above mentioned progress reports. D: Project Rationale 1. Project alternatives considered and reasonsfor rejection: Five project alternatives have been considered and rejected during a December 1996 ZOPP Planning Workshop and in the course of project preparation: Alternative 1: The predecessor of the project under preparation was the National Health Development Project (NHDP) which was a comprehensive sector-wide investment and reform project, coimpleted in June 1995. One option would be to develop a successor NHDP II sector investment project, covering all areas of the health care sector, including hospitals and urban areas. This approach was ap]propriate when many donors were involved in The Gambia and could have joined in a sector-wide operation. However, following the 1994 coup, there was a decline in donor involvement and a hiatus in the development of new projects. Now, some donors are coming back, but as commitments have in many instances not yet been made, it is too early for a sector-wide approach, and a more targeted investment in primary and secondary health is warranted, at this point in time. Alternative 2: A related alternative would be to wait with a new health project until other donors have firmly come back on board, and to then design the project as a sector investment project (SIP). This, however, would entail delaying project preparation until after the Public Expenditure Review (PER) has been completed as the PER is a pre-condition for support of some donors. After PER completion, its results would need to be discussed among Government and donors before a basic project concept could be developed. Given the long absence of donor assistance and the negative implications such a gap has for the provision of health services, further postponement of Bank assistance is not justified. However, the proposed project, has been formulated in a flexible manner so that the results of the PER and developments in other donors' assistance can be accommodated. As such it can be considered a "SIP in progress". Alternative 3: Another option for a targeted investment operation would be to address those illnesses responsible for the major share of morbidity and mortality of all population groups in The Gambia. Morbidity is largely due to malaria, acute respiratory infections, intestinal tract infections and skin disorders, while the principal causes of mortality are: (a) infectious and parasitic diseases (20.2%); (b) acute respiratory infections (13.6%); (c) circulatory system disorders (11.0%); (d) blood and blood- related problems (9.6%); and (e) digestive disorders (8.0%). This alternative was rejected for two reasons: Endemic disease control is being supported by other donors. Further, focusing on the most vulnerable groups of Gambian society - infants, small children and women of reproductive age, whose Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 12 health problems substantially overlap with the above diseases - is a more effective targeting approach in the context of human resource development than focusing on distinctive groups of diseases. Alternative 4: Another approach would be to rely extensively on the private sector to provide family health services. However, the capacity of the private sector is weak, and it provides services largely to the urban and relatively well-off population groups. Project support for private-sector provision of family health services to the poor population groups is therefore not a realistic option at this time. However, the project supports institutional reforms to strengthen the cooperation between Government and the private sector in those areas where the latter does have comparative advantages relevant to primary health care targeted at poor population groups. The management of civil works, the execution of maintenance activities, and the implementation of the social marketing program will be delegated to the private sector. Further, the project includes activities which depend upon private financing of services (through cost recovery in the Bamako Initiative and the social marketing of contraceptives). Finally, the project will be cooperating extensively with NGOs, such as GAFNA for nutrition and the Gambia Blood Association (GAMBLOOD) for blood donors supply, as well as with non-profit research and other non-public institutions. Alternative 5: A fifth alternative would be not to address the health care sector at all, and instead to improve living conditions (e.g. water and sanitation, inc6me-generation, agriculture) and to focus on activities to improve individual health-maintaining behavior (e.g. through girls' education). This option was rejected because it is in part already addressed, or will be, by other projects, and because the health issues targeted in this project rely extensively on medical care. For example, improved maternal health services are a key factor in reducing maternal mortality by dealing with complications during delivery, and many of the major childhood illnesses require an early detection through a health professional and adequate medical treatment. It is, however, understood that strong coordination with other relevant sectors will be sought. In addition, the project includes IEC activities in all project components to improve individual health behavior, and the Local Initiative Fund to improve living conditions. 2 Major related projects financed by the Bank and/or other development agencies (completed, ongoing andplanned): Sector issue Project Latest Supervision (Form 590) Ratings (Bank-financed projects only) Implementation Development Progress (IP) Objective (DO) Bank-financed Health System National Health U U Development Project, (ICR) (ICR) Cr. 1760; effective: FY88 closing: FY95 Gender Issues Women in Development S S Project, Cr. 2141; (ICR Draft) effective: FY90 closing: FY98 Other development agencies Support to National Health Netherlands, Italy and Development Program DFID (completed) (NHDP) Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Counitry: The Gambia Page 13 Support to Women in Norway Development Project (completed) Gambian German Family GTZ Planning Project (ongoing) Health Training Facilities ADB (ongoing) Technical Assistance for DFID (ongoing) Public Expenditure Review Health Services Development ADB (approved) Project Social Development Fund ADB (ongoing) Health Information Systems WHO (completed) Strategy Study Accelerated Malaria Program WHO, UNICEF (ongoing) Bamako Initiative UNICEF (ongoing) EP][ Vaccine Program/New UNICEF, EU (planned) Vaccine Initiative Population Country Program UNFPA (approved) Rapid Assessment of WFP (planned) Institution-Based Feeding Programs for Children National Poverty Alleviation UNDP (ongoffg) Prcigram Support to Secondary and IDB (ongoing) Tertiary Health Facilities IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory) The PHPNP has been designed to complement and build upon efforts undertaken by other'donors in ifamily health. DFID has been supporting the on-going Public Expenditure Review which will be an important basis for the health financing policy to be developed under the project. The ADB has recently approved a Health Services Development Project which will strengthen the management capacity of Divisional Health Teams, restructure and develop the Directorate of Planning and Information in the DSH, develop and introduce a Human Resources Information System (HRIS), support logistics for drug distribution, rehabilitate or construct and equip Central Medical Stores, the public health laboratory, five health centers and one dispensary. The civil works will be carefully coordinated among the two projects Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 14 which is facilitated by the fact that the ADB will house an architect within the PIU. All other project activities will have a mutually reinforcing effect in the areas of decentralized service delivery and management, planning and information, drug management, staff development, and the introduction of an integrated Health Management Information System (HMIS) of which the HRIS will form an important part. In supporting the development of a comprehensive HMIS, the project will also build upon the WHO supported information systems strategy study. WHO and UNICEF are addressing one of the major causes of morbidity and mortality in the country by supporting the "Accelerated Malaria Program". The PHPNP will support this program by including bednet dipping insecticides in social marketing. WHO's collaboration is further indicated for introducing IMCI in The Gambia and for the development of a staff retention strategy. Strong cooperation with UNICEF will be sought in the expansion of the Bamako Initiative which may be jointly supported by UNICEF, WHO and the project. UNICEF's recent provision of 20 ambulances to health centers will facilitate emergency referrals, e.g. of women with obstetric complications or of severely sick children. UNICEF will also continue its support to the EPI vaccine program, at some level. The EU has indicated that it will finance a new vaccine initiative. UNFPA has recently approved a new 5-year country program. The program will provide support in reproductive health and advocacy, as well as contraceptives for the public health sector. UNFPA's procurement capacity in contraceptives will be utilized for the project. WFP's plans to assess child feeding programs complements project activities in assessing maternal food supplement programs. As part of the National Poverty Alleviation Program, UNDP is providing support in STI/HIV prevention and control. This will be closely coordinated with the project's reproductive health component. The Islamic Development Bank supports the secondary and tertiary levels whose strengthening is an important complement of the Primary Health Care Strategy. 3. Lessons learned and reflected in the project design: The PHPNP design benefits from lessons learned during the National Health Development Project, which was completed in June 1995. Major lessons to be learned from the NHDP experience, which are incorporated into the PHPNP, include: (a) Adequate lead time needs to be given for formal approval of policy decisions and these will be incorporated into the time schedules of the final project implementation plan. (b) Key policy decisions need to be reinforced in the Development Credit Agreement to avoid losing leverage to promote such decision-making. A key policy issue is the elaboration and approval of a national nutrition policy which is an important carry-over from commitments made already under the NHDP. Therefore, the provision of a nutrition policy framework was made a condition of negotiations. In addition, the approval of the full-fledged nutrition policy will be a condition of disbursement for all disbursements, starting in calendar year 2000. (c) The risk of ineffectiveness of interministerial coordination committees established under the former NHDP approach has been taken into account. The interministerial Project Coordination Committee (PCC) created for project preparation and oversight tries to avoid this risk by having members who, unlike in the case of the NHDP, are stakeholders in the project. (d) The importance of having a project implementation unit (PIU) within the DSH which is capable of serving as a channel for donor funding and coordination is taken into account by the creation of the PIU with said functions and capacities. Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Page 15 (e) The shortcomings of the NHDP with regard to project management will be avoided by adequately staffing the PIU with a manager and deputy manager, qualified accountants and procurement staff, as well as technical and support staff as needed. All PIU administrative staff will undergo relevant training, and accounting and financial management systems will be put in place. (f) The NHDP underscored the importance of an early involvement of stakeholders, service providers, NGOs, and key donors into project design and preparation. Emphasis has therefore been given to the client consultation process. This emphasis is reflected in the December 1996 participatory planning ZOPP workshop in which DSH officials, service providers, NGOs and key donors collaborated in the formulation of the current project design as well as active Gambian participation in the drafting of the PCD and PAD. (g) Based on the experience with the NHDP where the lack of qualified human resources, especially of nurses and community-based health providers, became a major impediment to implementation, the PHPNP includes extensive training activities and curricula revision. Support to a staflf retention strategy shall further address personnel bottlenecks. In addition, project design takes into account experience gained under the Women-in- Development Project (WID) by incorporating elements from successful WID interventions, such as the bab,y-friendly rest houses and the baby-friendly community initiative to improve maternal and infant nutrition. Further approaches similar to those utilized by the Kabilo project with respect to the identification and referral of pregnancy-related complications, and the project to solicit Imam support for family planning, will be included. Finally, project design will be kept flexible enough to accommodate reccommendations following from the Public Expenditure Review. 4. Indications of borrower commitment and ownership: The health sector has been high on the Government's agenda even after the 1994 coup. The health sector's share of the national recurrent budget is approximately 6%, and in terms of human resources, health service employees represent the second largest group of the civil service (23%). With respect to the proposed project, in December 1996, Government decision-makers participated in a five- day ZOPP planning workshop. The Secretary of State for Health, who is also Vice President of The Gambia, and the DSH Permanent Secretary have been directly engaged in on-going project design discussions. The DSH has held its own workshops to further advance project preparation, under the direction of a Project Coordinating Committee (PCC) that has been established to oversee project preparation and, thereafter, management and implementation. A Project Implementation Unit (PIU) has also, been established and actively manages the preparation process which already includes the drafting of temis of reference for first-year consultancies under the project as well as the elaboration of the Project Operations Manual, Project Implementation Plan and LIF Implementation Manual. In its document "Government of The Gambia's Presentation of the Participatory Health, Population and Nutrition Project and its Commitments", the Government describes a program of actions, objectives and policies designed to improve the quality and access to health services in The Gambia. It identifies a number of specific commitments it will make to the project. These include commitments to: a) a national nutrition policy framework, with the Vice President to chair a National Nutrition Policy Council; b) the family health approach; c) preparation of a sustainable health financing policy; d) out- sourcing of new construction, rehabilitation and maintenance of facilities, vehicles, and biomedical equipment; e) a public sector health maintenance budget which in 5 years represents at least 1% of the value of the capital infrastructure and 2% of the value of vehicles and equipment (with a goal in 10 years Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Page 16 of 2% and 4%, respectively); f) a management decentralization approach which results in greater decision-making at Divisional level, including control of recurrent and maintenance expenditures; g) community-based activities to address family health; h) improved donor coordination through annual reviews; i) maintaining and possibly increasing per capita expenditures on health to recommended minimum levels consistent with Public Expenditure Review recommendations and emphasis on basic health services. Prior to Board presentation, the Government submitted the above-mentioned document as an attachment to a signed letter to IDA, in which it (i) declares the Government's commitment to the execution of the project; (ii) requests IDA's assistance in the financing of the project; (iii) gives assurances that (a) adequate financing for primary and secondary health care will be provided in line with recommendations following from the health Public Expenditure Review, which will be a subject of discussion at the annual reviews, and (b) about the funds to be made available through the health sector budget during and after the execution of the project in amounts sufficient to cover the Government counterpart contribution during project execution and the project's sustenance thereafter; and (iv) also gives assurances that (a) a separate budget for "maintenance" will be maintained, independent from budgets for "operating costs"; (b) the maintenance budget will be progressively increased as described in the Project Appraisal Document; (c) the main maintenance activities will be out-contracted to private firms. s. Value added of Bank support in this project: The Government considers its experience with the completed, first Bank-supported health project in The Gambia - the NHDP - as a valuable basis on which to base the sector's next phase of development. After an extended period of absence of most donors, the Bank is seen as a catalyst and a way to leverage involvement of other donors, and as providing the basis for creating a multi-donor forum for effective coordination of all support received for the health sector. The Bank's experience in addressing policy and institutional reforms, particularly in the areas of health financing and private sector involvement, provides it with a comparative advantage to support Government's reform efforts as described in section C.2. The Bank is seen as a crucial contributor to quality improvement, accountability, transparency and more effective utilization of limited Gambian and external resources in health. The establishment of the Project Implementation Unit within the DSH, particularly when combined with ADB project management, will be a means to improve operational management and procedures throughout the DSH, and to facilitate the channeling of future assistance from other donors to the health sector. E: Summary Project Analyses (Detailed assessments are in the project file, see Annex 8) 1. Economic Analysis (supported by Annex 4): ERR= NA [X] Cost Effectiveness Analysis: [X] Other The project's support to public health services, i.e. the public financing and provision of health services, is justified on grounds that (i) many of the supported activities concern public goods, (ii) enhance equity, or (iii) cannot be supplied by the private sector because of market failures. The family health interventions supported by the project are goods with large externalities, that is, the benefits go well beyond those receiving the services, or pure public goods - goods that can not be withheld from persons who do not pay and are, thus, not profitable for the private sector to supply. An example for a Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 17 project activity with large externalities is the prevention and control of STIs as benefits flow to more than just the individual affected by slowing the spread of the disease in the general population. Similarly, improvements in maternal health and nutrition increase survival chances and well being of children that, in turn, will lower fertility rates in the long run and lead to environmental and social gains for the population. Many of the PHPNP activities are pure public goods. Examples include the IEC campaign to adopt family planning practices, and the collection and dissemination of health sector information and epidemiological surveillance. Both will provide significant social gains and would not otherwise be undertaken by the private sector. Public health services financing and provision is also justified for activities with the potential to significantly enhance equity. From this equity perspective, there is a strong rationale for public intervention because the poor, women and children have limited access to and ability to pay for health services. A 1993 Household Survey indicates that access to health facilities is limited in rural areas where the average household spends up to four times the time traveling to and from facilities as households in urban areas. Furthermore, health expenditures comprise as much as 36% of the poorest income quintile's household's annual income while comprising just 3% of the wealthiest quintile's. The envisaged activities will play an important role in redistributing social opportunities and benefits by focusing on the most vulnerable population groups and by targeting rural services and regions of the cou:ntry. A third argument for supporting public health services in the Gambian context is that even where services do not have large externalities, are not public in nature or would not enhance equity, there is a need for public health services because of supply side market imperfections. The private health sector in The Gambia is very small and basically limited to the Greater Banjul area. Private practitioners are almost non-existent in rural areas. While public financing and provision of services are well justified, there is nevertheless a need to provide these services in the most efficient way. Therefore, the PHPNP targets interventions that respond to the Gambia's particular health situation and that are recognized worldwide by health experts as being among the most cost-effective interventions available. Reproductive health activities, such as maternal health services and the treatment of STIs are cost-effective as measured by cost per year of heallthy life gained (DALYs). Furthermore, STI presence facilitates the transmission of HIV, and therefore early STI treatment is one of the most cost-effective ways of slowing the spread of HIV/AIDS and its economically crippling effect on developing countries. Similarly, mainstream child health interventions were evaluated in the 1993 WDR as being among the most cost-effective of all health interventions. Bank publications indicate that up to 15% of the disease burden in Sub-Saharan Africa could be averted through adoption of IMCI at a per capita cost of US$ 1.60 (Health, Nutrition and Population Sector Strategy, World Bank, 1997). In the case of nutrition, it is estimated that globally 56% of childhood mortality is associated with some form of malnutrition. The high levels of malaria found in The Gambia, for instance, are often associated with malnutrition. With the development of a comprehensive nutrition policy, nutrition interventions will be more carefully tailored to Gambia's priority needs and will have a significant impact on health status. In sum, the PHPNP tackles some of the most important problems in The Gambia, with cost-effective measures that are unlikely to be undertaken by the private sector. 2. Financial (see Annex 5): NPV NA ; FRR NA The project emphasizes quality improvements in the sector rather than expansion. Therefore, many project-related costs are already being incurred. The PHPNP will not pose a large fiscal burden on the country neither during the project nor after project completion. During project implementation, Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Page 18 Government contributions will average at about $375,000 annually which is only 4.9% of the total 1996/97 health budget. After project completion, Government will have to carry the recurrent costs produced by the project, and extrapolating from the figures for the last 6 project months in 2003 (see figures in annex 5), this will mean financing about $600,000 annually. This can be achieved if the health budget is increased by a total of only 7.8% over the whole project period of 5 years. If recent projections come true, and the health budget increases by 3% annually, this goal will be more than achieved. The prospects for the fiscal sustainability of the project are positive. 3. Technical: The project seeks to address major public health issues and equity concerns in The Gambia. It relies on widely known, available, and cost-effective techniques, with consensus among stakeholders regarding implementation mechanisms. The design takes into account lessons learned from health and other sector projects in The Gambia. Efforts were made to improve and obtain baseline information in order to identify the scope and targeting for components. Project design was discussed and developed intensively with representatives of the Government, NGOs, and other donors in order to be sure that the program is adapted to, and consistent with, the needs of those who will be responsible for implementing it. Investmnent and recurrent costs estimates were based on detailed discussion and analysis of prevailing costs, with appropriate allowances for price and physical contingencies. An issue which affects project implementation is the availability of adequately trained and available qualified health staff and their supervisors. Therefore, substantial training activities are included in each component, and resources identified to support regular supervision. In addition, the project will support efforts to formulate a long-term staff development and retention strategy. 4. Institutional: A crucial aspect of the PHPNP is its strong emphasis on capacity building. Thus, the project is geared to addressing institutional weaknesses which limit the capacity to implement and manage a family health program. For example, coordination capacity in reproductive health, infant and child health, and nutrition has been limited. This is addressed by the creation of a Project Coordination Committee which engages the main DSH Directorates, other Departments of State, and other partners in project oversight. The creation of a National Nutrition Policy Council will provide, for the first time, a framework for intersectoral collaboration in nutrition and food security. The coordination at the operational level will be fostered through the PHPNP Action Group, which brings together the key implementors of project components, and through the Group's strong interaction with the Project Implementation Unit. Typically, project management capacities have been weak. The project will, therefore, foster the PIU's capacities in procurement, accounting, and monitoring and evaluation. The capacity to monitor and report on project activities will be substantially improved through the establishment of health information and financial information systems. In the area of procurement, the project will provide training, technical assistance, and lessen the burden on the PIU by out-contracting the management of civil works contracts to the AGETIP-like GAMWORKS. Technical Assistance will strengthen the PIU's accounting capacity. Each of the entities implementing project components have been assessed for their technical capacities, and determined to have sufficient experience and capacity to implement the specific tasks assigned. Where gaps have been identified, the project will provide training and Technical Assistance. The limited capacity of the DSH to implement maintenance activities will be addressed by out- contracting these activities to the private sector. The capacities of formal and of community health workers will be improved through the project's extensive training activities. The project will also address Proje-ct Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 19 staff motivation by supporting the development of a staff retention strategy. Overall, the existing capacities coupled with immediate capacity building project elements are sufficient to successfully implement the project and achieve its objectives. 5. Social: The principal social issue underlying the project's thrust is the disadvantaged role women play in Gamabian society. Generally faced with lower education levels and more limited access to productive resources than men, they also suffer from the consequences of poor reproductive health and inadequate nutrition. This, in turn, has a negative impact on the health of their children. The PHPNP attempts to improve women's health and thereby to improve their conditions for a broader participation in economic activities and in society at large. The Health Management Information System to be introduced by the project as well as monitoring and evaluation activities under the project will disaggregate data by gender, to the extent possible, to measure any gender differences that may be important for project modifications or the design of future polices. 6. Environmental assessment: Environmental Category []A []B [X] C Environmental concerns will be addressed as a pre-condition for the rehabilitation, reconstruction or construction of health care facilities. Appropriate systems will be established for the collection and disposal/elimination of clinical waste produced in these health centers. This will also be reflected in the preparation of norms and standards as well as in the terms of reference for GAMWORKS. Long-term posiitive environmental improvements are expected from the project because it will work towards reducing population growth, thus, lessening the pressure on scarce natural resources, particularly, on biological energy. 7. Participatory approach [key stakeholders, how involved, and what they have influenced; if panticipatory approach not used, describe why not applicable]: a. Primary beneficiaries and other affected groups: Primary beneficiaries are women of reproductive age and infants and children under 5 years of age. Other affected groups are the women's sexual partners and family, community groups, community heallth workers, and professional health sector staff. Beneficiaries were consulted during preparation through surveys on the Local Initiative Fund (LIF), the Bamako Initiative (BI), and a study on maternal morbidity and mortality including satisfaction with maternal health services. Their responses have influaenced project design, especially of the reproductive health component. Through the LIF, beneficiaries will be actively collaborating in the project as they design, apply for and implement micro projects to improve their living conditions and their health status. Formal and community-based health care providers were consulted during an assessment of training needs and, thus, influenced the design of the project's training activities. In addition, focus group discussions were conducted with health sector staff on the issue of staff retention. Their views will impact on the elaboration of a staff retention strategy. Throughout project implementation, primary and secondary beneficiaries will be continuously involved through their active participation in the LIF and the Bamako Initiative (community management), as well as through client and staff surveys and the incorporation of survey results in the further implementation of the project. The surveys will place special emphasis on collecting gender- disaggregated data. b. Other key stakeholders: Other key stakeholders are the leadership and the staff of the Department of State for Health, the Department of State for Local Government and Lands (Directorate of Community Development), the Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 20 National Population Commission Secretariat, local government authorities, the leadership of Divisional Health Teams, NGOs, research institutions, UN organizations, and other donors. The December 1996 ZOPP participatory planning workshop assembled these key stakeholders around one table for a full week of discussions. The result was the basic project design as well as the establishment of Gambian ownership of the project. These stakeholders have been actively involved ever since in the further refinement of project design. During project implementation some of the stakeholders are responsible for distinctive components of the project, as described in section C.4 and in the Project Operational Manual. UN agencies and other donors will be consulted on a continuous basis and during the annual project reviews, and possibilities for collaboration utilized to the extent possible, e.g. in the implementation of the IMCI approach, in the operationalization of recommendations following from the staff retention study, in the provision of contraceptives, and the expansion of the Bamako Initiative. Cooperation with the African Development Bank was fostered through a joint ADB project preparation mission and there is an ongoing dialogue with other potential donors. The Project Implementation Unit will be jointly utilized by the PHPNP, the ADB and IDB health projects. F: Sustainability and Risks 1. Sustainability: The project is designed to promote long-term sustainability, which principally depends on continued and expanding Gambian commitment and support for family health. Factors important in this regard include: (a) continuing review by Government of its expenditures in the health sector and of the share of public resources allocated to primary and secondary health care levels, as well as annual increases in these expenditures; (b) addressing key policies, in particular health financing, drugs, staff retention, and nutrition on an ongoing basis; (c) developing and using information systems to improve the efficiency of service delivery; (d) building human resource capacity; and (e) providing regular financing to maintain and manage physical and program resources. The project will strengthen these factors through on-going policy dialogue, including during the annual project reviews, and through capacity building activities contained in all components, especially component 4. The demonstrated Gambian ownership of the project, developed during the project preparation process, will be a key factor to continued Government commitment. 2. Critical Risks (reflecting assumptions in the fourth column ofAnnex 1): Risk Risk Rating Risk Minimization Measure A. PROJECT OUTPUT TO DEVELOPMENT OBJECTIVES Family health policies and programs not given M Widespread sensitization of major high priority, new policies not legislated, and political and managerial stakeholders, as stakeholder ownership not expanded. well as communities/beneficiaries; project policy development support for health care financing, drugs, nutrition, maintenance, staff retention. Insufficient funding of family health program. S Gambian Government commitment to maintain adequate funding levels; World Bank financing of recurrent costs on a declining basis; Public Expenditure Review provides budget allocation recommendations; analysis of health care financing provides a sound basis for cost Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 21 sharing; annual reviews allow sufficient time to modify budget submissions. Inadequate donor coordination. M Gambian Government provides assurances that donor contributions are complementary and coordinated; Project Implementation Unit and Project Coordination Committee coordinate donor assistance; donor meetings held quarterly with resident donors and with World Bank and other donors at annual reviews. Key constraints outside the project are not S Continuing dialogue with policy makers, systematically addressed. DSH leadership and line Departments to address constraints such as slow decentralization and civil service reform, bad roads and sanitation, low education quality, especially for girls. B. COMPONENTS TO OUTPUTS Staff and institutional mechanisms are not M Project design provides for extensive adequate to carry out components. training and staff development to build capacity, support for a staff retention strategy, technical assistance, regular performance reviews, allocations based on absorptive capacity and performance; supervision missions. Insuifficient implementation, monitoring and M Program management strengthened, and troubleshooting. monitoring supported in all components; annual meetings to monitor risk factors and performance indicators. OVERALL RISK RATING M Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N (Negligible or Low Risk) 3. Possible Controversial Aspects: * Discouraging practices which are harmful to women, i.e. female genital mutilation. * Increasing use of modem contraceptives and other health practices which may contradict traditional and/or religious beliefs. * Readiness of the DSH and other Departments of State to cooperate in carrying out an inter-sectoral nutrition approach. * Acceptance by DSH staff of outsourcing services to the private sector. * Willingness of hospital sector to increase its cost coverage from non-public sector sources. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 22 G: Main Credit Conditions 1. Negotiations Conditions. As conditions of negotiations, the Government has: (a) provided a draft nutrition policy framework, including provision for the establishment of a National Nutrition Policy Council; (b) drafted a first year Project Implementation Plan, satisfactory to IDA; (c) provided a set of draft critical performance indicators to be included in a supplemental letter to the Development Credit Agreement. 2. Board Condition: As a condition of Board presentation, the Government has submitted to IDA a signed letter of Government commitment. 3. Effectiveness Conditions: As conditions of effectiveness, the Government would: (a) deposit into the project account the initial deposit of Government counterpart funds; (b) appoint an independent auditor acceptable to IDA; (c) submit a final Project Operations Manual including an Accounting Procedure Manual, satisfactory to IDA; (d) appoint a financial controller and an accountant to the PIU; (e) install a computerized accounting software and train the financial controller and accountant in its use. 4. Other: A. As a condition of disbursement, a revised Local Initiative Fund Implementation Manual (LIFIM), satisfactory to IDA, will be submitted before disbursements for the Local Initiative Fund can be effected. B. As covenants of project implementation, (a) implementation will be in accordance with an IDA approved Project Operations Manual and annual Project Implementation Plans; (b) annual reviews will have to result in agreed work plans and budgets for each subsequent year, except as IDA may otherwise agree; and (c) a National Nutrition Policy and Plan of Action are approved before January 1, 2000, for any subsequent project disbursements. C. As a covenant for monitoring, review and reporting, Government will annually present to, and discuss with IDA, a progress report on project activities and information on relevant donor activities. H. Readiness for Implementation [X] Procurement documents for the first year's activities have been drafted for the start of project implementation. The Project Procurement Plan has been proposed by the Government and generally agreed upon. The Government proposes using World Bank standard bidding documents for NCB. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Page 23 [XI The following items are lacking and are discussed under Credit Conditions (Section G): The Project Implementation Plan (PIP) and the Project Operations Manual (POM) are available in draft fonm and were discussed during negotiations. Submission of the draft PIP was a condition of negotiations under G. 1. above and submission of the final POM is a condition of effectiveness under G.3. above. I. Compliance with Bank Policies [X] This project complies with all applicable Bank policies. Richard Seifman Nicholas Burnett Mahmood A. Ayub Task Team Leader Sector Manager Country Director I Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 1 - Page 1 of 3 Annex 1 Project Design Summary' The Gambia: Participatory Health, Population and Nutrition Project Narrative Summary Key Performance Indicators Monitoring and Evaluation CriticalAssumptions CAS Objective Socio-political stability; economic stability and Improved quality of life for growth; the Gainbian population no natural disasters or new health threats in The Gambia. Project Development Objective Improved family health Maternal malnutrition reduced by Health Surveys Improvements in: 20% from baseline by 2003 Health Management (i) access to safe drinking Total Fertility Rate reduced by 10% Information System water and sanitation; (ii) from 6.0 (in 1993) throughout the (HMIS) educational levels, esp. lifespan of the project (to be revised Census among girls and women; at annual reviews) (iii) food security; (iv) 50% reduction in STI prevalence Household Surveys infrastructure; and (v) among pregnant women (prevalence Rapid assessment of STIs environmental hygiene. of 25% acc. to 1994 rapid assessment) Infant Mortality Rate reduced from 80/1000 to 65/1000 by 2003 Child malnutrition reduced by 25% from baseline by 2003 Project Outputs Family health programs A. Improved Reproductive and policies given high Health Services priority, with new policies legislated and 1. a Improved technical skills la. Proportion of health providers la. Supervision reports; stakeholder ownership of reproductive health service successfully trained according to plan results of pre- and post-training expanded. providers (target: 90%); tests; lb. Increased utilization of lb. Increase in the utilization of lb. Routine records/reporting Satisfactory funding of prenatal and postpartum care; services by 10% per year; family health program I c. Increased number of I c. Increase in the number of I c. Routine records/reporting deliveries attended by trained deliveries attended by trained health Adequate donor health providers providers by 5% per year; coordination. Id. Increased number of Id. Proportion of referral facilities Id. Supervision reports; referral facilities that are appropriately staffed and equipped Key constraints outside appropriately staffed and according to plan (target: 90% by the project addressed. equipped to handle obstetric end of project) emergencies le. Increased understanding le. Proportion reporting knowledge I e. KAP survey of the harmful effects of FGM of harmful effects of FGM increased from 25% to 50% 2. Improved prevention of 2. Contraceptive Prevalence Rate for 2. Reports from social marketing unwanted pregnancies modern methods increased from 14% program and from health to 22% by 2003 facilities; 3. Improved prevention and 3. Decreased prevalence of STIs 3. Supervision reports; treatment of STIs and HIV among pregnant women(target: 50% Routine records/reporting reduction by end of project) 'Detailed project design summary in annex 11 Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 1 - Page 2 of 3 B. Management of Childhood Illnesses Integrated Strengthened capacity to 1. Health-seeking behavior of KAP study prevent, identify and treat parents improved Statistics from Central Medical main infant/child illnesses 2. Diagnostic tools and treatment Store and from Social protocols developed/improved, Marketing Program integrated and disseminated BHF and VHW surveys 3. Health workers skilled in correct and integrated case management C. Nutrition Policy Formulated and Improved Nutrition Services for Women, Infants and Children 1. Policy basis for nutrition la. Nutrition policy and action plan National nutrition policy and programs established and adopted in 1999 action documents institutional capacity lb. Permanent coordination and PIU progress reports strengthened implementation mechanism for nutrition policy established in 1999 2. Nutrition education strategy 2. Proportion of children < 4 months PIU progress reports for behavioral change exclusively breastfed increased from Training reports implemented 17% to 40% KAP study 3. Implementation of maternal 3. 40 supplement distribution outlets HRIS supplements program implementing program by 2000 Supplement program assessment 4. Effective strategies for the 4. Strategies on micro-nutrient Strategy documents prevention and control of deficiencies to prevent and control PIU progress reports micro-nutrient deficiencies iron deficiency anemia, iodine Evaluation report deficiency disorder and vitamin A deficiency implemented D. Improved Capacity to Manage and Implement a Family Health Program 1. Expansion of Bamako 1. 24 additional BI facilities I a. BI documents Initiative (BI) supported by 2003 lb. PIU progress reports 2. Capacity built to 2a. Comprehensive IEC strategy 2a. IEC strategy document, implement and coordinate IEC developed by 1999 IEC Curriculum 2b. KAP studies conducted in 1999 2b. KAP reports and 2003 3. Capacity built to monitor 3. Health activities monitored; 3. Annual reports on health and evaluate health sector expenditures managed; and activities; finance; status of activities; sector financing; maintenance program monitored physical facilities/maintenance and maintenance through newly established HMIS program, and work plans/ budgets for following year 4. Capacity for planning the 4. Health mapping mechanism, 4. DSH's Operational Directives development of the health approved by DSH by end 1999 on the mechanism sector improved Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 1 - Page 3 of 3 5. Research activities better 5. Minimum of three operations 5. Operations research reports integrated into health policy research undertaken in family health and service delivery 6. Improved staff 6a. Staff development and retention 6a. Staff strategy document development and retention strategy in place by 2000 6b. Improved staff satisfaction 6b. Staff surveys 7. Health financing policy 7. High level workshop discusses and 7a. Workshop reports developed adopts new financing policies 7b. Health financing pol. document 8. Drug management, and 8. Drug Action Plan up-dated 8. Drug Action Plan Document rational drug use improved 9. Capacity built for 9. Maintenance policy formulated 9. Maintenance policy document developing/implementing a and approved by mid-2000 maintenance policy 10. Selected primary and 10. Yearly program of civil works 10. GAMWORKS' quarterly secondary health facilities and maintenance of facilities reports providing evidence of upgraded and maintained executed at 100% by GAMWORKS official acceptance of works I I. Catpacity of communities 11 a. LIF micro-grants disbursement I Ia. LIF financial reports strengthened for carrying out of $100,000 per year micro-projects through Local I lb. LIF accomplishes its new I lb. LIF review in 2000 Initiative Fund (LIF) objectives by 2000 12. Capacity for project 12a. Project Coordination Committee 12a. Regular reports issued management and component and Project Action Group in place 12b. Contract signed with each coordination in place and 12b. Human Resources in PIU fully individual operational in place by mid 1998 12c. Review of the application 12c. Project funds are monthly forms from PIU to WB and of requested and timely received. WB payments, by Bank's supervision missions. Project Components Input (budget per component) (Components to Outputs) A. Reproductive Health US$4.7m Project reports; supervision visits Staff and institutional Services mechanisms are adequate to carry out components. B. Integrated Management of US$0.9m Project reports; supervision visits Childhood Illnesses Appropriate monitoring and trouble-shooting. C. Nutrition Policy and US$2.3m Project reports; supervision visits Services for Women, Infants and Children D. Management and US$10.7m Project reports; supervision visits Implem entation of a Family Health Program I Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 2 - Page 1 of 8 Annex 2 Participatory Health, Population and Nutrition Project Project Description The following project components are closely interrelated. Activities under one component may at the same time support goals under another component, and all components include monitoring and evaluation, operations research, extensive training activities and IEC. These cross-cutting activities will be coordinated by project management, the PHPNP Action Group and specially appointed coordinators to avoid duplication and to optimize synergy. Project Component 1: Reproductive Health Services - US$4.7m The reproductive health component includes three sub-components: Maternal Health Services, Prevention of Unwanted Pregnancies, and Prevention and Control of STIs/HIV. They are designed to address the problems identified in earlier sections of this document. Sub-Component I - Maternal Health Services: This sub-component will improve the coverage, quality and utilization of maternal health services, address some of the risk factors contributing to maiternal morbidity and deaths, and improve the knowledge base about maternal mortality. The project will finance the training of new TBAs and will place great emphasis on improving the skills of existing TlBAs and of BHF staff. Clinical skills for prenatal, delivery and postpartum care as well as for the identification, referral and management of emergency obstetric complications will be enhanced through the: assessment of existing training programs, the revision of pre- and in-service training curricula for all relevant health care providers and the inclusion of Life Saving Skills training, the provision of pre- and in-service training, the development and implementation of new clinical practice guidelines, and the strengthening of clinical and field supervision. Communication skills for improving the interaction with clients will be enhanced by specifically designed training (under component 4), and guidelines for user- friendly service provision will be incorporated into the curricula. To monitor the satisfaction of women with maternal health services, a consumer survey will be developed and administered to health facility clients once every year and used as a problem solving tool. Other important quality-enhancing activities include the provision of equipment and supplies needed for routine and emergency obstetric care, the rehabilitation of health facilities and the introduction of a blood supply system (under component 4), the strengthening of postpartum care, and the facilitation of emergency transports. Postpartum care will be expanded by revising protocols for postpartum care, and augmenting TBAs' postpartum visits with home visits conducted by CHNs, and by incorporating postpartum care into child health visits. The improved coverage and quality of maternal health services should have a positive effect on their utilization. To further increase demand, community-based IEC activities and mass media campaigns will be supported to encourage women to seek early and regular prenatal, delivery and postnatal care. IEC will also focus on educating women, their families and communities about the warning signs of pregnancy complications and actions which must be taken. Outreach workers will work with cornmunities to encourage and assist in organizing emergency transport. The project will finance operations research to test appropriate means of communication between villages and health facilities to call for ambulances. Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Annex 2 - Page 2 of 8 Factors which increase the risk of reproductive morbidity and mortality include female genital mutilation (FGM), by which a significant number of Gambian women are affected and iron deficiency anemia. The project will address these risk factors by providing iron supplements to health facilities and TBAs (through the nutrition component) and by supporting community-based IEC aimed at increasing knowledge, changing attitudes and reducing the practice of FGM. Finally, knowledge about maternal mortality in The Gambia will be increased by supporting audits of maternal deaths occurring in health facilities and in communities and possibly verbal autopsies. Sub-Component 2 - Prevention of Unwanted Pregnancies: This sub-component will seek to increase demand for and availability of family planning services and contraceptives through IEC and social marketing. IEC activities will be conducted through a social marketing program and as part of other project-supported IEC activities, and utilize all available media and channels of communication. Their focus will be on affecting attitudes towards family size, addressing fears and concerns about using contraceptives, and providing information on how to obtain family planning services. The target audiences for these messages will include women and men of reproductive age and older and religious leaders. These activities will build upon initiatives begun under the recently completed WID Project, and include community-based IEC activities, such as local dramas. The PHPNP will also support the expansion of family planning services through the development of clinical protocols which incorporate family planning services into postpartum and child health care. The social marketing program will serve the dual purpose of preventing unwanted pregnancies and reducing the transmission of STIs and HIV, and will receive support from the PHPNP for three years, during its introduction. The program will market condoms, oral contraceptives and oral rehydration salts. All available commercial outlets will be utilized for marketing. To attract consumers to buy contraceptives, the program will also market oral rehydration salt and bed-net dipping insecticides because these are items which are already valued by the Gambian population. In addition, the program thereby supports child health and malaria control. The initial phase of the program will involve formative research, i.e. a KAP study, marketing research and development of IEC messages. Sub-Component 3 - STI/HIVPrevention and Control: This sub-component will finance extensive lEC to increase knowledge about STIs and HIV, change attitudes, promote condom use, and encourage those with STI symptoms to seek care and to inform their partners about the necessity to equally seek treatment (contact tracing). The IEC approach will include community-based activities, counseling, literacy-appropriate education materials and mass media. For the management and control of STIs, the project will principally rely on and support the syndromic management approach, because regular screening tests are not feasible on a large scale in a setting with few clinical laboratories and limited resources. To this end, a training manual and clinical practice guidelines will be developed for the syndromic management of STIs, and the respective training prepared (training of trainers) and conducted for public and private health workers and pharmacists. The training manual will be incorporated into the curricula revision of the CHN and SEN schools and of the SEN/CHN midwifery program. As women with STIs often do not show symptoms, the project will also expand pre-natal STI screening for women. This will include their referral to one of the major health centers for testing for gonorrhea and syphilis. The laboratories of these centers will be provided with the necessary equipment and supplies. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 2 - Page 3 of 8 Project Component 2: Integrated Management of Childhood Illnesses - US$0.9 m The project will improve infant and child health services by supporting the implementation of the Integrated Management of Childhood Illnesses (IMCI) approach. This approach will combine existing vertical programs against the major child killers malaria, acute respiratory infections, diarrhea and malnutrition because many children have two or more diseases at the same time but are only treated for one disease while the others go undetected. In a first step, preparatory activities for the introduction of IMCI in The Gambia will be undertaken. Key persons will be trained in the IMCI concept to act as core facilitators for the early phase of [MCI implementation. An in-depth IMCI assessment of the current situation of infant and child health services will be carried out. Its findings will be presented at a national orientation seminar at which point IMCI implementation will be started by the creation of an IMCI task force. Subsequently, the generic IMCI material (e.g. systematic assessment guidelines, diagnostic charts, treatment protocols, training modules) will be adapted to Gambian conditions, including the production of training materials for community health workers with limited literacy capacity. The customized material will then be pre-tested and disseminated. The next step will consist of training of trainers, followed by several rounds of training of health workers in the implementation and supervision of IMCI. Training curricula will be revised to integrate IMCI into pre-service training of health staff. These clinically-oriented activities will be complemented by an IEC campaign addressed at parents to promote early help-seeking behavior, and educate about danger signs. The nutrition component's IEC activities will promote correct feeding practices, and the project's social marketing prcigram will support the use of oral rehydration salts and of impregnated bednets for malaria control. The Local Initiative Fund under component 4 provides an opportunity to communities to organize emergency transport of sick children to health facilities and to build baby-friendly rest houses to enable mothers to take care of their babies even during the busy rainy season. The introduction of a blood supply system under component 4 will benefit children with severe anemia. During the implementation phase, the project will support continuous monitoring, staff supervision, operations research, and technical studies, as needed. This includes surveys of BHFs and BHF staff as well as of VHWs to assess their capacity for correct and integrated case management. In year 4, an evaluation of the IMCI implementation and of its impact will be conducted. Project Component 3: Nutrition Policy and Services for Women, Infants and Children - US$2.3m The goal of the nutrition component under the PHPNP is to create an enabling institutional environment for nutrition policies and programs, strengthen capacity at national, divisional and local levels to recognize and address malnutrition, improve nutrition knowledge, attitudes and practices of the population, and to implement interventions to improve the nutritional status of women and children. The project will attempt to achieve this goal and thereby address the problems identified in earlier sections of the document by implementing two sub-components: Nutrition Policy Formulation and Institutional Strengthening, and Community and Micro-Nutrient Approaches to Improve the Nutritional Status of Women and Young Children. Sub-component I - Nutrition Policy Formulation and Institutional Strengthening.: Under this sub-component, a National Nutrition Policy Council (NNPC) will be established which will be chaired by the Vice President of The Gambia and Secretary of State for Health, and comprised of Secretaries of State and Permanent Secretaries from key ministries, NGOs and the private sector. A nutrition policy coordinator will be appointed, and a Technical Working Group (TWG) established to provide technical Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 2 - Page 4 of 8 leadership and facilitate inter-sectoral collaboration. The NNPC will provide guidance to a participatory policy development process, including divisional and national workshops, which will culminate in the adoption of a national nutrition policy and nutrition action plan in 1999. The policy development process will be supported by an IEC strategy for nutrition advocacy to create awareness about nutrition among the general population and among policy makers and community leaders. With respect to institutional strengthening, the nutrition-relevant competencies required for implementing the nutrition policy and plan of action will be identified. Then, the pre-service curricula for all relevant cadres, including CHNs, SENs, SRNs, Family Life Education teachers, agriculture extension workers, community development assistants, and nutrition officers in government and NGOs will be revised, accordingly. The respective in-service training will be provided as well as more specialized training, including one Masters and one Doctorate level training. To strengthen the nutrition knowledge base, an improved anthropometric data collection survey system will be developed and implemented. Sub-component 2: Community and Micro-Nutrient Approaches to Improve the Nutritional Status of Women and Young Children: This sub-component will implement a nutrition education strategy, support maternal food supplement programs, and address micro-nutrient malnutrition. A nutrition education strategy will be developed and implemented to improve nutrition practices. This will include an assessment of existing relevant IEC programs and operations research. Emphasis will be placed on appropriate child feeding practices and the use of balanced weaning foods. The strategy will focus on the use of village based volunteers as peer counselors as well as of CHNs and TBAs who will all be trained and supervised. Support will be given to communities to erect Baby Friendly Rest Houses, traditional sheds built close to women's fields, to enable women to continue breast feeding while working. Existing maternal food supplementation programs will be assessed to determine their potential to improve the nutritional status of both mother and infant, and to achieve program sustainability. Food supplementation programs positively assessed along these lines will receive support from the project. Possibilities will also be explored with communities on how to better place the production and preparation of food supplements in their own hands. The project will address micro-nutrient malnutrition by determining the prevalence and causes of selected micro-nutrient deficiencies and conducting operations research to improve the effectiveness of existing strategies. The Gambia Iron Deficiency Anemia (GIDA) strategy will be reviewed and refined; iron and folate supplements will be procured and distributed (see also component 1); IEC materials prepared and workers trained in anemia prevention and control. A locally relevant Iodine Deficiency Disorder (IDD) strategy will be developed. Vitamin A status will be assessed and an IEC strategy implemented to promote diet diversification for increasing the intake of vitamin A-rich local foods. Community-based activities under this sub-component are eligible for support from the Local Initiative Fund (LIF) under component 4. Project Component 4: Management and Implementation of a Family Health Program - US$10.7m The management and implementation of a family health program, whose operations will be strengthened directly through project components 1, 2 and 3, requires that a number of critical cross- cutting inputs be provided and relevant support services strengthened. Component 4 is designed to address these needs as well as the need for coordinating the extensive work on training, IEC, operations research and monitoring and evaluation conducted under each component. To this end, four sub- Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Annex 2 - Page 5 of 8 components will be implemented: Capacity Building and Policy Development, Up-grading and Maintaining Health Infrastructure, Local Initiative Fund, and Project Management. Sub-component I - Capacity Building and Policy Development: Capacity building will be supported in the following areas: (i) cost recovery through the expansion of the Bamako Initiative; (ii) IEC; (iii) monitoring and evaluation through the development and implementation of Financial and Health Information Systems; (iv) health mapping; (v) research application; and (vi) staff development and retention. This sub-component also supports (vii) the development of a Health Financing Policy; (viii) the up-dating and partial implementation of the National Drug Action Program; and (ix) the development of a Maintenance Policy. (i) The project will support the expansion of the Bamako Initiative (BI) by providing seed stock drugs for up to 24 additional BI facilities, supporting the training of BI trainers and health care supervisors, and training health facility staff and members of Catchment Area Committees (CACs) in the BI approach, with special emphasis on cost recovery aspects, like e.g. prices of drugs, drug need estimates, cost-effective selection of drugs for prescription and re-ordering. Prior to expansion, a project- financed review will be undertaken to analyze and make recommendations on the BI's fee structure, exemptions, cost recovery aspects, drug requirements, inventory controls and the role of CACs. (ii) Information, Education and Communication (IEC) is integral to the success of the project by promoting behavior change of the affected population in the areas of reproductive health, infant and child health, and nutrition. In order to coordinate and improve IEC message development, training, and delivery undertaken in project components 1, 2 and 3, a full-time IEC coordinator will be appointed to the DSH Health Education Unit (HEU) and equipped. She/he will report to the PIU. The coordinator will strengthen the capacity of the HEU in IEC management and implementation. She/he will developa comprehensive IEC strategy, and work with an international consultant in conducting a training workshop in the integrated marketing communications (IMC) approach for all health education officers involved in the project. This approach identifies "ready markets" for behavior change instead of feeding information to reluctant audiences. The coordinator will also coordinate formative research for message development and correct targeting in all project areas, identify opportunities to incorporate IEC into the training of health workers, and implement a training program on inter-personal communication for health workers. KALP (knowledge, attitude, practice) studies will be conducted to measure the impact of IEC on behavior change for all components of the project. (iii) The project will strengthen DSH's management, monitoring and evaluation capacities through the elaboration and installation of a comprehensive computerized Health Management Information System (HMIS). It will be comprised of: (a) a Health Information System (HIS) providing data on the population's health status and sector-wide inputs and outputs, distribution of health services ancl population access to them; (b) a Financing and Accounting Information System (FAIS) designed to be 100% compatible with the DSFE's computerized budget management system, and implemented to gradually cover the management of public and private resources for investment and recurrent expenditures of the health sector in all divisions and levels of care, as well as management of donors' support; (c) a Maintenance Information System (MIS) providing data on facilities, equipment status and maintenance/replacement needs. These systems will be complemented by an ADB financed Human Resources Information System (HRIS) providing necessary data to manage the provision of sector-wide hurnan resources including needs and training requirements. IDA financed systems will be conceived as intranets accessible from all concerned health managers and linked: (i) for data exchange and intrasectoral cross analysis particularly on cost-efficiency matters, and (ii) to other sectors' intranets when available (the existing DSFE's one and the planned DSE's one) for intersectoral cross analysis. Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Annex 2 - Page 6 of 8 They will be designed to provide regular feedback to practitioners and effective monitoring and evaluation of health sector activities to managers. These systems will thus benefit the health sector as a whole and the project in particular because it will generate the data needed for the monitoring and evaluation of project activities. Project monitoring and evaluation itself will be carried out by the DSH line units in charge of implementing singular components, whereas the coordination of such M&E will be the responsibility of project management. (iv) A health mapping capacity will be developed in the DPI to provide a basis for projecting investment and recurrent expenditure needs, and managing resources allocations. This will include an assessment of existing health service needs, a clearer definition of the health sector structure (which is currently composed of 7 layers), the definition of norms and standards linked to the notion of"minimum packages of activities" at each level of the health pyramid, the definition of criteria for the allocation of funds, and the capacity to develop optional projections to support decision making. (v) The project will strengthen capacity in the area of applied research by (a) financing operations research under all components as well as needed surveys for the monitoring and evaluation of project activities, and supporting the coordination of such research, and by (b) supporting a new Gambian initiative called "Getting Research into Policy and Action"(GRIPA) in the areas of reproductive health, infant and child health, and nutrition. This initiative will seek to close the gap between the extensive health research done in The Gambia and Gambian health policy and program formulation. This initiative would take advantage of the presence of an international research institution, the Medical Research Council (MRC), with its research, knowledge and information base, and training competencies. The project will build on existing collaborative agreements between the Government and MRC and establish GRIPA as a means to better translate research findings into Gambian policies, programs, and projects. (vi) The project will support staff development and retention by following up on the staff retention study undertaken during project preparation and extending support to the development of a staff retention strategy. This will be achieved by reviewing the issues raised in the study during the annual project reviews and by supporting workshops which will review the study and fornulate a strategy. Staff motivation and retention will also be addressed in other project components. Staff housing will be financed in the project's civil works component, and extensive training will be provided in all project components. Project management will ensure the coordination and transparent execution of the training program. Staff satisfaction will be measured every 2 years with a staff survey. (vii) With the goal of helping to develop a more efficient, equitable and sustainable health care system, the project will support the development of a health financing policy. The process will build on the recommendations emanating from the on-going Public Expenditure Review (PER) and include an examination of different options for health financing, including community and household financing, and the private sector's role in health care service delivery. Current fee levels, household willingness and ability to pay for health care, the extent and nature of private health care provision, legislation governing private health care provision, and linkages between the public and private health care sectors will be analyzed. The project will finance studies, workshops, and study tours which are likely to deepen Gambian understanding and skills in these areas. During a final workshop, the major findings and recommendations will be translated into specific policy reforms. The PHPNP annual reviews will then determine how best to incorporate priority reforms into planned project activities. (viii) The project will support the up-dating and the partial implementation of the National Drug Action Program. This includes: (a) the review of drug management practice, in particular, the establishment of a system to quantify drug needs in the public sector, the introduction of a computerized Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Annex 2 - Page 7 of 8 system for drug procurement and inventory management, and the review of pricing practices; and (b) support to education campaigns for drug prescribers and dispensers to promote the rational use of drugs. The project will also support activities to strengthen the National Pharmaceutical Services Aclministration. (ix) The project will support the development and the implementation of a new maintenance policy which will clearly delineate, on the one hand, DSH activities concentrating on planning, funding, managing, monitoring and evaluating the maintenance program and, on the other hand, execution of maintenance activities which will be outcontracted to professionals in the private sector. The new policy will shift from a centralized to a decentralized management, including decentralization of fund management with adequate mechanisms of accountability. The DSH maintenance budget will be increased from an estimated 0.4%, 0.01% and 1.5% of asset value, respectively, for the maintenance of buildings, equipment and vehicles in 1996, to 1%, 2% and 2.5%, respectively, in 2003. This corresponds to an annual increase, estimated at D860,000 per year (in real terms). These additional budget resources will be complemented by an additional equivalent support from the PHPNP. Sub-component 2 - Up-grading and Maintaining Health Infrastructure: Under this sub- coimponent, the project will support DSH efforts to provide and maintain: (i) adequate quality of physical facilities to insure good conditions for the delivery of quality services related to maternal, infant and child caire, and (ii) adequate blood supply for the sector. Physical investments comprise: (a) construction, reconstruction, refurbishing and equipment of dispensaries as needed to: (i) maintain the existing dispensaries/population ratio during the project period, given the population increase, and (ii) to insure and maintain good conditions for the delivery of basic health services; (b) construction of waiting sheds in front of dispensaries to protect waiting patients from sun/rain and provide accommodation for community activities including IEC meetings; (c) construction of latrine-blocks in dispensaries when neieded to provide adequate sanitation; (d) construction of staff quarters in remote facilities to help retain qualified personnel; (e) refurbishing of maternal wards in Minor and Major Health Centers which are not sulpported by the ADB health project; (f) limited refurbishment and equipment of selected surgery theaters, laboratories and blood banks in Major Health Centers as needed to insure quality surgery for m.aternal care; and (g) support to the maintenance of: (i) building and equipment of health facilities at the primary and secondary levels, and (ii) DSH vehicles, through out-sourced contracts with private firms. The management of civil works contracts for the above mentioned works as well as the implementation of a yearly building maintenance program will be carried out by a specialized contract management agency (GAMWORKS). As maintenance services for all new equipment purchased by DSH will be included in the suppliers' contracts, this new mechanism will progressively expand maintenance to all equipment in the sector. The increase of blood supply will be obtained from a charitable organization (GAMBLOOD) which has already developed a sound experience in blood-donor mobilization in three regions and will expand and intensify its activities with this support. Sub-component 3 - Local Initiative Fund: The project will complement its activities at the grassroots level by supporting a Local Initiative Fund. The Fund will enable communities to carry out acitivities in the areas of reproductive health, infant and child health, and nutrition by providing micro grants. Possible examples for such activities include community transport to and communication with health facilities for emergency referrals, baby-friendly rest houses, or the production of food supplements. The LIF will thus help communities to deal with barriers to health seeking behavior. The LIF had already been piloted during project preparation, but with the different objective of inducing reproductive behavior change. An evaluation demonstrated that the LIF was an effective means of generating community participation and of building grassroots capacities, but that it could not achieve the stated objective of reproductive behavior change. Therefore, a decision was taken to link the LIF more Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 2 - Page 8 of 8 closely to the project by making it a complementary tool of the project at grassroots level. The project will therefore only support the LIF after its objectives have been modified accordingly. The pilot phase will be extended for two more years. A review after two years will determine whether the LIF should be expanded nation-wide or whether it should be integrated with other social funds. The project will finance the LIF micro grants and part of the operation of the LIF which includes training, equipment, IEC, monitoring, supervision and the review of the extended pilot phase. Funds will only be expended after the LIF Implementation Manual has been revised. Sub-component 4 - Project Management: Project management will be the responsibility of the Project Implementation Unit (PIU) which will receive guidance from a Project Coordination Committee (PCC) and support from a PHPNP Action Group. It will also coordinate activities of the ADB and IDB health projects. The PIU will have the following responsibilities: (i) the management of project funds including Government's counterpart account and IDA Special Account; (ii) all procurement activities including convention with GAMWORKS for IDA financed civil-works, procurement of goods and services in accordance with World Bank procedures for IDA financed contracts, and other donors' procedures for their respective funds; (iii) installation and maintenance of sound financing and accounting procedures for all funds; (iv) providing to the Govemment and IDA audit reports about PHPNP funds; (v) reporting on project activities to IDA every six months; (vi) organizing the joint Govemment-IDA annual reviews and mid-term review (as well as review of other projects managed by the PIU); (vii) coordinating all training activities under the project to ensure a comprehensive implementation; (viii) coordinating all monitoring and evaluation activities, and compiling all results in comprehensive progress reports with indicators to be revised during the annual reviews; (ix) supervision of the activities of a PHPNP Nutrition Coordinator located in the Directorate of Medical Services and of a PHPNP IEC Coordinator housed in the Health Education Unit (HEU). The PIU, will comprise a project manager, two deputy project managers, a financial controller, two accountants, a procurement officer, a senior health, population and nutrition advisor, secretaries and support staff. The project will finance the project manager, a deputy project manager, the financial controller, an accountant, a procurement officer and a senior health, population and nutrition advisor. The ADB project will finance a deputy project manager, an architect and an accountant. The secretaries and support staff at the PIU will be financed through the Govemment budget, with IDB funds contributing towards the operating costs of the PIU. The PIU will also receive support under the project for carrying out the above-mentioned activities, including for procurement training, and auditing services. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 3 - Page 1 of 1 Annex 3 Participatory Health, Population and Nutrition Project Estimated Project Costs Project Component Local Foreign Total ------------------US$ million----------------- Baselline Cost 1. Reproductive Health Services Maternal Health Services 0.9 0.6 1.5 Prevention of Unwanted Pregnancies 0.6 1.4 2.0 STI/HIV Prevention and Control 0.2 0.4 0.6 Subtotal Reproductive Health Services 1.7 2.4 4.1 2. Integrated Management of Childhood Illinesses 0.5 0.4 0.9 3. Nutrition Policy and Services for Mlomen, Infants and Children Nutrition Policy Formulation and 0.2 0.5 0.7 Institutional Strengthening C ommunity/Micronutrient Nutrition 0.8 0.5 1.3 Programs Subtotal Nutrition Policy and Services 1.0 1.0 2.0 for Women, Infants and Children 4. Management and Implementation of Family Health Program Capacity Building and Policy Development 0.9 1.6 2.5 Up-grading and Maintaining Health 2.4 2.7 5.1 Infrastructure Local Initiative Fund 0.6 0.2 0.8 Project Management 0.5 0.4 0.9 Subtotal Management and Implementation of Family Health Program 4.4 4.9 9.3 5. Non Allocated Provision 0.2 0.3 0.5 6. P]?F 0.4 0.4 0.8 Total Baseline Cost 8.2 9.4 17.6 Contingencies Physical Contingencies 0.5 0.7 1.1 Price Contingencies 0.6 0.6 1.2 Total Contingencies 1.1 1.3 2.3 Total Project Cost 9.3 10.6 19.9 Projeict Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 4 - Page 1 of 9 Annex 4 Participatory Health, Population and Nutrition Project Economic Analysis An economic analysis of the Participatory Health, Population and Nutrition Project (PHPNP), and the larger health sector in which it will operate, has been undertaken during the course of project preparation and appraisal. The findings support the PHPNP as a viable, cost-effective and appropriate use of public funds that will improve the health outcomes of the country's most vulnerable population groups. The following discussion spells out the economic justification of the project, focusing on several areas: (i) rationale for public financing and provision of health services; (ii) cost-effectiveness of project activities; (iii) financial analysis; and (iv) risks to successful project implementation. I. Rationale for Public Financing and Provision of Health Services The project's support to public health services, i.e. the public financing and provision of health services, is justified on grounds that (i) many of the supported activities concern public goods, (ii) enhance equity, or (iii) can not be supplied by the private sector because of market failures. The project focuses on a range of public health interventions, including improving the quality and access to maternal health services, promoting the use of modern contraceptives, strengthening STI prevention and management, implementing a more integrated approach to managing childhood illnesses, and strengthening nutritional policies and programs targeted at women and children. Such family health interventions can be justified on grounds that they are goods with large externalities, that is, the benefits go well beyond those receiving the services, or pure public goods - goods that can not be withheld from persons who do not pay and are, thus, not profitable for the private sector to supply. An example for a project activity with large externalities is the prevention and control of STIs as benefits flow to more than justl the individual affected by slowing the spread of the disease in the general population. Similarly, improvements in maternal health and nutrition increase survival chances and well being of children that, in turn, will lower fertility rates in the long run and lead to environmental and social gains for the population. Many of the PHPNP activities are pure public goods. Examples include the IEC campaign to adopt family planning practices, and the collection and dissemination of health sector information and epidemiological surveillance. Both will provide significant social gains and would not otherwise be undertaken by the private sector. Public health services financing and provision is also justified for activities with the potential to significantly enhance equity. From this equity perspective, there is a strong rationale for public intervention because the poor, women and children have limited access to and ability to pay for health services. A 1993 Household Survey indicates that access to health facilities is limited in rural areas where the average household spends up to four times the time traveling to and from facilities as households in urban areas. Furthermore, health expenditures comprise as much as 36% of the poorest income quintile's household's annual income while comprising just 3% of the wealthiest quintile's. The envisaged activities will play an important role in redistributing social opportunities and benefits by focusing on the most vulnerable population groups and by targeting rural services and regions of the cotntry. A third argument for public health services in the Gambian context is that even where services do not have large externalities, are not public in nature or would not enhance equity, there is a need for public health services because of supply side market imperfections. The private health sector in The Gambia is very small and basically limited to the Greater Banjul area. Private practitioners are almost non-existent in rural areas. The reasons for this behavior have not been studied in detail, but one can Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 4 - Page 2 of 9 assume that the income potential for private providers is too small in rural areas. Even though an annual per capita health expenditure of $6.5 of the poorest income quintile (see chapter on private health expenditures below) is not insubstantial, this might still constitute too small a market to attract private providers who are likely to find the wealthiest income quintile in the capital who spend $35 annually on health. Further, living conditions may be too unattractive in rural areas to pull private health practitioners. II. Cost-Effectiveness of Project Activities While public financing and provision of services are well justified, there is nevertheless a need to provide these services in the most efficient way. Therefore, the PHPNP targets interventions that respond to the Gambia's particular health situation and that are recognized worldwide by health experts as being among the most cost-effective interventions available. Reproductive health activities, such as maternal health services and the treatment of STIs are cost-effective as measured by cost per year of healthy life gained (DALYs). Furthermore, STI prevalence facilitates the transmission of HIV, and therefore early STI treatment is one of the most cost-effective ways of slowing the spread of HIV/AIDS and its economically crippling effect on developing countries. Similarly, mainstream child health interventions were evaluated in the 1993 WDR as being among the most cost-effective of all health interventions. Bank publications indicate that up to 15% of the disease burden in Sub-Saharan Africa could be averted through adoption of IMCI at a per capita cost of US$ 1.60 (Health, Nutrition and Population Sector Strategy, World Bank, 1997). In the case of nutrition, it is estimated that globally 56% of childhood mortality is associated with some form of malnutrition. The high levels of malaria found in The Gambia, for instance, are often associatet with malnutrition. With the development of a comprehensive nutrition policy, nutrition interventions will be more carefully tailored to Gambia's priority needs and will have a significant impact on health status. In sum, the PHPNP tackles the most important problems in The Gambia with cost-effective measures that are unlikely to be undertaken by the private sector. Without the PHPNP, the health status of the population would be worse than without it. A set of indicators has been chosen to monitor and evaluate health care progress and provide an indication of conditions with and without the project. Table 1: Selected Key Indicators for Monitoring and Evaluating the PHPNP Output/Outcome Indicators Target 2003 Monitoring Frequency Total Fertility Rate reduced by 10% from 3 yr. 6.0 (in 1993) throughout the lifespan of the project _ Contraceptive Prevalence Rate 22% 3 yr. STI prevalence among pregnant women 50% reduction 3 yr. % infants < 4 months exclusively breastfed 40% 3 yr. Infant Mortality Rate reduction to 65/1000 3 yr. Child Malnutrition Rate 20% reduction 3 yr. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 4 - Page 3 of 9 Clearly, these outputs and outcomes are important and relevant to The Gambia and the likelihood of their attainment will be significantly enhanced as a result of the PHPNP. Cost-effectiveness will be monitored annually and non-performing interventions will be adjusted. III. Financial Analysis Ov,erview The newly elected Government of The Gambia is committed to restart the economic reform process. Following a contraction in 1994 and 1995, the economy grew by 2.6% in 1996 and by 3.0% in 1997. The economic outlook will depend on private sector response to the Government's ability to undertake strong corrective fiscal measures, resume policy reforms, and normalize relations with the international community. A recently fielded IMF mission assessed the fiscal performance as being on track, and projected continued economic growth of 3% annually in real terms over the next three years. It recommended that the share of public expenditure to GDP be kept constant, which would mean an annual increase of 3% in public expenditures. If in addition the IMF's recommendation will be followed that total current spending on health and education will increase to 30% as compared to 27.5% in 1995/96, this would mean that public health expenditures would grow by at least 3% per year. Table 2 provides an overview of past health budgets. Table 2: Total Public Health Expenditure (000 Dalasis, current prices)l 1994/95 1995/96 1996/97 actual actual estimate Health Recurrent Expenditure 62,169 55,622 60,901 Health Development Expenditure 6,670 7,107 15,373 Total Health Expenditure 68,839 62,729 76,274 Total Health Expenditure (1990/91 constant 53,641 46,659 55,567 prices) _ Share of Total Government Expenditure (%) 8.2 5.5 5.7 Per capita public health expenditure (Dalasis; 48 40 45 1990/91 constant prices) I I I A Public Expenditure Review (PER) has been initiated in the health sector to assess the effectiveness and efficiency of government health expenditure, and to ensure that health priorities are clearly identified and adequately funded. The PER will be an ongoing exercise whereby the DSH annually spells out its priority programs, with relevant and measurable indicators to monitor its progress, while the DSFE provides a clear and predictable level of resources to enable the health sector to undertake rational and proper planning. A Health Management Information System (HMIS), linked to DSFE's own financial management system, will be integral to the success of the PER process and its development will be financed under the PHPNP. ' Figures are based on table 5.1.1 of the January 1998 PER draft presented by the Government of The Gambia, which excludes Social Welfare and Women's Bureau. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 4 - Page 4 of 9 Fiscal Implications of the PHPNP The PHPNP will not pose a large fiscal burden on the country neither during the project nor after project completion. During project implementation, Government contributions will average at about $375,000 annually which is only 4.9% of the total 1996/97 health budget. After project completion, Government will have to carry the recurrent costs produced by the project, and extrapolating from the figures for the last six project months in 2003 (see figures in annex 5), this will mean financing about $600,000 annually. This can be achieved if the health budget is increased by a total of only 7.8% over the whole project period of 5 years. If projections come true, and the health budget will increase by 3% annually, this goal will be more than achieved. The following table summarizes in detail the required annual Government contributions to the project and the fiscal implications thereafter, as well as the amounts and percentages by which the budget would have to increase to satisfy these additional demands, and the budget amounts if the 3% annual growth projection materializes. It shows that the fiscal implications of the project can be easily accommodated in the likely scenario of a 3% annual budget increase, in fact less than that is required. Table 3: Fiscal Implications of the PHPNP (US$, in 1996/97 current prices) Project- Absolute Health budget Annual Annual related increase in required to percentage health additional allocation finance project- increase in budget expen- needed as related Government amount ditures for compared to additional budget assuming Govern- previous year expenditures3 needed to 3% annual ment2 with increase bring budget growth in required to required starting Government level from contribution 1996/97 budget X________ figure Estimated 7,627,421 7,627,421 total health budget in 1996/97 1998 230,000 230,000 7,857,421 3.0 7,857,421 1999 472,000 242,000 8,099,421 3.0 8,099,421 2000 410,000 0 8,099,421 0.0 8,334,687 2001 336,000 0 8,099,421 0.0 8,584,727 2002 288,000 0 8,099,421 0.0 8,842,268 2003 436,000 0 8,099,421 0.0 9,107,536 after 600,000 128,000 8,227,421 1.6 9,380,762 2003 (in 2004) annually 2 Figures calculated on basis of Annex 5 - Governrent contribution to project; figure for 2003 contains additional $300,000 to include recurrent costs for six months of 2003 after project completion; figure after 2003 consists of recurrent costs created by the project. " Government contributions required for years 2000-2003 can be financed out of the increases to be achieved in 1998 and 1999; this column therefore leaves budget stagnant during 2000-2003. Prciject Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Coiuntry: The Gambia Annex 4 - Page 5 of 9 The recurrent costs the project will produce consist mainly of operating costs for supervision, monitoring and evaluation (M&E), and of maintenance costs, and will result in significant effectiveness and efficiency gains. Better supervision and M&E will improve the quality of services, and increased maintenance allocations will lead to decreased demand on the investment budget in the future. These recurrent costs are concentrated on the primary and secondary levels of health care. The long-term recurrent cost implications of the project could therefore also be accommodated in a different scenario with zero budget growth but a shift of the intra-sectoral budget allocation from the tertiary level to the primary/secondary level. As table 4 shows, the current allocation of overall recurrent Govemment expenditure is 82% for all levels of health service delivery, with 43% going to the tertiary level and 39% going to the primary/secondary level. In a zero-growth scenario, financing the increase in recurrent costs of $600,000 for the latter level by the end of the project could also be achieved by adding 2% points each year to the primary/secondary level and subtracting the same from the tertiary level. This would mean that by 2003, 51% of all recurrent cost allocation would have to go to the primary/secondary level and 31% to the tertiary level. However, with the addition of two hospitals (Farafenni and Bwiam) and their likely recurrent cost implications, such a scenario is unlikely (see also risk analysis below), unless policy changes are enacted. These could involve further improvements in the financing of hospitals from private out-of-pocket moneys which has already begun under the semi-autonomous hospital management. Table 4: Functional Composition of Recurrent Expenditure ('000 Dalasis, current prices)4 Level of Expenditure 1996/97 estimates Administration (central and division) 9,458 as % 16% Primary and Secondary Health Care (dispensaries, sub-dispensaries, health 23,438 posts, minor and major health centers, community health, family health and vector control) o as % 39% Tertiary Health Care (hospitals)5 26,362 as % 43% Training and Research 1,455 as % 2% Total 60,713 as % 100% Economic Composition ofRecurrent Public Health Expenditure The economic composition of public expenditure is set out in table 4 below. Drug expenditures comprised approximately 34% of DSH recurrent expenditures and, on a per capita basis, reach about 4Figures are based on table 5.2.1 of the January 1998 Govemment PER submission, and exclude cleansing services. 5 Excludes cleansing services of $18,720 which are included in table 2. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 4 - Page 6 of 9 $1.30 annually. Such levels of public drug expenditure are roughly on par, or above, other countries in the sub-region and are complemented by private expenditures that are discussed below. The maintenance expenditures (infrastructure, equipment and transport) are a fraction of operations expenditures and are not adequate to properly maintain the health capital stock. The PHPNP plans to address this by increasing the share of the budget directed to maintenance and improving its management structure. Table 5: Economic Composition of Recurrent Expenditure ('000 Dalasis, current prices)6 Category 1996/97 estimate Personnel 31,656 as % 52% Drugs and other medical supplies 20,546 as % 34% Transport/travel (include. operation, maintenance 2,195 and purchase of vehicles) as % 4% Equipment 458 as % 1% Office expenses and communication 923 as % 2% Building maintenance and running costs 2,667 as ',4%I Other 2,266 as % 4% Total Spending 60,713 as % 100% Private Expenditure on Health Public spending on health is complemented by significant private out-of-pocket expenditure. The 1993/94 Household Survey of 1600 individuals in 2,000 households provides information on the nature and extent of private health expenditure. The findings, disaggregated by income quintiles, are shown in Table 6. 6Figures are based on table 5.2.2 of the 1998 Government PER submission, and exclude cleansing services. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 4 - Page 7 of 9 Table 6: Household Demand and Expenditure on Health Care Quintile 1 2 3 4 5 Total A. Hlousehold expenditure on health care (Dalasi) Average annual household income 2074 5182 10,041 16,664 55,236 17,760 Average annual household health 749 521 763 772 1590 876 expenditure Average annual per capita health 62.4 52.1 76.3 96.5 318.0 109.5 expenditure % iricome spent on health 36.1 10.1 7.6 4.6 2.9 4.9 provision B. Demand for health care % c]hildren report illness or injury 38.8 41.1 38.8 38.2 39.7 38.7 w/im past 2 weeks % c]hildren report illness or injury 34.7 53.7 45.9 35.8 36.0 41.7 who consulted health provider % private health consultations 24.5 27.2 27.2 33.9 43 31.1 The -survey indicates that private household health expenditures are significant. Average annual household health expenditure - comprising health consultation, medicine and travel costs to/from facilities - comprised D876 or nearly $90. On a per capita basis, average private health expenditures were DI09 or approximately $11. This compares favorably with public health expenditures which were approximately $6.5 in 1993/94. When compared with overall yearly household income, health expenditure comprises 4.9% of annual income. When the household survey is disaggregated into income quintiles, the findings indicate that the percentages of those falling sick and those consulting health providers is not significantly affected by income (access, however, varies on a divisional basis with travel times significantly higher in NBD and URD). The poorest households spend about D62.4 or $6.50 per capita on health while the wealthiest households spend up to D318 or approximately $35 per capita. However, despite higher health expenditures by wealthier households, health's share in total income is just a fraction that of poorer households. The percentage of total household income spent on health is 36% in the poorest quintile com:pared to just 3% in the wealthiest quintile. IV. Risk Analysis Several risks have been identified to the successful implementation of the project. These risks comprise both general risks in the overall policy environment and DSH implementation capacity, and specific risks related to specific project components. Successful implementation of the PHPNP will depend on sufficient Government recurrent financing to implement the proposed interventions in family services and primary and secondary level health care. While the additional recurrent costs generated by the PHPNP alone will be modest, other donor's and Government's own plans to expand the health sector suggest that the health sector's financing requirements will grow significantly and could pose a risk to project implementation. The major additional cost items which are known to require Government financing are the operating costs of Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Annex 4 - Page 8 of 9 the new Farafenni and Bwiam hospitals. While more accurate projections of recurrent expenditures are being undertaken in the PER and should be available in 1998, indications of Farafenni's operating budget is D22.7 million in its first full year of operation (Government Health Sector Requirements Study, 1996). Bwiam's bed capacity is currently planned for about 100 beds - less than half that of Farrafenni - and its operating budget is estimated at about D1I million. Thereafter, the hospitals' operating costs would increase at an annual rate: of 15% based on historical rates of expansion. The additional two hospitals would require a 45% increase in overall DSH expenditure.- Such an increase would represent a major shift in the functional composition of recurrent expenditures towards tertiary level care and could put the PHPNP emphasis on primary and secondary health care at risk unless there are mitigating measures. The above increase in Government's financing requirements for hospital expansion is premised on the assumption that there be no changes in cost recovery policies. However, if higher cost recovery rates are adopted for tertiary level care, the effect of the additional facilities on the budget would be much less. The PHPNP will finance development of a health financing policy, as well as a study of the Bamako Initiative (BI), the current fee structure, fee exemptions, levels of cost recovery, and the ability and willingness of Gambians to pay for their health care needs. The results of the study will assist the Government in understanding the trade-offs it faces in constructing any additional hospitals and the need to compensate by charging higher rates for cost recovery. A further risk to project implementation is the limited human resource basis in The Gambia. Implementation capacity within the DSH to sustain and coordinate ongoing operations, undertake additional projects and programs, as well as review and develop the proper policy environment is limited. Human resource constraints within the DSH will be addressed through extensive training, Technical Assistance, the development of a staff retention and development strategy, and by utilizing NGOs and the private sector as much as possible to implement project components. Table 7 lists several implementing institutions and their activities. In gaining the assistance of these institutions, the DSH will be relieved from considerable work loads which will free resources it can concentrate on the formulation of health policies and the delivery of health services. Table 7: Institutional Arrangements Implementing Institution Activity GAMBLOOD Mobilize blood donors and supply blood to health facilities GAFNA Carry out a maternal supplement program GAMWORKS Rehabilitation of health facilities and maintenance Medical Research Council Getting research into policies, programs and training Risks of specific project components include risks associated with the need to rely on multiple donor support and the integrated nature of such support to achieve component objectives. An effective reproductive health strategy, for example, will rely on multiple donors to deliver IEC messages, supply sufficient and accessible contraceptives, and provide technical assistance. There is a risk that important gaps could be left in this strategy which could jeopardize its effectiveness. Similarly, the IMCI approach and associated infant and childhood interventions rely on sufficient drugs and vaccines to support the program, many of which are supported by other donors and Government. The PHPNP has attempted to provide sufficient flexibility in its design and resource allocation to fill key gaps should they arise. A risk observed in countries which have implemented IMCI is that health workers may resist change to the more integrated approach. To mitigate this potential risk, the PHPNP will begin to train a core group of health professionals early in the project to build ownership and involvement in the Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 4 - Page 9 of 9 approach. A nutrition policy has been discussed for many years, but with little action taken. This may reflect insufficient government ownership. Again, the PHPNP intends to involve high level Government officials in the policy process and has simultaneously agreed on programs that will give tangible results that can be scaled-up as appropriate. Finally, few explicit policy conditions have been set in the project. Rather, the PHPNP takes the approach that policy development is gradual and must be based on thorough information and analysis. The: project will support studies that will provide the basis for policy development and will review these stu(dies, as well as other proposals, to move the policy process forward to actual policy reform. The annual review meetings will provide a useful forum and will set and monitor benchmarks for measuring progress in policy formulation and implementation. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 5 - Page 1 of 1 Annex 5 Participatory Health, Population and Nutrition Project Financial Summary Years Ending December 31 Implementation Period 1999 2000 2001 2002 2003 Total Project Costs (US$m) Investment Costs 5.3 3.5 2.1 1.1 0.5 16.0 Recurrent Costs 0.6 0.6 0.7 0.7 0.3 3.2 PPF 0.8 Total 5.9 4.1 2.8 1.8 0.8 20.0 Financing Sources (% of total project costs) IDA 92 90 88 84 83 Government 8 10 12 16 1 7 Total 100 100 100 100 100 Project Appraisal Document Project Title: Participatory Health Population and Nutrtion Project Country: The Gambia Annex 6 - Page 1 of 8 Annex 6 Participatory Health, Population and Nutrition Project Procurement and Disbursement Arrangements Procurement Methods A Country Procurement Assessment Review (CPAR) was carried out in 1985. So far, findings of the CPAR remain valid. In general, The Gambia's procurement laws and regulations do not conflict with IDA Guidelines. No special exceptions, permits, or licenses need to be specified in the Credit documents for International Competitive Bidding (ICB) since The Gambia's procurement practices allow IDA procedures to take precedence over any contrary provisions in local regulations. The proposed project will be financed through IDA and Govemment funds. All Bank-financed procurement of goods and services under the project will be carried out in accordance with World Bank Guidelines: Procurement under IBRD Loans and IDA Credits, January 1, 1995, revised January and August 1996, and under Selection and Employment of Consultants by World Bank Borrowers, January 1997. Preference for domestically manufactured goods will apply in accordance with the World Bank Guidelines. The procurement methods applicable to expenditures financed by the IDA credit are summarized in Table A. International Competitive Bidding (ICB). To the extent practicable, contracts for goods will be grouped in bid packages estimated to cost an amount equivalent to US$ 100,000 or more for each package and procured in accordance with the Guidelines: Procurement under IBRD Loans and IDA Credits, January 1, 1995, revised January and A ugust 1996 and September 1997. National Competitive Bidding (NCB) procedures acceptable to IDA will be used for all goods and works contracts that cannot be grouped into packages of at least US$ 100,000. NCB procedures will include: (a) explicit statement of the evaluation and award criteria in the bidding documents; (b) national advertising with public bid opening and time allowed for the preparation of bids not less than four weeks from the date of invitation to bid or the date of availability of bidding documents, whichever is later; (c) award to the lowest evaluated bidder; and (d) foreign bidders would not be precluded from participating in NCB. IDA Standard Bidding Documents to be used for NCB were agreed upon during negotiations. Other Procedures include : (a) National Shopping procedures in accordance with provisions of paragraph 3.5 of the Guidelines will be used for works (construction and maintenance) and goods (purchase and maintenance) estimated to cost less than US$25,000 equivalent per contract, up to an agrgregate of US$2.6 million; (b) Consultant Services that will be carried out in the following way: (i) Quality- and Cost-Based Selection (QCBS) procedures for all contracts estimated to cost an amount equivalent to US$75,000 or more; (ii) Least Cost Selection (LCS) for audit contracts to cost less than US$100,000; (iii) Consultants' Qualifications for individual consultants; and (iv) Single Source Selection (SSS) for specific tasks in cases where only one firm has specific qualified experience; and (c)Services ofrUNprocurement agencies for the purchase of limited quantities of drugs, small medical equipment and contraceptives which cannot be grouped into ICB packages, estimated to cost less than US$100,000 per contract, up to an aggregate of US$1.0 million. Procurement will be handled by the PIU reinforced by a procurement officer. In order to reduce the workload of the PIU and the need of consultants, the implementation of all civil-works (construction/rehabilitation and maintenance) financed by IDA credit will be delegated by DSH to the local Construction Management Agency (GAMWORKS), which will contract out consultants services for the preparation of detailed design and bidding documents and to contractors for the execution of the works. The DPI will be responsible for the overall planning of the works and any information needed by Project Appraisal Document Project Title: Participatory Health Population and Nutrition Project Country: The Gambia Annex 6 - Page 2 of 8 GAMWORKS to prepare the detailed design and bidding documents. Also, procurement of small specialized equipment, drugs and contraceptives may be done through IAPSO for specialized equipment, WHO, UNICEF and/or UNFPA for drugs and contraceptives - in accordance with the provisions described below for the procurement of goods. Table A: Project Costs by Procurement Arrangements (a) (in US$m equivalent) (b) Prn,iarpmpnt Mpthnrl International National Other Competitive Competitive Procedures N.B.F RoiHiongi Riddling (e') (H) _Tnft:l A. Investment Civil works - 1.9 1.0 - 2.9 (1.7) (0.9) (2.6) Equipment 2.5 0.4 0.7 - 3.5 (2.5) (0.3) (0.6) (3.4) Pharmaceuticals - 1.0 - 1.0 (1.0) (1.0) Training - - 2.4 - 2.4 (2.2) (2.2) Consultant Services - - 5.1 - 5.1 (4.8) (4.8) LIF - - 0.5 - 0.5 (0.5) (0.5) B. Recurrent Costs Operating Costs - - 1.8 - 1.8 (1.6) (1.6) Building Maintenance - - 0.6 - 0.6 (0.3) (0.3) Equipment Maintenance - 0.3 0.3 - 0.7 (0.2) (0.2) (0.4) Personnel - - - 0.1 0.1 C. PPF - - 0.8 - 0.8 (n4R) (n R) Total 2.5 2.6 14.1 0.1 19.4 (2.5) (2.2) (12.8) - (17.5) Notes: (a) Procurement arrangements in the above Table A apply to US$17.5 out of the credit amount of US$18.0 and do not include an amount of US$ 0.5 million which will be allocated, according to needs, during annual reviews. Related procurement arrangements for this amount will be decided simultaneously. (b) Figures may not add up due to rounding. Figures in parenthesis are amounts to be financed by IDA. (c) Other procedures include National Shopping, procedures for Consultant Services and procurement through UN agencies. (d) N.B.F. = Not Bank-financed Civil works, goods and services. Civil works. Civil works contracts include: the construction/reconstruction of up to 12 Dispensaries; the rehabilitation of 9 others, of surgery theaters, laboratories and bleeding rooms in 5 Major Health Centers, and of maternity wards in the latter Centers and 5 Minor Health Centers, located in all regions, and the maintenance of all peripheral health facilities. Costing less than US$100,000 per contract, up to an aggregate of US$1.9 million, they would be procured through NCB procedures in accordance with procedures described in the Project Operations Manual (POM) and acceptable to IDA. Bidding procedures and contracts will be managed by the Contract Management Agency (CMA) that will maintain and update a roster of contractors eligible to NCB, according to procedures acceptable to IDA Project Appraisal Document Project Title: Participatory Health Population and Nutrition Project Country: The Gambia Annex 6 - Page 3 of 8 and spelled out in the POM. Contracts for small works (construction and maintenance) estimated to cost less than US$25,000 per contract, up to an aggregate amount of US$1.0 million for construction and US$0.6 million for building maintenance, would be procured by the CMA under lump-sum, fixed-price contracts awarded on the basis of quotations obtained from three qualified domestic contractors invited to bid by way of discounts either on the total price or on the unit prices. The invitation shall include reference unit prices established by an engineer, a detailed description of the works, including basic specifications, the required completion date, a basic form of agreement acceptable to IDA, and relevant drawings where applicable. The award would be made to the contractor who offers the lowest price quotation for the required work, provided he demonstrates he has the experience and resources to complete the contract successfully. These contracts will mostly be small works in rural areas. Goods. Most contracts for goods financed by IDA related to the procurement and maintenance of medical equipment and supplies (for dispensaries, surgery theaters in major HC and all maternal wards for major and minor HC), furniture, office equipment, computers and vehicles would be procured through ICB. Contracts for procurement and maintenance of office furniture and equipment, vehicles and materials locally available, and contracts for maintenance of biomedical equipment which cost more than US$25,000 but less than US$100,000 per contract, up to an aggregate amount of US$0.7 million (including US$0.3 for maintenance contracts) would be procured through NCB procedures acceptable to IDA. Procurement of small equipment, printed materials for IEC, textbooks and other instructional materials, furniture and vehicles, and small contracts for equipment maintenance, costing less than US$25,000 equivalent, up to an aggregate amount of US$1.0 million (including US$0.3 million for maintenance), will be procured through prudent national shopping on the basis of quotations obtained from at least three reputable suppliers. Spare parts, operating expenditures, minor off-the-shelf items, pharmaceuticals and other proprietary items costing less than US$5,000 equivalent per contract up to an aggregate of US$50,000 equivalent, may be procured directly from manufacturers and authorized local distributors. Pharmaceutical, small medical equipment and contraceptives which will be difficult to group into ICB packages and costing less than US$100,000 per contract, up to an aggregate amount not to exceed US$1.0 million over the project duration, would be procured respectively through UNIPAC, UNICEF, the UNDP's Inter-Agency Procurement Services (IAPSO) and UJNFPA. Consultants' Services. Consulting Services financed by IDA would be for: (i) studies - health policy including national nutrition and drug policies and health sector financing policy, staff retention stirategy, health mapping and needs assessment, computerized financial management and information system (FMIS) and health information system (HIS), nutrition studies, IMCI, social marketing program, STI/HIV prevention, Bamako Initiative, operations research, architectural designs for dispensaries, preparation of bidding documents, maintenance of facilities and other technical studies as needed; (ii) consultancies on technical matters; (iii) training of health personnel; (iv) community mobilization and training, IEC activities, monitoring and evaluation; and (v) project management. Consultants will be hired through competition based on Quality- and Cost-Based Selection (QCBS) among qualified short- listed firms, by evaluating the quality of the proposal before comparing the cost of the services to be provided. The Least-Cost Selection (LCS) will be used for audits - the firn with the lowest price will be selected, provided its technical proposal received the minimum mark. Services for small studies will be procured from Individual Consultants (IC) selected through comparison of qualifications of those expressing interest. Single Source Selection (SSS) will be exceptionally used for the management of civil work contracts (construction and maintenance), for community-based programs, and for a limited research program. The Government of The Gambia proposes to select: (a) the Gambian Agency for the Management of Civil Works (GAMWORKS) as a Construction Management Agency (CMA) through a contract estimated at US$0.15 million - this AGETIP-type agency created under the IDA financed "Public Works and Capacity Building Project" has successfully proven its capacity to manage civil-works contracts since 1995; (b) two local NGOs through contracts approximately estimated at US$0.3 million each - these NGOs are the only private nation-wide-experienced organizations in their respective field of expertise, namely: (i) the Gambia Food and Nutrition Association (GAFNA) for food supplementation Project Appraisal Document Project Title: Participatory Health Population and Nutrition Project Country: The Gambia Annex 6 - Page 4 of 8 and nutrition; and (ii) the Gambia Blood Association (GAMBLOOD) for grassroots blood donor mobilization; (c) the Medical Research Council (MRC) through a contract estimated less than US$0.1 million -- this Gambia-based British institution is world-wide renowned for its research. Contracts will be up for two years, and thereafter annually renewable after assessment of performance against pre- determined indicators spelled out in the respective contracts. Methods for consultants' selection are summarized in Table Al. Short-lists for contracts estimated under US$150,000 may be comprised of national consultants provided that a sufficient number of qualified firms (at least three) are available at competitive costs. However, if foreign firms have expressed interest, they will not be excluded from consideration. The standard Letter of Invitation and Form of Contract as developed by the Bank will be used for appointment of consultants. Simplified contracts will be used for short-term assignments of individual consultants, i.e. those not exceeding six months. The Government was briefed during negotiations about the special features of the new guidelines, in particular with regards to advertisement and public bid opening. To provide flexibility during project implementation, activities to be financed by IDA are defined in detail before project start for a total amount of US$17.5 million representing 97% of the credit amount of US$18 million, leaving an amount of US$0.5 which will be defined, according to needs, during annual joint reviews of the Government and IDA. Procurement arrangements for this latter part of the Credit will be simultaneously and jointly defined. Support for NGO activities for community based nutrition programs and blood donor mobilization selected on a sole source basis. These NGOs will sign an agreement with the PIU for the activities described in their terms of reference estimated to cost less than US$0.3m for GAFNA and US$0.3 for GAMBLOOD according to procedures defined in the relevant sections of the Project Operations Manual. The agreements will stipulate that (i) procurement procedures carried out by NGOs will conform to the above mentioned procurement provisions for goods, civil works, and services; (ii) the NGOs will receive an advance of 30% for the estimated costs for a year of activity; and (iii) eligible expenditures will be reimbursed at 100% on the basis of documentation justifying expenditures and the procurement methods used for these expenditures. Local Initiative Fund (LIF) The LIF provides small financial support to communities for developing innovative and experimental micro-projects that will contribute to the achievement of project objectives at grass-roots level. Funds will be made available to community-based organizations (CBO) for the financing of eligible micro-projects according to the LIF Implementation Manual (LIFIM). A first version of the LIFIM has been developed and tested during a pilot phase implemented in two regions during project preparation with JPHRD resources. Based on the lessons learned, a revised version of the LIFIM acceptable to IDA will be submitted by the Government as a condition for disbursements on the LIF which will be expanded to a third region. IDA Reviews Contracts for goods and works above the threshold value of US$100,000 equivalent will be subject to IDA's prior review procedures. Contracts awarded below this threshold will be subject to post- review during IDA's supervision missions. During negotiations, it was agreed that the Government will use Bank standard bidding documents for NCB. Prior IDA review will not apply to contracts for the recruitment of consulting firms and individuals estimated to cost less than US$75,000 and US$35,000 equivalent, respectively. However, the exception to prior review will not apply to the Terms of Reference of such contracts, regardless of value, to single-source hiring, to assignments of a critical nature as determined by IDA, or to amendments of contracts rising the contract value above the prior review threshold. For consultant contracts estimated above US$75,000, opening the financial envelopes will not take place prior to receiving the Bank's no-objection to the technical evaluation. Documents related to Project Appraisal Document Project Title: Participatory Health Population and Nutrition Project Country: The Gambia Annex 6 - Page 5 of 8 procurement below the prior review thresholds will be maintained by the borrower for ex-post review by auclitors and IDA supervision missions. The first five contracts with Communities for Micro-Projects financed through LIF will be subject to prior review during the first year of the Project. Annex 6, Table Al: Consultant Selection Arrangements (in US$tbousand equivalent) CatP- Comp Selection Method Total cost (inclu- gory onent Nature of Consultations QCBS ICS IC SS Other ding contingencies) A. 1 Reproductive Health Firms 1.1 Maternal Health Services - Development of Inservice training, codes, guidelines, ToT X 71 1.2 Prevention of Unwanted Pregnancies - Social Marketing Program (Int TA & Nat TA) X 499 1.3 STI/HIV Prevention and Management - Development of curriculum, ToT, training, manual, guidelines X 52 2 Integrated Management of Childhood llnesses - Development & Implement. of IMCI (incl. Int TA & Nat TA) X 165 3 Nutrition Policy and Services for Women, Infants and Children 3.1 Nutrition Policy Formulation & Institutional Strenghtening - Nutrition policy, including 5 main themes (int TA & Nat TA) X 370 3.2 Community / Micronutrient Nutrition Programs - Strategy, program revision, specific studies, program eval. X 231 - Community nutrition program implementation (GAFNA) X 324 4 Management & Implementation of Family Health Program 4.1 Capacity Building and Policy Development - Needs Assess / Health Map / Health Policy X 153 - Maintenance Policy and Implementation X 212 - Health Financing (Int TA & Nat TA) X 122 - Research Program (MRC) X S0 - Development of Drug Policy and Bamako Initiative (int & Nat) X 92 -Financial MIS and Health MIS X 410 - IEC development X 65 - HMIS & HIS Administrators X 264 4.2 Up-grading and Maintaining Health Infrastructures - Architectural Studies and Site Supervision X 267 - Contract Management Agency - GAMWORKS (const & maint) X 154 - Expansion of Blood-donors Support and Blood Supply X 275 4.3 Project Management - Auditing Services X 83 - Procurement Training X 39 B. I Reproductrve Health Indi- 1.1 Matemal Health Services vi- - Consumer Survey X duals - Development of Strategy for Emergency Evacuation X - IEC activities related to FGM (several contracts) X 4 1.2 Prevention of Unwanted Pregnancies 10 - Design TOR for the Social Marketing Program X 3 Nutrition Policy and Services for Women, Infants and Children 3.1 Nutrition Policy Formulation & Institutional Strenghtening Nutrition Coordinator X 82 4 Management & Implementation of Family Health Program 4.1 Capacity Building and Policy Development - Drug Policy and Development of Bamako Inititative X 26 - Conceptualization of sectorwide Manag & Infomm System X 13 - Development of low literate materials X 27 - IEC Coordinator X 82 4.3 Local initiative Fund - Technical & Financial Evaluation X 14 - LIF Coordinator X 82 4.4 Proiect Management - Project Manager X 99 - Deputy Project Manager X 82 - HNP Advisor X 82 - Procurement Officer X 82 - Financial Manager (Senior Accountant) X 82 - Assistant Accountant X 41 - Provision (several contracts) X 115 Note: QCBS = Quality- and Cost-Based Selection; LCS = Least-Cost Selection; IC = Individual Consultant; SS= Single Source; Other = GAMWORKS' procurement procedures as stated in GAMWORK's Procedures Manual Project Appraisal Document Project Tdle: Participatory Health Population and Nutrition Project Country: The Gambia Annex 6 - Page 6 of 8 Table B: Thresholds for Procurement Methods and Prior Review ** (in US$ equivalent) Expenditure Category Contract Value Procurement Method Contract Subject to (Threshold) ICB NCB Other Prior Review uss ioo,ooo or more - ~~US$100,000 or more 1. Works Construction US$ 100000 or morer e l , l l ~~~~~~~~~~~Prior IDA review Construction & below US$100,000 - No prior review. Maintenance US$25 000 or more Aggregate amount | ___________ i ___________________ '_____________ l_______ _ l U S$1.9 m illions Construction . below US$25,000 - - No prior review. l CostrCtl° &l below US$2500 °° X i Aggregate amount Maintenance Ageaeaon M aintenance ___________ '_________________ i____________ _________ US$1.6 million 2. Goods US$ 100,000 or more X- - US$100,000 or more 2. Goods US$ or Prior IDA review l below US$100,000 i i No prior review. below US$100,000 m X - Aggregate amount US$25,000 or more IU$. ilo proc. through |UN Agencies |below US$100,000 X Aggregate amount l(includ. drugs, lI US$1.0 million contraceptiVes) 4 - i__ _ __ _ _ _ !__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ No prior review. l below US$25,000 - - X Aggregate amount ______ _ _ ~ 2 ___ US$1.0 million below 5,000 direct purchase from l No prior review. manifacturers for - - I Aggregate amount authorized dealers for [ US$50,000 _ proprietary items i 3. Services Audit N/A N/A l N/A Least Cost Prior Review -------------------------- Prior Review of Convention + Review of work and I ~~~~~Sole service contracts managed GAMWOKS US$150,000 or more N/A N/A Soue b s AMWora s ! l [ ~~~~~~~~Source by GAMWORKS according to present l ________ i _____________ j__i_ threshold Table GAFNA Sl GAMBLOOD US$75,000 or more N/A N/A Prior Review MRC Source Prior Review + Review of Firms US$75,000 or more N/A N/A l QCBS Technical Evaluation before opening financial proposal below US$75,000 N/A N/A Consultant's Post Review, Qualification except TOR Consultant's US300orme Individuals US$35,000 or more N/A N/A US$35,000 or more Qualificationi Prior Review ! [ i i ~~~~~~~~~~~~~~below US$35,000 below US$35,000 N/A N/A Csualtaonto Ueve3, Qualification otReiw _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _except TO R NB: * Including Maintenance. ** Prior review also required for the first five NCB contracts for goods each project year, regardless of the amount, and for the terms of reference for all consultants, including studies and training. IProject Appraisal Document Project Title: Participatory Health Population and Nutrtion Project Country: The Gambia Annex 6 - Page 7 of 8 All thresholds stated in this section shall be reviewed by the Borrower and IDA on an annual basis. Modifications may be agreed upon, based on performances and actual values of procurement implemented. Amendments to the Development Credit Agreement may be prepared as necessary. As a condition of negotiations, the Government submitted to IDA a draft first-year Project Implementation Plan for Project Management, a draft Operation Manual and a draft Procurement Plan. The Government gave assurances it will take the necessary measures so that the various steps for procurement procedures will not be longer than the following: Steps Maximum number of weeks - Preparation of bidding documents 4 (12 for large contracts) - Preparation of submissions by the bidders 4 (12 for ICB) - Bid evaluation 2 (4 for large contracts) - Contract Signature 4 - Payments 4 During negotiations, the Government proposed using The World Bank's standard bidding documents for NCB procedures for civil works and goods, and agreement was reached on the proper monitoring of procurement. As a condition of effectiveness, the Government will submit to IDA a Project Operations Manual. The Government gave assurances at negotiations that it will: (a) use the Project Operations Manual for Project Implementation; (b) use the LIFIM; (c) use the Bank's Standard Bidding Documents; (d) apply the procurement procedures and arrangements outlined in the above documents; and (e) review the procurement plan and procurement arrangements each year at the annual review with IDA. Disbursement Allocation of credit proceeds. The project is expected to be completed over a five-year period according to the categories shown in Table C, and the credit closing date would be six months after the fifth year to allow payment of last invoices for contracts completed before the completion time. Government's counterpart funds needed for each fiscal year to cover the share of investments and recurrent costs not financed by IDA will be deposited by the Government in a Project Account (PA) managed by the PIU Manager, not later than January 31 each year. This amount includes amounts for maintenance of building, equipment and vehicles. The Government has given assurances at negotiations that the allocations for maintenance of building, equipment and vehicles will be increased each year in order to reach respectively 1%, 2% and 2.5% of the assets' value in 2003. The Credit includes provisions to match the increase of the public maintenance budget. Use of statements of expenditures (SOEs). Disbursement of the IDA Credit for contracts valued at less than US$100,000 equivalent for civil works and goods, and less than US$75,000 for consulting firms (US$35,000 for individual consultant contracts), and local training, grants under the LIF, operating c:osts, and maintenance will be made against Statements of Expenditures, (SOEs) for which clocumentation would be made available for examination by auditors (including technical audits) and by IDA supervision missions. Special account. To facilitate disbursements, the government will open a Special Account (SA) at the Central Bank of The Gambia for the IDA's share of eligible expenditures. All IDA expenditure of less than US$100,000 equivalent would be paid from the SA. The authorized allocation would be US$875,000 representing about three months of disbursement. IDA would make an initial deposit of US$500,000 upon credit effectiveness. Once payments through the SA will amount to US$500,000, the Project Appraisal Document Project Tite: Participatory Health Population and Nutrition Project Country: The Gambia Annex 6 - Page 8 of 8 fully authorized amount will be paid. Disbursement of the IDA credit would be fully documented. All supporting documentation will be retained by the DSH or GAMWORKS, and will be available for review as requested by IDA supervision missions and project auditors. Annex 6, Table C: Allocation of Credit Proceeds Expendture CtegoryAmount Expenditure Category | (in US$ million) Financing Percentage 1. Civil Works 2.39 100% of foreign and 1. Civil Works 2.39 90% of local expenditures 100% of foreign and 2. Equipments 3.21 90% of local expenditures 100% of foreign and 3. Phannaceuticals / Commodities 0.92 90% of local expenditures 4. Consultant services 4.55 100% 5. Training 2.32 100% 6. Grants under the Local Initiative Fund 0.45 100% 7. Operational costs 1.47 90% 8. Maintenance 0.26 50% 9. Unallocated (a) 1.68 10. PPF 0.75 Total financed by IDA 18.00 Note (a): The unallocated category includes an amount of US$0.5 which will be allocated during annual reviews to finance new expenditures (not defined in the PAD) identified during annual reviews Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 7 - Page 1 of 2 .Annex 7 Participatory Health, Population and Nutrition Project Project Processing Budget and Schedule A. Project Budget (US$000) Planned Actual (At final PCD stage) Through FY97 605.0 605.0 (since 1993) (since 1993) FY98 132.4 132.4 B. Project Schedule Planned Actual (At final PCD stage) Time taken to prepare the project 15 15 (months) First Bank mission 2/93 2/93 (identification) Appraisal mission departure 11/15/97 11/23 /1997 Negotiations 1 /15/1998 02/17/1998 Planned Date of Effectiveness 6 /30/1998 / /19 Prepared by: The Gambian Department of State for Health, Social Welfare and Women's Affairs Preparation assistance: PHRD Grant (US $600,00 equivalent); PPF (US $750,000); Netherlands Consultant Trust Fund (US $33,000 equivalent); Swedish Consultant Trust Fund ($100,000). Bank staff who worked on the project included: Name Specialty Bernard Abeille Procurement and Implementation Amy Ba Staff Support ]Premila Bartlett IEC Specialist (Consultant) Alan Berg Nutrition Logan Brenzel Health Economics David Bruns Health Economics Shiyan Chao Health Economics Rudi Chevannes Staff Support 'Veerle Coignez-Sterling Pharmaceuticals Sharon Cox Gender Pedro De Bias Martin Legal E]dna Jonas Reproductive Health lIans Lindblad Child Health (Consultant) Soheyla Mahmoudi Disbursements Milla McLachlan Nutrition (Consultant) Sigal Nissan-Felber Staff Support Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 7 - Page 2 of 2 Kees Kostermans Public Health Ok Pannenborg Health, Nutrition, Population Angelika.Pradel Public Health Claudio Schuftan Operations Richard Seifman Nutrition Robert Soeters Public Health (Consultant) Serge Theunynck Procurement, Implementation Debrework Zewdie Reproductive Health Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 8 - Page 1 of 2 Annex 8 Participatory Health, Population and Nutrition Project Documents in the Project File A. Project Implementation Plan B. Bank Staff Assessments - Initial Executive Project Summary, May 1993 - Implementation Completion Report, Report No. 15738, National Health Development Project - Mission Aide Memoires and Back-to-Office Reports (BTOR) of: * August 10, 1994, Aide Memoire * March, 1996 BTOR * December 9-21, 1996, Participatory Health, Population, and Nutrition Project consensus workshop * February 14-21, 1997 - Appraisal Mission Aide Memoire of November 23, 1997 - Technical Notes of Appraisal Mission of November 23, 1997 - Portrait of the Health System in The Gambia; August 1994 C. Other - Government of The Gambia's Presentation of the Participatory Health, Population and Nutrition Project and Its Commitments, December 12, 1997 - The Republic of The Gambia "Health Policy: 1994-2000; Improving Quality and Access" - The National Population Policy, The Gambia - The Gambian National Drug Policy - The Strategy for Poverty Alleviation, The Gambia - National Poverty Alleviation Program, The Gambia - "Vision 2000 - The Gambia Incorporated, May 1996 - 1993 Population and Housing Census - 1997 World Development Indicators, March 1997 - Assessment of the State of Dilapidation of Secondary Health Facilities in The Gambia - Cost Analysis of the Health Care Sector in The Gambia (WHO and Ministry of Health, June 27, 1995) - Gambian Contraceptive Prevalence and Fertility Determinants Survey GCPFDS - 1990, January 1993 - The Gambia Contraceptive and ORS Social Marketing Program; PSI, prepared for The Government of The Gambia; August 1995 - Program Review and Strategy Development (PRSD); UTNFPA/Government, August 1996 draft - Rapid Assessment of Sexually Transmitted Diseases in The Gambia, May-August 1994 draft - Report of the 1990 Maternal Mortality Survey; The Republic of The Gambia, The Ministry of Health and Social Welfare, September 1991 - The Gambia Strategy Paper; September 1997 - The Gambia, An Assessment of Poverty, Report No. 11941 -GM, June 30, 1993 Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 8 - Page 2 of 2 - The Gambia; National Human Development Report, (UNDP in collaboration with the Central Statistics Department Banjul, 1997 - Traditional Birth Attendants Training Manual; Department of Health Services, Ministry of Health, The Gambia, and Save the Children Federation, 1992 - Report on a Study Tour to Kenya; Participatory Health, Population and Nutrition Project, March 1997 - Baseline Survey of Maternal Health Services; Participatory Health, Population and Nutrition Project, 1997 draft - Survey on Maternal Health Services in The Gambia; Report on Focus Group Discussions held with Beneficiaries and Service Providers on their Perceptions of the Quality of Health Care Services, October 1997 - Social Marketing of Contraceptives; Participatory Health Population and Nutrition Project, 1997 draft - Reproductive Health Training Needs Assessment Report and First Year Reproductive Health Training Plan; Participatory Health, Population and Nutrition Project, September 1997 draft - Blood Banks and Transfusion Services and Vaccine Cold Storage; Participatory Health, Population and Nutrition Project, 1997 draft - Report on the Preparation of a Framework and Action Plan for a Nutrition Policy and Review of the Nutrition Component of the PHPNP, October 1997 Project Appraisal Document Project Tile: Parilcipatory Healilt, Population and Nutiitlon Project Country: The Gambia Annex 9- Page 1 ol 2 Aiitiex 9 Shtciticn( of Loamais :ii. Credi(s Stuitls or IIBaia c(iotup, Olicr-"tiois it, Guintbia, '1'nie 1IBRID L,oans :111(1 I)A CrcIits in (lic Opcrfitions l,o,tfolio (as of January 31, 1998) Difllerence Between expected Ozl lnal Amount In US$ Hillons and actual Loan or Fiscal disbursements a/ Project ID Credit Year Dorrower PuIpose NEo. 10)IID IDA Cancellations Undtabursed Oriq rcm Rev'd Itumber of closed Loana/credits: 20 Active Loans G34-PE-1328 IDA25540 1994 RCPUnIl.IC OF TIIE GAH Puni. wi)Ks £ CAlP m.t) 0.00 11.00 0.00 .86 .61 .61 QI-PE-631 IDA26020 1994 REPUWlC OF TItI GAM EIsYIFllir FiGHiT CAP 111. o.00 2.60 0.00 1.28 1.25 1.25 Gil-PE-file 10A24530 1993 RIEPU0LIC Of TIIE GAIIB1A AG SEIIVICES 0.03) 12.30 0.00 .34 -.79 0.00 Glt-PE-821 IDA21420 1990 GOVEtIMEIIT £DUC SE:CTOR CIREDIT 0.00 14.60 0,00 1.46 -.18 0.00 Total 0.00 40.50 0.00 3.94 .95 1.92 Active Loans Closed Loans Total Total Dlsburaed (0RD0 and IlAIt 30.85 130:3 169.7e1 of whitci bas been repald: 0.00 6.41 6.41 Total now held by lon and IDA: 40.50 115.09 155.59 Amount sold : 0.00 0.00 0.00 Of which repaid : 0.00 0.00 0.00 Total Ua:dtsbursed a 3.94 .36 4.70 a. Intended ulishuraements to (late minus actual disbursements to date as pro)ected at appraisal. b. Rating of 1-1: see oD 13.0%. Annex 02. Preparation of Implementation Siuemnay (Form 591ll. l'ollowlni the 1Y94 Aniuiiual Review of Porttollo performance IARPPI, a letter based system will be used IIS - highlly Satls:factoty, S - satisfactory, t . unisatisfactoty, IIU 1g1q1hly un1sat.l3actoryI: see proposed lmprovemeunts In Puoject and Porttolio Performance Rating Hethodology lSecH94-90t), August 23, 1994. Note: Disbursement data is updated at the end bf the first week of tLie month. Project Appraisal Document Project Title: Parddpatory Health, Popuaton and Nutrion Project Country: The Gambia Annex 9- Page 2 of 2- Gambia, The STATEMENT OF IFC's Committed and Disbursed Portfolio As of31-Jan-98 (In US Dollar Millions) Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic Loan EquitY Quasi Partic 1984/90 Kombo Beach 0.00 0.00 0.00 0.00 0.00 0.00 . 0.00 0.00 1993 AEF Ndebaan .20 0.00 0.00 0.00 .20 0.00 0.00 0.00 1993 AEF Radville .40 0.00 0.00 0.00 .40 0.00 0.00 0.00 1994 AEF Lyefish .37 0.00 0.00 0.00 .37 0.00 0.00 0.00 Total Portfolio: .97 0.00 0.00 0.00 .97 0.00 0.00 0.00 Approvals Pending Commitment Loan Eauitv Ouasi Partic Total Pending Commintent: 0.00 0.00 0.00 0.00 Generated by the Operations Information System (OS) on 03/02/98 Project Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project Country: The Gambia Annex 10 -Page 1 of 2 Annex 10 The Gambia at a glance 8/28/97 Sub- POVERTY and SOCIAL The Saharan Low- Gambia Africa income Development diamond Population mid-1996 (millions) 1.1 600 3,229 GNP per capita 1996 (USS) 350 490 500 Life expectancy GNP 1996 (billions USS) 0.40 294 1,601 Average annual growth, 1990-96 Population (%) 3 6 2.7 1.7 GNP Labor force (%) 3.2 2.6 1.7 Gross per primary Most recent estimate (latest year available since 1989) capita enrollment Poverty. headcount index (% of population) 64 Urban population (% of toal population) 26 31 29 Life expectancy at birth (years) 46 52 63 Infant mortality (per 1,000 live births) 126 92 69 Access to safe water Child malnutrition (% of children under 5) - Access to safe water (% of population) 61 47 53 Illiteracy (% ofpopulation age 15+) 61 43 34 - Gambia, The Gross primary enrollment (% ofschool-age population) 76 72 105 Male 87 78 112 Low-income group Female 65 65 98 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1975 1985 1995 1996 Economic ratioe GDP (millions USS) 109.8 217.6 393.0 405.5 Gross domestic investment/GDP 12.2 12.5 26.4 25.5 Openness of economy Exports of goods and services/GDP 47.1 40.8 47.9 46.1 Grossdomesticsavings/GDP 15.2 5.1 -0.8 8.8 Gross national savings/GDP 15.2 -3.6 2.8 12 0 Current account balance/GDP 6.1 -16.3 -23.1 -13.0 Interest payments/GDP 0.0 0.2 0.9 1.2 Savings - Investment Total debt/GDP 12.2 112.6 108.3 Total debt servicelexports 2.6 10.4 10.7 6.3 i Present value of debt/GDP .. . 59.0 Present value of debt/exports .. .. 107.1 Indebtedness 1975-85 1986-96 1995 1996 1997-05 (average annual growth) - Gambia, The GDP 3.6 2.4 3.1 2.1 4.4 GNP per capita -1.1 0.2 0.7 -0.7 2 2 Lowincome group Exports of goods and services 3.0 2.3 13.0 -6.4 2.4 STRUCTURE of the ECONOMY 1975 1985 1995 1996 (% of GDP) Growth rates of output and Investment (%l) Agriculture 34.6 29 7 31.0 29.1 40 - Industry 10.2 11.4 141 14.0 30- Manufactunng 3.2 6.3 64 63 20- Services 551 58.9 54.8 56.9 10 0* . Private consumption 71.1 81.9 83.0 72.5 -10 91 92 93 94 9s 96 General govemment consumption 13.7 13.0 17.8 18.7 0GDI --D-GOP Imports of goods and services 44.1 48.3 75.1 62.8 1975-85 1986-96 1995 1996 (average annual growth) Growth rates of exports and imports (%) Agriculture 2.0 -02 2.9 -3.5 40 - Industry 2.6 1.6 5.7 2.3 i Manufacturing 90 2.3 -2.1 2.7 .2 Services 3.8 3.4 4.1 5.2 Private consumption -3 8 5.5 -2.6 -0.6 A, General govemment consumption 12.1 -5.6 -3.0 5.2 9 51 92 Gross domestic investment 6.0 6.1 36.5 -3.6 -20 - Imports of goods and services -3.5 4 2 31.0 -17.7 - Exports --0-Imports Gross national product 2.0 4 2 3.9 2.0 Note: 1996 data are preliminary estimates. The diamonds show four key indicators in the country (in bold) compared with its income-group average. If data are missing, the diamond will be incomplete. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 10 - Page 2 of 2 The Gambia PRICES and GOVERNMENT FINANCE 1976 1985 1995 1996 Domestic prkes Inflation (%) (% change) Is - Consumer prices 25.9 18.3 5.0 5.2 4 Implicn GDP deflator 16.7 53.6 5.1 3.1 1 Govenmment finance (% of GDP) - Current revenue 15.8 24.8 18.1 19.3 91 r2 93 54 95 aS Current budget balance . 1.4 0.3 0.7 GDPWde. -C- CPi Overall surplus/deficit .. -1.5 -12.2 -11.4 TRADE 1975 1985 1995 1996 (millions USS) Export and import levels (Ml. US$) Totalexports(fob) 57 65 119 111 2so Groundnuts .. Fish .. Manufactuires 5 Total imports (cif)47 8 21 8 Food .i Fuiel and energy 5 Capital goodsa Exportpriceindex(1987=100) .. .. 124 119 se 5s Import price index (1987=100) .. .. 120 125 z Exports osrlmports Ternms of trade (19S7=100) .. .. 104 95 BALANCE of PAYMENTS 1975 1985 1995 1996 (millions US$) Current account balance to GOP ratio (%l Exports of goods and services 66 88 184 181 0 Imports of goods and services 60 104 289 247 s 5i Resource balance 7 -16 -105 -66 1 i Net income 0 -24 4 -4 I j Net currenttransfers 0 5 18 17 -° I Current account balance, -tI before official capital transfers 7 -35 -91 -53 !i Financing items (net) .. 49 109 60 Changes in net reserves .. -14 -18 -7 *2 i Memo., Reserves including gold (mill US$) 29 2 104 100 Conversion rate (lcaLUS$) 2.0 5.0 9.5 9.7 EXTERNAL DEBT and RESOURCE FLOWS 1975 1965 1995 1996 (millions USS) ComposIton of total dobt, 1995 (mill. USS) Total debt outstanding and disbursed 13 245 426 IBRD 0 0 0 0 G IDA 5 35 162 166 16 E Total debt service 2 9 25 15 80 IBRD 0 0 0 0 ' B IDA 0 0 2 2 1\62 Compostion of net resource flows Official grants 2 20 18 24 Offcial creditors 2 13 6 -17 Private creditors 0 0 0 0 D Foreigndirectinvestmert 0 0 10 8 . c Portfolio equity 0 0 0 0 26 World Bank program Commitments 0 0 0 0 A - IRD E - Biatul Disbursements 1 4 12 10 B-IDA D- Othermultilateal F -Private Principal repayments 0 0 1 1 C- IMF G - Short-term Net flows 1 4 11 9 _ Interest payments 0 0 1 1 Net transfers 1 4 10 8 Development Economics 8f28197 Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 11- page 1 of 8 Annex 11 Detailed Project Design Summary1 Participatory Health, Population and Nutrition Project Narrative Summary Key Performance Indicators Monitoring and Evaluation Critical Assumptions CAS Objective Improved quality of life for Socio-political stability; the Gambian population economic stability and growth; no natural disasters or new health threats in The Gambia. Project Development Objective Improved family health - Maternal malnutrition reduced Health Surveys Improvements in: by 20% from baseline by 2003 Health Management (i) access to safe - Total Fertility Rate reduced by Information System drinking water and 10% from 6.0 (in 1993) (HMIS) sanitation; (ii) throughout the lifespan of the Census educational levels, esp. project (to be revised at annual among girls and reviews) women; (iii) food - 50% reduction in STI Household Surveys security; (iv) prevalence among pregnant Rapid Assessments of STIs infrastructure; and (v) women (prevalence of 25% acc. to environmental hygiene. 1994 rapid assessment) - Infant Mortality Rate reduced from 80/1000 to 65/1000 by 2003 - Child malnutrition reduced by 25% from baseline by 2003 Project Outputs Family health programs A. Improved Reproductive and policies given high Health Services priority, with new policies legislated and 1. a Improved technical la. Proportion of health providers Ia. Supervision reports; stakeholder ownership skills of reproductive health successfully trained according to results of pre- and post- expanded. service providers plan (target: 90%) training tests Satisfactory funding of lb. Increased utilization of lb. Increase in the utilization of lb. Routine records/reporting family health program prenatal and postpartum services by 10% per year care; Adequate donor coordination. I c. Increased number of I c. Increase in the number of I c. Routine records/reporting deliveries attended by deliveries attended by trained Key constraints outside trained health providers health providers by 5% per year the project addressed. Id. Increased number of Id. Proportion of referral facilities Id. Supervision reports; referral facilities that are appropriately staffed and equipped appropriately staffed and according to plan (target: 90% by equipped to handle obstetric end of project) emergencies ' T'arget values in key performance indicators 9.d, 9.e and 9.f are subject to revisions during the annual reviews and subject to the outcome of the maintenance policy. Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex II- page 2 of 8 le. Increased 1 e. Proportion reporting I e. KAP survey understanding of the knowledge and understanding of harmful effects of FGM harmful effects of FGM increased from 25% to 50% by end of project 2. Improved prevention of 2. Contraceptive Prevalence Rate 2. Reports from social unwanted pregnancies for modem methods increased marketing program and from from 14% to 22% by 2003 health facilities; 3. Improved prevention and 3.a Proportion of facilities in 3. Supervision reports; treatment of STIs and HIV which syndromic management of Routine records/reporting STIs implemented (target: 90% of facilities by end of project) 3.b Decreased the prevalence of STIs among pregnant women (target: 50% reduction by end of project) 3c. 50% increase in the proportion Social Marketing KAP survey of men and women reporting knowledge of at least two appropriate ways of protecting themselves from HIV, by the end of the Project B. Management of Childhood Illnesses Integrated Strengthened capacity to prevent, identify and treat main infant/child illnesses: 1. Health-seeking behavior la. Proportion of children 0-4 Ia. KAP study of parents improved months (inclusive) exclusively breastfed increased from 17% to lb. Increase of 50% in use of lb. Statistics from Central ORS by 2003 Medical Store and from Social Marketing Program I c. Reduction of 25% in number I c. BHF and VHW surveys of children brought to health worker later than appropriate by 2003 2. Diagnostic tools and 2a. IMCI systematic assessment 2a. BHF survey treatment protocols guidelines, diagnostic charts and developed/improved, treatment protocols available and integrated and used in every BHF facility by disseminated. 2000 2b. IMCI literacy-appropriate 2b. VHW surveys systematic assessment guidelines, diagnostic charts and treatment F'roject Appraisal Document Project Title: Participatory Health, Population and Nutrtion Project C ountry: The Gambia Annex 11- page 3 of 8 protocols available and used by 50% of all VHWs by 2003 3. Health workers skilled in 3a. 50% of staff of every BHF 3a. BHF survey correct and integrated case facility successfully trained in management IMCI and applying correct and integrated case management in every BHF facility by 2003 3b. 40% of all VHWs successfully 3b. VHW survey trained in IMCI and applying correct and integrated case management by 2003 C. Nutrition Policy Formulated and Improved Nutrition Services for Women, Infants and Children 1. Policy basis for nutrition la. National Nutrition Policy la. NNPC reports prograrns established and Council (NNPC) established in institutional coordination 1998 and appointment of a strengthened nutrition coordinator lb. Nutrition policy and action l.b National nutrition policy plan adopted in 1999 and action documents 1 c. Permanent coordination and 1 c. PIU progress reports implementation mechanism for nutrition policy established in 1999 2. Improved nutrition 2a. Nutrition component of pre- Curricula revisions capacity at all levels service training curriculum for Training reports nutrition-relevant workers revised by 1999 2b. 15 program managers trained in community-based nutrition programs by 2001 2c. 40 field level staff trained in community-based nutrition programs by 2003 2d. Two candidates trained at Master and Ph.D. level by 2003 3. Effective nutrition 3a. Revised strategy for nutrition PIU progress reports education strategy for education at community level in Training reports behavioral change place by mid-1999 KAP study implemented 3b. 250 communities implementing the revised strategy by 2003 3c. At least 40 peer counselors trained by 2003 3d. At least 40 CHNs trained by 2003 3e. At least 250 TBAs trained by 2003 Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 11- page 4 of 8 3f. Proportion of children < 4 months exclusively breastfed increased from 17% to 40% by 2003 3g. Percentage of children > 6 HRIS months receiving foods high in Supplement program protein, fats and sugar increased assessment from 50% to 70% by 2003 GAFNA semi-annual progress reports 4. Implementation of 4a. Reduction in reported low PIU progress reports community-based local birth weight in participating maternal supplements communities by 10% from program baseline assessment estimate, by 2003 4b. Strategy for the production and distribution of local supplements revised by mid- 1999 4c. 2,000 women in 240 villages receiving supplement per year by 2000 4d. 40 supplement distribution outlets implementing program by 2000 5. Effective strategy for the 5a. Strategy to prevent and control Strategy document prevention and control of IDA designed by 2000 IDA Protocol iron deficiency anemia Sb. Protocol for the prevention PIU progress reports (IDA) and treatment of IDA revised by Training reports 2001 Evaluation report 5c. IEC materials in IDA developed and distributed by 2001 5d. 100 community health workers and health facility workers trained in revised protocol by 2001. 5e. 75% of women regularly visiting ante-natal clinics receive iron daily for 6 months 5f. Effectiveness of revised protocol evaluated by 2003 6. Locally relevant strategy 6a. IDD strategy developed by IDD strategy document for prevention of iodine 2001 deficiency disorder (IDD) implemented 7. Effective intervention 7a. VAD prevalence determined VAD strategy document strategy developed against and strategy to combat VAD Evaluation report Vitamin A deficiency developed by 2000 (VAD) 7b. Effectiveness of diet diversification strategy for changing dietary practices pilot tested and evaluated by 2001 Prcject Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Coiuntry: The Gambia Annex 11- page 5 of 8 D. Improved Capacity to Manage and Implement a Family Health Program 1. Expansion of Bamako la. Fee structure, cost recovery BI study document Initiative (BI) aspects and inventory controls PIU progress reports analyzed by 1999 Training reports 1.b 24 additional BI facilities supported by 2003 l c. Trainers, health workers, communities participated in at least 30 workshops by 2003 2. Capacity built to 2a. IEC coordinator appointed in PIU progress reports implement and coordinate 1998 IEC strategy document IEC 2b. Comprehensive IEC strategy Training reports developed by 1999 Research reports 2c. All health education officers IEC Curriculum trained in integrated marketing KAP reports communications approach by 1999 2d. Formative research for message development on reproductive health, IMCI and nutrition conducted by 1999 2e. IEC training curriculum developed for inclusion in pre- service curricula of health workers by 2000 2f. 30 training workshops on inter-personal communication for health workers conducted by 2001 2g. KAP studies conducted in 1999 and 2003 3. Capacity built to (a) 3a. Design of a computerized 3a. Consultant's final report monitor and evaluate health integrated HMIS conceptualized approved by DSH in relation sector activities; (b) manage by end 1998 with DSFE sector financing resources; 3b. Networks including hardware 3b. DSH's official acceptance and (c) project and monitor and softwares HMIS in place and of works upon completion and investment and maintenance operational (including staff after checking plans training) by end of 1999 3c. Health activities tracked and 3c. Annual report on sector- monitored through the HMIS from wide health activities and 2000 results and work plan for following year 3d. Financing resources and 3d. Financial reports expenditures managed through the transmitted by PIU to DSH, HMIS from 2000 DSFE and all donors 3e. Maintenance program planned, 3e. Annual report on status of monitored and evaluated through physical facilities and the HMIS from 2000 maintenance program and work plan for following year Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 11- page 6 of 8 4. Capacity for 4a. Study to develop (a) 4a. Consultant's report planning/projecting the standardized definitions of the approved by DSH development of the health different layers of the health sector improved pyramid, (b) norms and standards for construction, equipment and staffing of health facilities at each level of the health pyramid, (c) mechanism and criteria for the evolution of the health, executed in 1999 4b. Health mapping mechanism, 4b. DSH's Operational including norms and standards for Directives for the each layer of the health pyramid implementation of the Health and criteria for projecting the Mapping mechanism; norms, evolution of the health system, standards and criteria approved by DSH by end 1999 published and disseminated 5. Research activities better Sa. Minimum of one operations 5a. Operations research integrated into health policy research undertaken in each (i) reports and service delivery reproductive health, (ii) infant and child health, and (iii) nutrition by 2003 5b. Necessary M&E surveys 5b. M&E reports undertaken for project PIU reports 5c. Minimum of two research 5c. MRC/Gambia programs directly linked to Government reports modifications in family health activities by 2003 6. Improved staff 6a. Staff development and 6a. Staff strategy document development and retention retention strategy in place by 2000 6b. Improved staff satisfaction by 6b. Staff surveys 2000 7. Health financing policy 7. High level workshop discusses Workshop reports developed and adopts new financing policies Health financing policy by 2000 document 8. Drug management and 8. Drug Action Plan up-dated by Drug Action Plan Document rational drug use improved 1999 9. Capacity built in the DSH 9a. Study for the development and 9a. DSH's approval of the for developing and implementation of an effective study implementing an effective maintenance policy executed by maintenance policy based mid-1999. on increased DSH 9b. Maintenance policy 9b. Maintenance policy maintenance budget and formulated and approved by mid- document outsourcing maintenance 2000. services 9c. Yearly maintenance budget for 9c. Documentation provided maintenance of buildings, by DSFE about yearly equipment and vehicle available to recurrent public budget voted PIU management in a separate and executed account and increased to 1% of building asset value, 2% of equipment asset value and 2.5% of Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 11- page 7 of 8 vehicle asset value at end of project 9d. Financial volume of Contracts 9d. GAMWORKS' quarterly signed for building maintenance reports transmitted to PIU represent 90% of DSH providing evidence of official maintenance budget for buildings acceptance of maintenance works upon completion and after checking 9e. Financial volume of Contracts 9e. PIU's reports prepared for signed for maintenance of Annual review equipment represent 80% of the maintenance budget for equipment in 2003 9f. Financial volume of Contracts 9f. PIU's reports prepared for signed for maintenance of vehicles Annual review represent 80% of the maintenance budget for vehicles in 2003 9g. Operation Manual for 9g. Directive issued by DSH Maintenance of buildings, for the use of the Maintenance equipment and vehicle approved Operation Manual and operational by end 1999 10. Selected primary and 10a. Delegation of civil-works IOa. Contract between PIU secondary health facilities management delegated by PIU to and Contract Management upgraded and equipped a Contract Management Agency Agency signed (GAMWORKS) at project start. 10b. (i) 6 dispensaries built/rebuilt lOb. GAMWORKS' quarterly in 1999 and 12 by 2000; (ii) 5 reports providing evidence of existing dispensaries rehabilitated official acceptance of works and equipped in 2000 and 9 by upon completion and after 2001 (iii) 5 waiting sheds built in checking, according to 1999 and 9 by 2000; (iv) 5 latrines planned schedule built in 1999 and 9 by 2000; (v) 5 maternity wards rehabilitated in Minor Health Centers by 1999; (vi) 5 laboratories, blood supply areas and surgery theaters rehabilitated and equipped by 2000; (vii) 20 staff houses for dispensaries built by 2001. 11. Capacity of I la. LIF micro-grants 1 la. LIF financial reports communities strengthened disbursement of $ 100,000 per for carrying out micro- year projects through Local Initiative Fund (LIF) 1 lb. LIF accomplishes its new I lb. LIF review in 2000 objectives by 2000 12. Capacity for project 12a. Project Coordination 12a. Quarterly project reports managernent (including Committee in place at project start issued and communicated to financial management and and meeting monthly during the participating Departments of procurernent) and first year of the project and bi- State and IDA. component coordination monthly thereafter. (including training and IEC 12b. Project Action Group in 12b. Monthly and coordination and M&E) in place at project start and meeting subsequently bi-monthly Project Appraisal Document Project Title: Participatory Health, Population and Nutrition Project Country: The Gambia Annex 11- page 8 of 8 place and operational, monthly during the first year of reports of the Project Action according to planned the project and bi-monthly Group regularly issued and disbursement schedule, PIP, thereafter. communicated to PCC and to Procurement Plan and IDA Schedule and Project 12c. Human Resources including 12c. Contract signed with Operation Manual Project Manager, Deputy Project each individual personnel, and Manager, Heath Advisor, effective assignment of civil Nutrition and IEC Coordinators, servants (support staff) Financial Controller, Accountant, Procurement Officer and Support Staff in place by mid 1998 12d. Offices provided adequately 12d. Supervision Mission for good conditions of work, as report well as equipment supply 12e. Project funds (government 12e. Review of the application budget and IDA Credit) are forms from PIU to WB and of monthly requested by PIU and WB payments, by Bank's timely received. supervision missions. 12f. Time schedule up-dated for 12f. Quarterly updates of the all procurement procedures vis a detailed procurement plan vis the planned time schedule agreed upon during negotiations. Project Components Input (budget per component) (Components to Outputs) A. Reproductive Health US$4.7m Project reports; supervision Staff and institutional Services visits mechanisms are adequate to carry out B. Integrated Management US$O.9m Project reports; supervision components. of Childhood Illnesses visits Appropriate monitoring C. Nutrition Policy and US$2.3m Project reports; supervision and trouble-shooting. Services for Women, visits Infants and Children D. Management and US$10.7m Project reports; supervision Implementation of a Family visits Health Program MAP OF THE REPUBLIC OF THE GAMBIA JBRD 22203 &ataa a aa aabaaapaOy/ N MAURITANIA awaet s a Th Wad CctI THE SENEGAL [ /XS E N E G A L -.... GAMBIs MALI ' 8 r- - - / \ - -. - g X a *,ssAuv .87 G U I N E A i ,.o r,, .~~~~~~~~~~~~~~~~~~~~~~~~~~~~~lsrw-~ , U NE tatetaaaascaaae taapaaAa GINE 4 r6T KLIE ERIA R AO IRN - - - - - - - -._ _._ -> - - - -DonioR - -- -- L N t3r" ro j / f (> Dlvirior herJaqurJrters >~~~~~~S-K-A" Z~ k F,4 I s N D ~~a OO Eo\ Ea~ a C q S d K uNC Rat BhLsio I aSlatao 20aE,aU E30ad / Ya_Inancino oudre', N13-'CA FHO Yt\x/ R / Sdd E R E ANJUL I - Sates ~ as / - _ lM-dbRC II C N4PCC d.11 ~ ~ Ea.s t THE GAMBIA t Gsesla, -- @CJSCateaIC~~~~~~~~~~~~~~~~~~~~~.t.)-p. \ No Ztgomchor