Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD2370 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT PROJECT APPRAISAL DOCUMENT ON PROPOSED FINANCING IN THE AMOUNT OF US$50 MILLION (INCLUDING AN IBRD LOAN AND SUPPORT FROM THE CONCESSIONAL FINANCING FACILITY) TO THE HASHEMITE KINGDOM OF JORDAN FOR A JORDAN EMERGENCY HEALTH PROJECT MAY 30, 2017 Health, Nutrition and Population Global Practice Middle East And North Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Exchange Rate Effective April 30, 2017 Currency Jordanian Dinar (JOD) JOD 0.710 = US$1 US$1.41 = SDR 1 FISCAL YEAR January 1 - December 31 Regional Vice President: Hafez M. H. Ghanem Country Director (Acting): Kanthan Shankar Senior Global Practice Director: Timothy Grant Evans Practice Manager: Ernest E. Massiah Task Team Leader(s): Aakanksha Pande ABBREVIATIONS AND ACRONYMS AB Audit Bureau CBA Cost-benefit Analysis CBJ Central Bank of Jordan CPF Country Partnership Framework COA Chart of Accounts CQS Selection Based on Consultants’ Qualifications CSB Civil Service Bureau DA Designated Accounts DLI Disbursement-linked Indicators EA Environmental Assessment ECHO European Commission’s Civil Protection and Humanitarian Aid Operations EVE Expenditure Verification Entity FBS Fixed Budget-based Selection FM Financial Management GBA+ Gender-Based Analysis Plus GBV Gender-Based Violence GCFF Global Concessional Financing Facility GDP Gross Domestic Product GFMIS Government Financial Management Information System GFSM Government Finance Statistics Manual GNI Gross National Income GOJ Government of Jordan GRS Grievance Redress Service HNP Health, Nutrition and Population IBRD International Bank for Reconstruction and Development ICT Information and Communications Technology IFR Interim Financial Reports IMCI Integrated Management of Childhood Illness IPF Investment Project Financing IsDB Islamic Development Bank LCS Least Cost-based Selection JEHP Jordan Emergency Health Project MENA Middle East and North Africa MCH Maternal and Child Health MOF Ministry of Finance MOH Ministry of Health MOI Ministry of Interior MOPIC Ministry of Planning and International Cooperation NEPCO National Electric Power Company NGO Non-governmental Organization NPF New Procurement Framework NPV Net Present Value PDO Project Development Objective PEFA Public Expenditure and Financial Accountability PHC Primary Healthcare Center POM Project Operations Manual PPP Public Private Partnership QCBS Quality- and Cost-Based Selection SDG Sustainable Development Goal STEP Systematic Tracking of Exchanges in Procurement TOR Terms of Reference UHC Universal Health Coverage UNFPA United Nation’s Population Fund UNHCR United Nation’s High Commission for Refugees USAID United States Agency for International Development UVE Utilization Verification Entity VSL Value of Statistical Life WA Withdrawal Application The World Bank Jordan Emergency Health Project (P163387) BASIC INFORMATION Is this a regionally tagged project? Country(ies) Financing Instrument No Investment Project Financing [✔] Situations of Urgent Need of Assistance or Capacity Constraints [ ] Financial Intermediaries [ ] Series of Projects Approval Date Closing Date Environmental Assessment Category 13-Jun-2017 29-Jun-2019 C - Not Required Bank/IFC Collaboration No Proposed Development Objective(s) The Project development objective (PDO) is to support the Government of Jordan in maintaining the delivery of primary and secondary health services to poor uninsured Jordanians and Syrian refugees at Ministry of Health facilities. Components Component Name Cost (US$, millions) Results based financing to deliver health care services at primary and secondary care 48.00 facilities of MOH for the target population Independent verification and institutional capacity building to improve efficiency of 2.00 health services delivered Organizations Borrower : Ministry of Planning and International Cooperation Implementing Agency : Ministry of Planning and International Cooperation Page 1 of 47 The World Bank Jordan Emergency Health Project (P163387) Safeguards Deferral OPSTABLE Will the review of safeguards be deferred? [ ] Yes [✔ ] No PROJECT FINANCING DATA (IN USD MILLION) [ ] [ ✔ ] IBRD [ ] IDA Credit [ ] IDA Grant [ ✔ ] Trust [ ] Counterpart Funds Parallel Funding [ ] Crisis Response [ ] Crisis Response Financing Window Window [ ] Regional Projects [ ] Regional Projects Window Window FIN_COST_OLD Total Project Cost: Total Financing: Financing Gap: 50.00 50.00 0.00 Of Which Bank Financing (IBRD/IDA): 36.10 Financing (in US$, millions) FIN_SUMM_OLD Financing Source Amount Concessional Financing Facility 13.90 International Bank for Reconstruction and Development 36.10 Total 50.00 Expected Disbursements (in US$, millions) Fiscal Year 2017 2018 2019 Page 2 of 47 The World Bank Jordan Emergency Health Project (P163387) Annual 0.00 35.10 1.00 Cumulative 0.00 35.10 36.10 INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population Contributing Practice Areas Gender Tag Does the project plan to undertake any of the following? a. Analysis to identify Project-relevant gaps between males and females, especially in light of country gaps identified through SCD and CPF Yes b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or men's empowerment Yes c. Include Indicators in results framework to monitor outcomes from actions identified in (b) Yes SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating 1. Political and Governance  Moderate 2. Macroeconomic  Substantial 3. Sector Strategies and Policies  Moderate 4. Technical Design of Project or Program  Moderate 5. Institutional Capacity for Implementation and Sustainability  Moderate 6. Fiduciary  Substantial 7. Environment and Social  Low Page 3 of 47 The World Bank Jordan Emergency Health Project (P163387) 8. Stakeholders  Substantial 9. Other  High 10. Overall  Substantial COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✔] No Does the project require any waivers of Bank policies? [ ] Yes [✔] No Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 ✔ Natural Habitats OP/BP 4.04 ✔ Forests OP/BP 4.36 ✔ Pest Management OP 4.09 ✔ Physical Cultural Resources OP/BP 4.11 ✔ Indigenous Peoples OP/BP 4.10 ✔ Involuntary Resettlement OP/BP 4.12 ✔ Safety of Dams OP/BP 4.37 ✔ Projects on International Waterways OP/BP 7.50 ✔ Projects in Disputed Areas OP/BP 7.60 ✔ Legal Covenants Sections and Description The Borrower shall: (a) cause the Audit Bureau to be responsible to conduct the Expenditure Verifications; (b) hire, no later than one (1) month after the Effective Date, and thereafter maintain, throughout Project implementation, the Expenditure Verification Entity (EVE), to support the Audit Bureau in conducting the Expenditure Verifications in accordance with the provisions set forth in the Project Operational Manual (POM); and (c) furnish: (a) the first Expenditure Verification to the Bank no later than six (6) months after the Advance is made under Category 1; and Page 4 of 47 The World Bank Jordan Emergency Health Project (P163387) (b) the second Expenditure Verification to the Bank no later than six (6) months after the Advance is made under Category 2. Sections and Description The Borrower shall hire, no later than one (1) month after the Effective Date, and shall thereafter maintain, throughout Project implementation, the Utilization Verification Entity, to conduct the Utilization Verification. The Borrower shall furnish: (a) the first Utilization Verification Audit no later than six (6) months after the Advance under Category 1 is made; and (b) the second Utilization Verification no later than six (6) months after the Advance is made under Category 2. Sections and Description The Borrower shall adopt, no later than one (1) month after the Effective Date, the POM, satisfactory to the Bank, and shall ensure that the Project is carried out in accordance with the POM, and shall ensure that the POM is not amended, suspended, abrogated, or repealed and that no provision of the POM is waived, without prior approval of the Bank. Conditions Type Description Disbursement No withdrawal shall be made under Category (1) and Category (2), unless the Bank has received satisfactory evidence showing that health care services have been delivered to the Target Population during the applicable Agreed Period, to be confirmed by: (a) an Expenditure Verification, satisfactory to the Bank, confirming the amount of Health Care Service Delivery Costs to be reimbursed; and (b) a Utilization Verification, satisfactory to the Bank, confirming the utilization of health care services by the Target Population during the applicable Agreed Period. PROJECT TEAM Bank Staff Name Role Specialization Unit Team Leader(ADM Team Lead; Senior Health Aakanksha Pande GHN05 Responsible) Economist Procurement Specialist(ADM Samira Al-Harithi Procurement Analyst GGO05 Responsible) Financial Management Senior Financial Management Jad Raji Mazahreh GGO23 Specialist Specialist Alexo Ramon Esperato Team Member Health Economist GHNDR Page 5 of 47 The World Bank Jordan Emergency Health Project (P163387) Martinez Andrianirina Michel Eric Team Member Finance Officer WFALN Ranjeva Concepcion Aisa Otin Team Member Senior Financial Officer FABBK Fatima-Ezzahra Mansouri Team Member Program Assistant GHN05 Fernando Montenegro Team Member Senior Health Economist GHN05 Torres Haneen Ismail Sayed Team Member Program Leader MNC02 Julie Rieger Counsel Senior Counsel LEGAM Lea Hakim Team Member Economist GMF05 Senior Social Development Mariana T. Felicio Safeguards Specialist GSU05 Specialist Miyuki T. Parris Team Member Operations Analyst GHNGE Moustafa Mohamed Team Member Health Specialist GHN05 ElSayed Mohamed Abdalla Senior Environmental Tracy Hart Environmental Specialist GEN05 Specialist Extended Team Name Title Organization Location Page 6 of 47 The World Bank Jordan Emergency Health Project (P163387) TABLE OF CONTENTS I. STRATEGIC CONTEXT ...................................................................................................... 7 A. Country and Sector Context ............................................................................................... 8 B. Higher Level Objectives to which the Project Contributes ............................................. 14 II. PROJECT DEVELOPMENT OBJECTIVES ............................................................................ 16 A. PDO ................................................................................................................................... 16 B. Project Beneficiaries ......................................................................................................... 16 C. PDO-Level Results Indicators ........................................................................................... 17 III. PROJECT DESCRIPTION.................................................................................................. 17 A. Project Components ......................................................................................................... 17 B. Project Cost and Financing ............................................................................................... 22 C. Lessons Learned and Reflected in the Project Design ..................................................... 23 IV. IMPLEMENTATION........................................................................................................ 24 A. Institutional and Implementation Arrangements ........................................................... 24 B. Results Monitoring and Evaluation ................................................................................. 26 C. Sustainability .................................................................................................................... 26 D. Role of Partners ................................................................................................................ 27 V. KEY RISKS ..................................................................................................................... 27 A. Overall Risk Rating and Explanation of Key Risks ........................................................... 27 VI. APPRAISAL SUMMARY .................................................................................................. 28 A. Economic and Financial (if applicable) Analysis .............................................................. 28 B. Technical ........................................................................................................................... 31 D. Procurement ..................................................................................................................... 36 E. SoE. Social (including Safeguards) .................................................................................... 37 F. Environment (including Safeguards) ................................................................................ 38 G. Other Safeguard Policies (if applicable) .......................................................................... 39 H. World Bank Grievance Redress ....................................................................................... 40 VII. RESULTS FRAMEWORK AND MONITORING .................................................................... 41 I. STRATEGIC CONTEXT Page 7 of 47 The World Bank Jordan Emergency Health Project (P163387) A. Country and Sector Context 1. Despite substantial economic and social progress, Jordan is currently facing fiscal challenges which have been exacerbated by the Syrian crisis. Jordan’s economy has proven sluggish the past couple of years, due to various challenges and exogenous shocks, most recently repercussions from the Syrian crisis.1,2 Economic growth has averaged 2.5 percent since 2010, a lower plateau from the 6.5 percent average growth over the preceding 10 years (2000-2009). A number of exogenous shocks have affected Jordan starting with the fallout from the 2007-2008 global financial crisis. Disruption of Egyptian gas supplies brought about the decision of National Electric Power Company (NEPCO), the electricity utility, to resort to more expensive oil imports, resulting in a 95 percent debt-to-GDP by end-2016.3 The Syrian crisis led to total closures of land routes to Iraq and Syria in mid-2015, significantly reducing exports.4 Tourism was also affected in 2015 and 2016, resulting in lower travel receipts which contributed to the widening of the current account deficit to 9.3 percent of GDP in 2016.5 The Government of Jordan has been providing public services to a large number of refugees from Syria, Iraq, and Yemen which has added to the fiscal stress and increased demand for public services such as education, health, and wastewater management. 2. Major macroeconomic challenges include stimulating growth and reigning in the fiscal deficit. This is even more important as labor market indicators deteriorate and inflationary pressures mount. Unemployment reached a historical high of 15.3 percent in 2016 with the labor force participation rate and employment rates decreasing to 36.0 and 30.5 percent (compared to 36.7 and 31.9 percent in 2015, respectively). While Jordan’s fiscal deficit has improved from 11.5 percent of GDP in 2013 to an estimated 3.2 percent of GDP in 2016, the fiscal situation remains dependent on grants. Since August 2016, Jordan is engaged in an Extended Fund Facility Program with the IMF, which aims at maintaining macroeconomic stability and fiscal consolidation in order to reduce the debt-to-GDP ratio to 77 percent by 2021. Following four years of expansionary monetary policy, the Central Bank raised rates in December 2016 and February 2017 by 25 and 50 bps, respectively. The stock of foreign reserves held at the central bank declined to reach US$12.9 billion (7.7 months of imported goods, excluding re-exports) by end-2016, 9.0 percent lower than end-2015. 3. According to the latest census, the Syrian population in Jordan is 1.3 million, of which 656,170 are 1 A 2014 IMF study estimated that the Syrian crisis had an overall negative impact on economic activity, with losses to output growth at around 1 percentage point of GDP in 2013. This has only been exacerbated with the rapid deterioration of the security situation since then. IMF. “Jordan: Selected Issues”, Country Report No.14/153, Washington DC, 2014. 2 World Bank analysis estimates the output forgone due to shocks since the 2011 Arab Spring. World Bank, Jordan Economic Monitor – Reviving a Slowing Economy, “Special Focus: The Economic Impact of the Arab Spring on Jordan”. Washington, DC, 2016. 3 While NEPCO reached cost recovery in 2015 and the authorities set up a Tariff Adjustment Mechanism as of 1 January 2017, larger pressures are stemming from the Water Authority of Jordan whose government debt is also guaranteed. 4 Prior to this, Iraq was Jordan’s largest export partner. Exports of goods to Iraq and Syria declined by 32 percent and 64 percent, respectively in 2016 and 2015. In 2016, exports to Saudi Arabia were also largely affected. They were 18 percent lower than in 2015. 5 The number of tourists arriving in Jordan from January to November 2016 was 7.9 percent less compared to the same period in 2015. Page 8 of 47 The World Bank Jordan Emergency Health Project (P163387) considered refugees by the United Nations High Commissioner for Refugees (UNHCR). 6,7 The remaining Syrians are considered to have either been living in Jordan for several generations or were living in Jordan prior to the crisis. Based on nationality, Syrians will receive care at public facilities at different rates set for “insured Jordanians” (almost free), “uninsured Jordanians” (some free services, about 20 percent copayment for remaining services), or “foreigners” (all out of pocket). Of the total number of refugees, about 9 percent live in camps (e.g., Za’atari, Al Azraq) and the rest live in the community. About 331,000 refugees have cards issued by the Ministry of Interior (MOI) which allow them access to several benefits, including highly discounted care at Ministry of Health (MOH) facilities. The large number of Syrian refugees, of which more than 80 percent are women and children, has significant implications for the Jordanian health system. Since 86 percent live below the national poverty line, and 78 percent depend on external assistance, they are considered an extremely vulnerable group. 4. The Syrian crisis threatens to reverse gains made by the Jordanian health sector and exacerbate existing limitations of MOH institutional capacity. The influx of Syrian refugees has increased demand for health services and has implications on the three outcomes of a health system—health status, citizen satisfaction, and financial protection.8 5. In terms of health outcomes, the reemergence of communicable diseases affects both Syrian refugees and their host communities. Communicable diseases had been successfully controlled by the Government of Jordan (GOJ) prior to the Syrian refugee crisis. Their reemergence puts at risk the substantial health gains achieved prior to the start of the Syrian conflict and has serious ramifications for both Syrian refugees and host communities. The incidence of communicable diseases such as measles, leishmaniasis, pulmonary tuberculosis, and diarrhea is higher among the Syrian refugee population than among the Jordanian host communities.9,10 A total of 34,314 communicable disease cases were reported among the Syrian population between 2013 and 2014. As 91 percent of refugees live outside camps, communicable disease outbreaks have spilled over to their host communities, jeopardizing the entire health system.11,12,13 Additionally, a quarter of Syrian refugees also suffer from chronic conditions, requiring costly and frequent long-term treatments.14 6. In terms of citizen satisfaction, the influx of refugees has led to increased waiting times and a shortage of health workers. The use of health services increased shortly after the refugee crisis. By July 2014, 6 Department of Statistics (Kingdom of Jordan). General Population and Housing Census, 2015: Main Results. Unpublished. 7 UNHCR. Syria Regional Refugee Response. Available: http://data.unhcr.org/syrianrefugees/country.php?id=107. Checked March 14, 2017. 8 Roberts M. et al. Getting Health Reform Right: A guide to improving performance and equity. Oxford University Press: UK, 2003. 9 High Health Council (Government of Jordan). National Health Strategy 2015-2019. Amman, 2015. 10 Ministry of Health (Jordan). Annual Statistical Book, 2015. Amman, 2016. 11 Department of Statistics (Kingdom of Jordan). General Population and Housing Census, 2015: Main Results. Unpublished. 12 High Health Council (Government of Jordan). National Health Strategy 2015-2019. Amman, 2015. 13 The World Bank. Towards Universal Health Coverage: A Comprehensive Review of the Health Financing System in Jordan. Washington DC, 2014. 14 The World Bank. Project Appraisal Document: Emergency Project to Assist Jordan Partially Mitigate Impact of Syrian Conflict . Washington DC, 2013. Page 9 of 47 The World Bank Jordan Emergency Health Project (P163387) public facilities registered 60,000 additional outpatient services delivered to Syrian refugees.15 Medicine stock outs have since become more common, Jordanians have had to wait in long queues, and the higher demand for health services at MOH facilities has resulted in Jordanian patients being referred to facilities outside MOH.16 Between 2011 and 2012, the cost of referrals to non-MOH hospitals increased by 50 percent, reaching US$124 million.17 To cope with the increased demand, MOH built new health facilities, particularly at the primary health care level. However, these facilities are not yet fully equipped, and a human resource shortage (primarily specialized doctors) remains a challenge. The number of doctors before and after the start of crisis declined from 28 to 23 and number of beds per citizen decreased from 18 to 15 per 10,000 people.18 In addition, the increased demand for services has hastened the wear and tear on machinery, resulting in an increased need for reagents and spare parts. The refugee crisis has also set back other major goals of the health system. This includes the goal of attaining universal health coverage (UHC) by 2020, which is now further away due to the growth of the uninsured population, a large part of which are refugees.19 7. MOH is in charge of stewardship of the entire health sector and is also a major provider of primary and secondary level of health care services in the public sector. These services are critical in prevention and early detection of infectious as well as non-communicable diseases. MOH also manages some secondary and tertiary levels of care. Following international good practices, MOH has developed a large nationwide network of primary health care facilities including, some comprehensive primary healthcare center (PHC) facilities with basic specialties (including mental health). Tertiary level of care services and specialized outpatient services are delivered in MOH hospitals and in other public sector facilities such as those managed by the University and Royal Medical Service. Jordan also provides social insurance for people in the formal sector and provides services using contracts with public and private facilities. Individuals who face catastrophic out-of-pocket health expenditures also can petition the Royal Court for subsidization of specific health care services on a case-by-case basis. As some waiting lists have increased with the influx of refugees, GOJ has used the existing contracts with public and private hospitals to provide inpatient and outpatient care alternatives for insured patients with urgent and expensive health care needs. 8. In terms of financial protection, prior to the refugee crisis, Jordan had reduced regressive health care out-of-pocket payments by half – from 42 percent to 24 percent of total health spending (2003-2013); however, demand increases have limited the Government’s ability to provide financial protection for all.20 From 2012-2014, GOJ allowed registered Syrian refugees to pay the same rate as insured Jordanians at MOH facilities, which rendered health services as almost free. This led to a steep increase in demand for health services by Syrian refugees. While access to free health services helped meet the needs of such vulnerable population in their first years of the crisis, it was fiscally unsustainable, and since November 2014 MOH requires Syrian refugees to pay approximately 20 percent of the cost of care 15 High Health Council (Government of Jordan). National Health Strategy 2015-2019. Amman, 2015. 16 The World Bank. Project Appraisal Document: Emergency Project to Assist Jordan Partially Mitigate Impact of Syrian Conflict . Washington DC, 2013. 17 The World Bank. Project Appraisal Document: Emergency Project to Assist Jordan Partially Mitigate Impact of Syrian Conflict. Washington DC, 2013. 18 High Health Council (Government of Jordan). National Health Strategy 2015-2019. Amman, 2015. 19 High Health Council (Government of Jordan). The National Strategy for Health Sector in Jordan, 2015-2019. Amman, 2015. 20 Amnesty International. Living in the Margins: Syrian Refugees in Jordan Struggle to Access Health Care. Amman, 2017. Page 10 of 47 The World Bank Jordan Emergency Health Project (P163387) for select services, while still providing free services for certain interventions such as antenatal care, vaccinations, and treatment of communicable diseases. 9. Registered Syrian refugees now pay the same price for health care as uninsured poor Jordanians. While 80 percent of the cost of care is still paid for by GOJ, even a 20 percent copayment has proven too high for many Syrians, resulting in a decrease in usage by more than 60 percent over the last two years (see Figure 1). One month after the introduction of copayments, 65 percent of refugees stated that cost was the biggest barrier to accessing health care, with one in five households facing catastrophic spending due to health care costs.21 Two years after the policy change, over half of Syrian refugees with chronic conditions stated that they could not access medicines and other services, and half of pregnant women reported that they could not afford to pay for the transportation for antenatal care services.22 As a result, there was a precipitous drop in health service use and a subsequent decline in health outcomes.23 This trend has persisted with a recent study of refugees living in communities in Irbid directorate in northern Jordan indicating that, on average, a third of adults and a quarter of children who require medical care still do not access it largely due to unaffordability.24 However, the services that remain free, such as vaccinations and antenatal care, continue to have a very high uptake.25 10. The reasons for this decline in utilization vary. Given that the copayment is still small, it is unclear why there has been such a sharp decline in service utilization. While cost is one clear explanation, other possible reasons could include MOI service cards being introduced around the same time, which are now required for Syrians to be able to access health services at MOH facilities. Only two in three Syrians in the community hold MOI cards, so this requirement has resulted in a much smaller number of potential users of MOH services. Other potential reasons include the entry of non-governmental organizations (NGOs) into the health sector in Jordan in 2014, which provide free services targeted to Syrians. Also, there could have been a potential overuse of MOH services by Syrians when free care was provided from 2012 to 2014 with “provider shopping” taking place. Despite the decrease in utilization, MOH facilities still provide about 1.5 million health services (outpatient and inpatient) to registered Syrians annually, thus filling a critical gap in service provision. 21 High Health Council – UNICEF. Policy Brief: Health Spending in Jordan. Amman, 2016; “catastrophic spending” is defined when more than 10 per cent of a household’s total expenditure is used to pay for health care, often resulting in the househol d selling assets to afford care and plunging the household into poverty. 22 Amnesty International. Living in the Margins: Syrian Refugees in Jordan Struggle to Access Health Care . London, 2016. 23 Amnesty International. Living in the Margins: Syrian Refugees in Jordan Struggle to Access Health Care . London, 2016. 24 Médecins sans Frontières. Health Service Access Survey Among Non-Camp Syrian Refugees in Irbid Governorate, Jordan. August 2016. 25 Médecins sans Frontières. Health Service Access Survey Among Non-Camp Syrian Refugees in Irbid Governorate, Jordan. August 2016. Page 11 of 47 The World Bank Jordan Emergency Health Project (P163387) Figure 1: Utilization of health services by Syrian refugees in Jordan over time Annual utilization pattern of health services by Syrian refugees 900000 800000 700000 600000 500000 400000 300000 200000 100000 0 2012 2013 2014 2015 2016 Utilized MOH Hospitals Utilized Health centers Total 11. Similar to registered Syrian refugees, about 2.1 million uninsured Jordanians also have to pay a copayment for select inpatient and outpatient services at Ministry of Health facilities. In Jordan, MOH is both the payer and provider of a large number of public health services. The MOH network includes over 477 primary health centers and 33 hospitals. While about 70 percent of Jordanians are insured, 30 percent are uninsured and make copayments for health services equal to what Syrian refugees are now paying. The last thorough assessment of the uninsured Jordanian population took place in 1999 and revealed that the majority of the uninsured were either unemployed or out of the labor force.26 More recent estimates suggest that the uninsured incur the highest out-of-pocket payments, which is the most regressive form of health financing. Among the uninsured there is a subgroup who are considered “poor” (according to the Ministry of Social Development criteria) or “unable to pay” (as determined at secondary care facilities) and are the target beneficiaries of this project. While the exact size of this group is unknown, it is not an insignificant share of the uninsured population. 12. Pre-existing inefficiencies in the health system have been exacerbated by the Syrian refugee crisis, and must be addressed to create a sustainable health system. The health system in Jordan, like many other health systems globally, is plagued by several issues related to technical and allocative efficiency including a highly fragmented insurance pool with several payers and purchasers including the Royal 26 Banks, D. A., Milburn, L., and Sabri, H. Profile of the uninsured in Jordan. Technical Report No. 37. Bethesda (USA), 1999. Page 12 of 47 The World Bank Jordan Emergency Health Project (P163387) Medical Service, Ministry of Health, and private sector providers. In addition, there is very little data available on critical components of the health system, including costing of the basic package of services delivered at primary and secondary health care facilities or usage of services by gender and income group. There are also several inefficiencies around the procurement of pharmaceuticals which if addressed could reduce the cost of care. 13. Emergency concessional support is vital to move from a humanitarian to a development response. Since 91 percent of Syrian refugees live outside of camps, public health services are the backbone of Jordan’s response to the refugee crisis.27 The World Bank provided technical assistance and delivered an emergency operation in 2013 to maintain health services and address household needs for the Jordanians affected by the refugee crisis.28 Yet public resources are strained and the fiscal space is limited. Public spending on health is 7 percent of GDP—far higher than most developing countries.29 At the same time, Jordan’s debt to GDP ratio increased from 67 to 95 percent over the last five years, which has forced spending cuts at the MOH. The combination of increased demand and fiscal pressures may thus undermine the public system’s sustainability, as well as its ability to provide services for free or at low cost. This can have implications for the containment of communicable diseases, which will affect both Syrian refugees and Jordanian host communities. Funding shortfalls for the Syrian refugee response have exacerbated these challenges. As a result, the Government of Jordan has requested emergency funding from international financial institutions. 30 14. The proposed project has been prepared and will be implemented in accordance with paragraph 12 of the World Bank’s Operational Policy 10.00 (Projects in Situations of Urgent Need of Assistance or Capacity Constraints). This is justified by the emergency nature of this project, as it responds to the impact of conflict (in Syria) and the ensuing man-made disaster, which has resulted in the refugee influx. The health system in Jordan has been challenged due to macro-fiscal pressures and the Syrian refugee crisis. The sustainability of the health system gains over the last decade is threatened without financial and technical support. Some line items in the MOH budget have been reduced in the last year and MOH public services are being strained due to the increasing utilization and unit cost of health services, particularly at the secondary care level. The refugee crisis has also impacted the system in other ways-- the percentage of uninsured has increased in the Kingdom, and the goal of attaining universal health coverage by 2020 is, therefore, further away.31 Without financial and technical support to the sector, access to health care for the vulnerable populations may deteriorate in the short to medium term. 15. In response to this emergency, the project is proposing to use the results-based financing (RBF) modality on concessional terms, with parallel financing by the Islamic Development Bank (IsDB). The Global Concessional Financing Facility (GCFF, see Box 1), the International Bank for Reconstruction and Development (IBRD) and the Islamic Development Bank will work together to provide the resources to 27 Ministry of Planning and International Cooperation (Jordan). Jordan Response Plan for the Syria Crisis, 2016-2018. Amman, 2015. 28 The World Bank. Project Appraisal Document: Emergency Project to Assist Jordan Partially Mitigate Impact of Syrian Conflict . Washington DC, 2013. 29 The World Bank. World Development Indicators: Health Nutrition and Population Statistics. Accessed on March 4, 2017. 30 Fakhoury, Imad. “New responsibility-sharing paradigms”, Jordan Times, 25 March 2017. Available at http://www.jordantimes.com/opinion/imad-najib-fakhoury/new-responsibility-sharing-paradigms 31 High Health Council (Government of Jordan), The National Strategy for Health Sector in Jordan, 2015-2019. Amman, 2015. Page 13 of 47 The World Bank Jordan Emergency Health Project (P163387) support GOJ in maintaining the delivery of primary and secondary health care services to Syrian refugees and poor uninsured Jordanians—the target population-- in MOH facilities and increase the health system’s medium to long-term sustainability. Funds will be disbursed against the delivery of these services. In addition, the project’s second component will address the inefficiencies in the system to create a more sustainable and resilient health system in the medium to long term with an aim to create more health for the same amount of wealth. Box 1. Global Concessional Financing Facility The Global Concessional Financing Facility (GCFF) is a partnership sponsored by the World Bank, the UN, and the Islamic Development Bank Group to mobilize the international community in addressing the financing needs of middle income countries hosting large numbers of refugees. By combining donor contributions with multilateral development bank loans, the GCFF enables eligible middle-income countries that are facing refugee crises to borrow at concessional rates for providing a global public good. The GCFF represents a coordinated response by the international community to the Syrian refugee crisis, bridging the gap between humanitarian and development assistance and enhancing the coordination between the UN, supporting countries, multilateral development banks, and benefitting (hosting) countries. The GCFF is currently supported by Canada, Denmark, the European Commission, Germany, Japan, the Netherlands, Norway, Sweden, the United Kingdom, and the United States. B. Higher Level Objectives to which the Project Contributes 16. The proposed project directly supports two out of four key objectives of Jordan’s National Health Strategy (2016-2020).32 Objective 1 aims for a “Good Governance and Policy Environment to Promote Health System Performance”. This will be supported through the project’s technical assistance component, which will propose strategies to improve health system efficiency. Objective 3 focuses on providing “Health, Financial and Social Protection for all Citizens based on Fair Grounds”. The provision of health care services to the target population contributes directly to this objective. 17. The project contributes to the Sustainable Development Goals (SDGs) on health (#3), poverty reduction (#1), and peace (#16). The Project Development Objective (PDO) focuses on improving the wellbeing of highly vulnerable populations. The project is thus fully aligned with SDG #3, which seeks to “ensure healthy lives and improve wellbeing for all ages”.33 The project also seeks to maintain current health care levels at public facilities, which are highly subsidized for vulnerable populations. This decreases catastrophic health spending and thus contributes to reducing poverty (SDG #1). Finally, as the project directly addresses a global refugee crisis, it contributes to SDG #16, which focuses on 32 High Health Council (Government of Jordan). National Health Strategy 2015-2019. Amman, 2015. 33 United Nations Development Fund. Sustainable Development Goals. http://www.un.org/sustainabledevelopment/sustainable-development-goals/ Page 14 of 47 The World Bank Jordan Emergency Health Project (P163387) improving peace and justice. 18. The project contributes directly to the World Bank Group’s twin goals. In Jordan, 86 percent of Syrian refugees are below the poverty line and incur catastrophic health care costs.34,35 Similarly, the majority of uninsured Jordanians work in the informal sector and belong to the bottom 40 percent in monetary terms. By focusing on these populations, the project is fully aligned with the World Bank Group’s (WBG) twin goals of eradicating extreme poverty and boosting shared prosperity in a sustainable manner. 19. The project is technically and operationally aligned with WBG’s Middle East and North Africa (MENA) regional strategy. WBG’s MENA strategy supports peace and stability through social and economic inclusion via “four R’s” -- renewing the social contract; regional cooperation; resilience to internally displaced persons and refugee shocks; and recovery and reconstruction.36 The project supports GOJ’s inclusive public policies geared towards sustaining achievements in the social contract by providing universal health coverage to all – for Jordanian nationals as well as for refugees. It also assists GOJ with resilience to refugee shocks by directly financing the cost of care associated with this population and providing technical assistance (TA) to create a more efficient health system for all. In addition, the MENA strategy calls for a “strategic shift” in engagement by focusing on leveraging partnerships with other regional development institutions and crowding in international financial resources. In this vein, this project partners with IsDB to triple the available resources to GOJ (from US$50 million to US$150 million), and provides concessional financing through the GCFF, which mobilizes donor and private sector resources in response to the refugee crisis. 20. The project operationalizes the principles of WBG’s Jordan Country Partnership Framework (CPF). The CPF (Report 102746-JO)37 defines the World Bank engagement with Jordan. The main goal of the CPF is to renew the country’s “social contract and promote social and economic inclusion”. The CPF also plans to analyze the impact of the refugee crisis on the country’s financial sustainability, which is supported through the component on institutional capacity to improve the health system’s efficiency. By safeguarding the sustainability of public health services and focusing on vulnerable populations, the proposed operation is fully aligned with the CPF. 21. The project contributes to the Health, Nutrition and Population (HNP) Global Practice’s aim of assisting countries in accelerating progress towards achieving universal health coverage (UHC). Attaining UHC entails both increasing access to quality services and improving financial protection.38 34 Amnesty International. Living in the Margins: Syrian Refugees in Jordan Struggle to Access Health Care. Amman, 2017. 35 Médecins sans Frontières. Health Service Access Survey Among Non-Camp Syrian Refugees in Irbid Governorate, Jordan. August 2016. 36 The World Bank Group. Economic and Social Inclusion for Peace and Stability in the Middle East and North Africa: A New Strategy for the World Bank Group. Washington, DC, 2015. 37 The World Bank Group. Country Partnership Framework for the Hashemite Kingdom of Jordan for the Period FY17-FY22. Amman, 2016. 38 39 The World Bank Group. Priority Directions for the Health, Nutrition and Population Global Practice, 2016-2020. The World Bank. Fairness and Accountability: Engaging in Health Systems in the Middle East and North Africa – The World Bank Health, Nutrition and Population Sector Strategy for MENA (2013-2018). Washington, DC, 2013. Page 15 of 47 The World Bank Jordan Emergency Health Project (P163387) The proposed project supports the delivery of primary and secondary public health services to the target population, and thus contributes to these goals. 22. The project is in accordance with the principles of the MENA Health Strategy which focuses on the creation of fair and accountable health systems in a sustainable manner. 39 The project promotes the principle of fairness by providing subsidized health services for those who cannot afford to pay. Additionally, it helps build a more sustainable system by providing technical assistance on ways to increase the efficiency of the present health system. II. PROJECT DEVELOPMENT OBJECTIVES A. PDO 23. The Project development objective (PDO) is to support the Hashemite Kingdom of Jordan (the Borrower) in maintaining the delivery of primary and secondary health services to poor uninsured Jordanians and Syrian refugees at Ministry of Health facilities. B. Project Beneficiaries 24. There are two main groups that will benefit from this project-- registered Syrian refugees and poor uninsured Jordanians using primary and secondary care services at MOH facilities nationwide. These two groups would comprise the ‘target population’ of the project. Registered Syrian refugees are refugees registered with UNHCR who also have an MOI service card allowing them access to free or subsidized health services at MOH facilities (about 331,000 people). Poor uninsured Jordanians include those identified as “poor” by the Ministry of Social Development who are eligible for free primary care services, as well as those classified as “unable to cover their copayment” at the secondary level of care. The total pool of uninsured Jordanians is approximately 2.1 million people, and poor uninsured Jordanians are believed to constitute the majority of this group. 25. Since the project will be implemented over a short time period (two years only), the demand for services among the uninsured poor Jordanians is expected to remain stable. However, the demand for services among Syrian refugees could change based on external factors beyond the control of the project (e.g., if eligibility criteria for MOI card changes). Unregistered Syrian refugees are not currently included in the project given its limited budget envelope. Should this group become eligible for an MOI card, they will also be able to benefit from the project. 26. The project is national in scope as it applies to all eligible beneficiaries who can access care at all MOH primary and secondary care facilities. While the population of Syrian refugees is higher in certain governorates (Irbid, Mafraq), six years of the conflict has resulted in Syrians residing in host communities nationwide. In addition, the population of uninsured poor Jordanians is also nationwide. In an effort to be inclusive and cover all eligible beneficiaries, the project is national in scope. 39 The World Bank. Fairness and Accountability: Engaging in Health Systems in the Middle East and North Africa – The World Bank Health, Nutrition and Population Sector Strategy for MENA (2013-2018). Washington, DC, 2013. Page 16 of 47 The World Bank Jordan Emergency Health Project (P163387) 27. The project aims to assist GOJ in a sustainable way by helping maintain the current level of service provision which is already included in the MOH budget. While it would be useful to be able to increase the current utilization of services by increasing the subsidy provided by GOJ or increasing the number of people covered, this is beyond the budget envelope of the project and may be unsustainable once the project is completed in two years. Also since GOJ is under the IMF Extended Fund Facility, the budget of GOJ cannot be increased which is what would be required to provide more subsidized services to the target population. By including a component on capacity building to reduce the inefficiencies in the health system, the project aims to create more fiscal space in the health system to allow GOJ to increase benefits to all at a later date, if feasible. C. PDO-Level Results Indicators 28. Indicators to track the PDO include: a. Maintaining number of health services delivered at MOH primary health care facilities to: 40 1. Uninsured poor Jordanians, male 2. Uninsured poor Jordanians, female 3. Registered Syrian refugees, male 4. Registered Syrian refugees, female b. Maintaining number of health services delivered at MOH secondary health care facilities to: 1. Uninsured poor Jordanians, male 2. Uninsured poor Jordanians, female 3. Registered Syrian refugees, male 4. Registered Syrian refugees, female c. Completion and dissemination of a health sector roadmap to improve the efficiency of services delivered.41 III. PROJECT DESCRIPTION A. Project Components 29. The project follows a Results-Based Financing (RBF) model to support the delivery of primary and secondary health care services at MOH facilities, and provides technical assistance and capacity building to improve the efficiency of the health sector. The project will pay for the delivery of outputs at MOH facilities to target beneficiaries. For this, a unit cost has been established, and the government will be reimbursed according to the quantity of outputs (health service packages) delivered to the target 40 See operational definition of “health services” below in the description of subcomponents 1.1. and 1.2. 41 The roadmap needs to be approved by the MOH after a consultative process aimed at including participation and inputs from a broad representation of health sector stakeholders, including civil society, NGOs and donors. The roadmap has to include a chain of results that highlights how to move from inputs to outputs and to realistic and measurable results in a reasonable timeline. The roadmap is aimed to be a guide that can be periodically updated to identify inefficiencies in the health system (technical and allocative) and suggest policies to address these to control costs and increase fiscal space. It will be based on international and national health policy expert analysis and recommendations that are relevant to the specific context of Jordan. Page 17 of 47 The World Bank Jordan Emergency Health Project (P163387) population. These unit costs include the non-medical recurrent expenditures (HR costs and utilities; about 77 percent of total costs), but exclude costs of pharmaceuticals, medical equipment, and consumables (about 23 percent of total costs). 30. Three project design options were considered—an input-based option; an output-based option; and an output-based option with disbursement-linked indicators (DLIs). The input-based option was not deemed suitable as financing of inputs alone do not necessarily ensure results are accrued to the target population. The output-based option with DLIs, while useful, was not relevant to this particular project due to the short implementation timeline; limited scope to expand the GOJ program and introduce reforms through a set of changes linked to DLIs and targets; and need for a simple quick disbursing project which could best meet GOJ’s needs while ensuring benefits for the vulnerable. Therefore, an output-based option with an independent verification system for expenditures and utilization against which funds would be disbursed was found to be the most appropriate choice. 31. The project will help GOJ maintain its current support of primary and secondary health services to the project beneficiaries, as well as improve the efficiency of the health system in the long run . Therefore, the project will comprise of the following two components which will be financed in parallel by the Islamic Development Bank (IsDB), including concessional financing through the GCFF. 32. Component 1. Results-based financing to deliver health care services at primary and secondary health care facilities pf MOH to the target population (US$48 million). IsDB will provide US$100 million in parallel financing. This component is designed using the Results-Based Financing model in which MOH facilities are paid for the specified health services delivered to the target population. This builds on the World Bank’s Health, Nutrition and Population (HNP) Global Practice experience with RBF over the past ten years globally in several countries in Latin America, Africa, and Asia.42 33. This component will pay for services utilized by the target population at MOH facilities nationwide. The services covered are based on the country’s identified package of primary and secondary health care inpatient and outpatient services.43 The disbursements are based on a verification of: (i) the number of health services provided to the project beneficiaries verified by a Utilization Verification Entity (UVE); and (ii) the expenditures incurred by GOJ to deliver these services verified by the Audit Bureau (AB) of Jordan which will be supported in training and capacity building by an Expenditure Verification Entity (EVE). The EVE will also provide the first sign off on the technical quality of the verification reports and the AB will then provide final clearance before submitting them to the World Bank. It is envisaged that one firm will be able to provide both functions of the UVE and EVE. The Terms of Reference (TOR) of this firm will be based on TORs used in similar RBF projects and adapted to the specific circumstances of this project and country. 42 The model used in this project was originally used in Argentina’s project Plan Nacer to keep delivery of key primary and seco ndary level services in the middle of a major social and economic crisis in 2002-2003. Besides the several subsequent large scale nation- wide projects in Argentina, other examples of IPF where the bulk of the loan is disbursed against a specified set of services for a specified target population using the RBF model includes Djibouti, Dominican Republic, Nigeria, Panama. 43 Specific components of mental health relevant to refugees are being rolled out at the Primary Health Care level with eight specialized clinics already providing a broader scope of services needed by the target population. Page 18 of 47 The World Bank Jordan Emergency Health Project (P163387) 34. The project will fund part of the cost for delivering health care services to the beneficiaries, which will be up to US$13 per beneficiary for primary care and US$80 per beneficiary for secondary care. The costs mainly cover MOH’s expenditures for key recurrent non-medical expenditures such as human resources and operating costs of health facilities, including rental and utilities (water, electricity, fuel). The project does not finance the cost of medical items such as vaccines, medicines, equipment or consumables that will continue to be financed by GOJ and other donors (UNICEF, USAID). 35. The operational definition of a service delivered is either a visit to an outpatient facility (first or second levels of care) for medical, emergency, or diagnostic services (i.e. lab tests, x-rays, etc.) or a hospital discharge. A “primary health care service” is defined as an episode of primary health care such as one antenatal care visit. A “secondary health care service” can be considered to be an episode of outpatient or inpatient care such as the delivery of a baby. This component includes two subcomponents: a. Subcomponent 1.1. Results-based financing for the delivery of primary health care services to target populations. This subcomponent will pay at the national level for services provided at primary health care centers by MOH to the target populations. This subcomponent includes PHC services such as, but not limited to: (a) maternal and child health care services; (b) malnutrition prevention and treatment; (c) Integrated Management of Childhood Illness (IMCI); (d) treatment of communicable diseases; and (e) prevention, early detection and management of non-communicable diseases. The current utilization rates of primary health services among the target population represents around 10 percent of the total utilization rate of these services at MOH facilities. Based on 2015 utilization rates, it is estimated that the project will pay for approximately 289,000 services delivered to registered Syrian refugees and 1.75 million services delivered to poor uninsured Jordanians at PHC facilities over the two-year period. b. Subcomponent 1.2. Results-based financing for the delivery of secondary health care services to target populations. This subcomponent will pay at the national level for both outpatient and inpatient health care services received by the target beneficiaries at the 33 MOH hospitals in Jordan. The current utilization rates of secondary health services among the target population represents around 30 percent of the total utilization of these services at MOH hospitals. Based on 2015 utilization rates, it is estimated that the project will pay for approximately 215,000 services delivered to Syrians and 1.32 million services delivered to poor uninsured Jordanians at secondary care facilities over the two-year period. 36. Component 2: Independent verification and institutional capacity building to improve efficiency of health services delivered (US$2 million). This component has two subcomponents. a. Subcomponent 2.1. Independent verification of expenditures incurred and utilization of services by project beneficiaries and auditing of financial statements. This component will finance: (i) a verification of eligible expenditures incurred by GOJ to deliver the services to the target population which will be carried out by the Audit Bureau of Jordan with capacity building and first level technical sign off provided by an independent expenditure verification entity (EVE); (ii) a verification of utilization of services by the target population conducted by a UVE; and (iii) an external audit of project financial statements for all withdrawals from the designated account. If possible, one firm will be used for the EVE and UVE described in (i) and (ii) above. Page 19 of 47 The World Bank Jordan Emergency Health Project (P163387) b. Subcomponent 2.2. Capacity building to monitor and improve efficiency. Like many health systems globally, the health system in Jordan has several inefficiencies (both in terms of technical efficiency and allocative efficiency). This component will aim to make the Jordan health system more efficient, so that in the medium to long term GOJ can get more health for the same amount of wealth. This subcomponent will present a roadmap of efficiency bottlenecks and policy options to address them. This will allow GOJ to improve the quality and coverage of health services at the same cost and allow the system to become more sustainable. 37. One aspect of efficiency that this component will prioritize is related to gender. Gender-related inefficiencies appear to be hindering access to healthcare and affecting health outcomes. This component will support MOH plans to develop protocols, guidance, and communication on gender- based violence (GBV) among the target population and will help build capacity to collect, analyze, and utilize more gender-disaggregated data so as to mainstream a gender-based lens into all future programming. In an effort to increase use of services by target beneficiaries it will undertake a deep dive on ways to address barriers to care (transport, cost) based on which several policy options will be presented. It will also communicate the gender-based services being provided by this project to beneficiaries to help increase utilization. 38. This component will help strengthen the existing institutional capacity of the public health entities to analyze and plan sectoral reforms while building consensus on key priorities for the health sector to improve the efficiency in the medium to long term. While MOH and the High Health Council are evaluating health system efficiency, these institutions need support, and young professionals also need to be trained to start building institutional capacity to move forward with strengthening universal health coverage policies within the framework of limited fiscal space. Local and international consultants will help define the package of health care services and compute their associated costs, as well as the review of public expenditures in the sector will serve as a critical input to identify areas for improving resource allocation policies and coordination among public (MOH and other public facilities) and private providers. 39. The output of this subcomponent will be the development and dissemination of a roadmap identifying current inefficiencies in the health system and providing policy suggestions, based on global best practices, to increase efficiency and fiscal space. The project will look at both technical efficiency of inputs, outputs, and processes and allocative efficiency of the current health system in Jordan and make suggestions on how to improve efficiency based on global best practice. This subcomponent will also finance capacity building, analytical work, and knowledge sharing with translation into Arabic of training tools on various topics such as, but not limited to: (i) health financing and health economics with an emphasis on costing of services and cost-benefit analysis; (ii) fiscal space analysis, including means to improve revenue collection and increase technical and allocative efficiency; (iii) improving digital health information systems to improve efficient use of resources; and (iv) analyzing gender-related barriers to care including GBV and presenting policy recommendations. 40. The project covers the costs incurred by MOH for the delivery of primary and secondary health Page 20 of 47 The World Bank Jordan Emergency Health Project (P163387) services (outpatient and inpatient) to the target populations. The calculations are based on actual MOH expenditures for 2015.44 The line items used in the calculations are “Provision of Primary Health Services” (line 4610-601; US$152.9 million) and “Provision of Secondary Health Services” (4615 -601; $272.8 million). These line items, which accrue to US$425 million, reflect expenditures in non-medical costs (HR costs and overhead--rental, utilities, and maintenance) for the entire population in Jordan (insured Jordanians, uninsured Jordanians, registered Syrian refugees, foreigners). They exclude costs of pharmaceuticals, medical equipment, and consumables (US$126.2 million). 41. Cost of care estimates are adjusted based on actual health service utilization by the target populations. In 2015, MOH facilities provided 12.1 million primary care services and 3.4 million secondary care services to the entire population (insured Jordanians, uninsured Jordanians, registered Syrian refugees, foreigners).45,46 Based on this data and the previous expenditure line items, the average non-medical cost to MOH for providing each primary care service was estimated at US$12.7 (JD 9), and the average non-medical cost to MOH for providing each secondary care service was estimated to be US$80.3 (JD 57). During the same year, Syrian refugees received 178,273 primary care services and 132,712 secondary care services.47 Therefore, the total non-medical cost of providing primary and secondary care to registered Syrian refugees for MOH was US$13 million (JD 9.2 million). This is a highly conservative estimate, as it does not include other indirect costs borne by the MOH. An example is the referral of Jordanian patients to private facilities (due to overcrowding induced by the refugee crisis), which had reached US$124 million by 2012.48 42. Health service use by the uninsured Jordanian poor was significantly higher representing 86 percent of total utilization by the target population.49 Uninsured poor Jordanians were responsible for 1.1 million primary care services and 816,168 secondary care services.50 Therefore, the total non-medical cost for providing primary and secondary care to uninsured poor Jordanians for MOH was US$79.6 million (JD 56.4 million). The annual non-medical cost of providing primary and secondary services to both registered Syrians and uninsured poor Jordanians was US$92.6 million. Over two years, this would translate into US$185.2 million, of which US$150 million would be covered by the project (80 percent of need). Of the annual non-medical cost of providing primary and secondary health care services to the target populations, secondary care costs represent 83 percent (US$76.5 million) compared to 17 percent for primary care. 43. Assuming that the current utilization rates remain constant, the project will deliver 3.5 million health 44 General Budget Department (Kingdom of Jordan). Law No. 2 for the Year 2017, General Budget Law for the Fiscal Year 2017. Available http://www.gbd.gov.jo/GBD/en/Budget/Index/general-budget-law. 45 Calculating separately the costs of providing secondary outpatient and inpatient services was not possible. This is because the MOH budget lumps these two categories in the single budget line, “Provision of Secondary Health Service” (4615 -601). Therefore, the category of secondary health service was created, which encompasses both secondary outpatient visits and hospital admissions. 46 Ministry of Health (Jordan). Annual Statistical Book, 2015. Amman, 2016. 47 Ministry of Health (Jordan). Annual Utilization of Services by Syrian Refugees, 2012-2016. Unpublished. 48 The World Bank. Project Appraisal Document: Emergency Project to Assist Jordan Partially Mitigate Impact of Syrian Conflict. Washington DC, 2013. 49 Ministry of Health (Jordan). Health data from internal records. Amman, 2016. 50 Ministry of Health (Jordan). Annual Statistical Book, 2015. Amman, 2016. Page 21 of 47 The World Bank Jordan Emergency Health Project (P163387) services to beneficiaries, of which approximately half a million will be to registered Syrians and approximately 3 million to poor uninsured Jordanians. These figures refer to the project’s two-year duration. This was calculated by adjusting the current utilization rates and cost of services to the budget envelope of the project. In this way the project will pay for results and disburse against the actual services delivered to the beneficiaries. Table 1: Estimated number of beneficiaries who will be assisted by the project through Component 1 (based on 2015 prices and utilization rates) Registered Syrian Refugees Uninsured Poor Jordanians Number of Number of services Cost (US$) services Cost (US$) delivered delivered Primary care 284,601 $3,617,279 1,727,529 $21,956,894 Secondary care 212,028 $17,117,020 1,304,691 $105,327,704 Total (Primary and 496,629 $20,734,299 3,032,220 $127,284,598 Secondary care) Total Financing (US$) $148,000,000 B. Project Cost and Financing 44. The project uses an Investment Project Financing (IPF) instrument. It is financed by a US$50 million loan, consisting of a non-concessional portion of US$36.1 million and a concessional portion of US$13.9 million from the GCFF. The IsDB will extend US$100 million through a parallel co-financing arrangement, of which US$79.0 million will be through a “service ijarah” instrument and GCFF will extend funds for US$21.0 million. Therefore, the total financing package amounts to US$150 million, with IBRD providing US$36.1 million, IsDB providing US$79.0 million, and GCFF providing US$34.9 million. IBRD Financing, incl. IsDB Funding, incl. Project Components Total (US$) GCFF (US$) GCFF (US$) Component 1: Maintaining the delivery of health care services 148,000,000 48,000,000 100,000,000 at primary and secondary care Page 22 of 47 The World Bank Jordan Emergency Health Project (P163387) facilities of MOH for the target population Component 2: Verifying and improving efficiency of health 1,908,750 1,908,750 services delivered Total Costs Total Project Costs 149,909,750 49,909,750 100,000,000 Front End Fees 90,250 90,250 Total Financing Required 150,000,000 50,000,000 100,000,000 C. Lessons Learned and Reflected in the Project Design 45. Investing in the provision of basic services has a positive impact on the social contract. The financing of care provision has been deemed as an effective tool for preventing social unrest, both globally and in Jordan.51,52 Barriers to health care, including financial ones, could undermine the country’s social contract and contribute to increased social instability. The project will seek to support social cohesion in Jordan through sustaining the level of care provided to the vulnerable. 46. Supporting existing government systems allows for a fast response and prevents the creation of parallel systems—it shifts the response from an acute humanitarian response to a more sustainable development response. Using the government systems to implement projects has proven to be an effective tool to not only build institutional capacity, but also to allow for fast disbursement and implementation. In addition, it prevents the creation of a parallel system for particular population groups, which can lead to more inefficiencies. The project builds on global and country experiences, particularly in emergency situations where alternative implementation arrangements are not timely enough to cater to the project development objectives and emergent needs of the population. 47. Investing in the technical capacity of government institutions will ensure effectiveness and sustainability of the World Bank support. Global experience has revealed that sustained World Bank technical engagement during implementation improves government capacity not only for effective implementation, but also for sustained gains after the closing date. Accordingly, this project provides technical assistance to the government to improve the allocative and technical efficiency of the health sector and explore potential venues for expanding fiscal space. 48. Triggering OP 10.00 paragraph 12 will facilitate increased speed and flexibility. In light of its 51 World Bank. World Development Report 2011: Conflict, Security, and Development. Washington DC, 2011. 52 World Bank. Implementation Completion and Results Report: Emergency Project to Assist Jordan Partially Mitigate the Impact of the Syrian Conflict. Washington DC, 2015. Page 23 of 47 The World Bank Jordan Emergency Health Project (P163387) emergency nature, the proposed operation is carried out under OP10.00 paragraph 12 (Projects in Urgent Need of Assistance or Capacity Constraints). This allows projects to operate under a simpler framework and condensed procedures, ensuring a faster response to crisis situations.53 This has been found to be highly beneficial in previous operations in Jordan.54 Key features include: reliance on country systems, limited procurement, retroactive financing, and more flexible financial management rules. 49. Focusing on simple design, quick wins, and flexibility when responding to an emergency context. Experience in emergency context indicates the crucial need for design simplicity and flexibility to ensure adequate response to the emerging needs on the ground. Experience from other countries stresses the importance of focusing on quick wins to ensure a positive impact for the affected population during conflict. IV. IMPLEMENTATION A. Institutional and Implementation Arrangements 50. Under the proposed Jordan Emergency Health Project (JEHP), the Ministry of Planning and International Cooperation (MOPIC) will be the implementing agency, as well as the managing entity of the funds with focal points appointed in MOH. Based on the project design, both MOPIC and MOH will set up mechanisms through their existing public system structures to ensure the delivery of the project’s proposed outputs and the timely monitoring and reporting of the various activities during the project life. 51. MOPIC has demonstrated capacity to manage World Bank-financed projects in the past which is crucial for the proposed emergency project. Through previous project experience with the Bank, such as the Emergency Services and Social Resilience Project, MOPIC has accrued expertise on Bank operational policies and procedures. The Project’s Division under the Department of International Cooperation at MOPIC will be responsible for project management. Dedicated focal points will be assigned for the day-to-day communication with the Bank to support the various planned activities during project implementation. In addition, a steering committee, including the project management team at MOPIC, will comprise of focal points from the concerned departments at MOH and MOF to oversee the overall progress of the project implementation and facilitate the administrative process among the various stakeholders. On the implementation front, MOH focal points will ensure the timely implementation and reporting on the project progress and support the activities of Component 2. 52. MOH department of primary and secondary health care will submit regular utilization data to MOPIC. This data will serve to identify the number of primary health care services delivered to the project’s target population at MOH facilities. Similarly, the department of secondary health care will submit the 53 World Bank. World Development Report 2011: Conflict, Security, and Development. Washington DC, 2011. 54 World Bank. Implementation Completion and Results Report: Emergency Project to Assist Jordan Partially Mitigate the Impact of the Syrian Conflict. Washington DC, 2015. Page 24 of 47 The World Bank Jordan Emergency Health Project (P163387) actual utilization data on the number of secondary health services provided at 33 MOH hospitals. This utilization data will be verified by an independent utilization verification entity (UVE) to ensure that the target beneficiaries received the services. 53. MOH department of budget and department of expenditure will provide regular internally audited reports of actual expenditures on project-related expenses. This will be verified by the Audit Bureau of Jordan with capacity building provided by an independent expenditure verification entity (EVE) to ensure that the expenses claimed are eligible to be paid by the project. The EVE will provide the first level sign off on the technical quality of the verification report and the AB will provide final level clearance. 54. The independent verification entity which will provide: (i) an independent verification of utilization; and (ii) capacity building to AB on verification of expenditure and will be hired by MOPIC according to the Bank’s procurement procedures. Accordingly, the costs incurred by MOH to provide the services to the target population will be reimbursed to the project’s designated account (DA) based on the costing exercise estimates. For the Bank to disburse, GOJ will use agreed invoicing procedures that consist of: (i) presenting the results of an independent expenditure verification for the relevant line items of actual budget expenditure linked to delivering services to the target population prepared by AB with capacity building support and first level technical quality sign off provided by an EVE; and (ii) presenting the results of an independent utilization verification of outpatient and inpatient services provided to the target populations conducted by a UVE. The entities will verify the documentation based on a representative sample of services which will be reviewed using the clinical files of sampled facilities. Once the field verification is conducted, the UVE and AB will furnish MOPIC with a report describing the total utilization of services by beneficiaries and total eligible expenditures for this utilization at MOH facilities. MOPIC will in turn send the disbursement request with the documentation produced by MOH, AB, and the UVE. The Bank will review the documentation and, if complete and satisfactory, then proceed to disburse the amount. If possible, one firm will be used for both the UVE and EVE to streamline processes. 55. The World Bank financial management procedures will apply. The project will be financed in parallel by the IsDB (US$100 million). Three separate US Dollar DAs will be opened at the Central Bank of Jordan (CBJ) to receive the loan proceeds from each agency. The World Bank will have two DAs—one for each component—and IsDB will have one DA for component 1 which they are also funding. These DAs will be managed by MOPIC. 56. Retroactive financing will be used for 40 percent of the project amount for eligible expenditures made prior to the signing of the loan agreement date but on or after June 29, 2016. The project will finance services which have been already delivered by MOH prior to the signing of the loan agreement but on or after June 29, 2016 to ensure an adequate response to the health sector needs. The retroactive financing will not exceed US$20 million. 57. Given the scope of services and proposed activities under the project, procurement will be limited and mostly concerned with component 2 (US$2 million). This component is fully funded by the World Bank and these procurement activities will follow the World Bank procurement policies and procedures. Page 25 of 47 The World Bank Jordan Emergency Health Project (P163387) 58. The closing date and implementation schedule will be two years from the date of signing. Given the critical needs of the health sector in Jordan, the planned activities under the proposed emergency operation will be implemented over a period of two years (June 30, 2017 to June 29, 2019‐see the disbursement schedule). It is estimated that 65 percent of the total financing amount will be disbursed over the first year of implementation. According to the project disbursement profile, around 98 percent of the World Bank financing (US$50 million) will be disbursed within the first year of implementation. The IsDB funds (US$100 million) are expected to be disbursed over two years. B. Results Monitoring and Evaluation 59. The results framework outlines key performance indicators (disaggregated by gender), data collection methods, timetable for collection, and responsible agencies (Section VII). This framework will be used by both the World Bank and IsDB to supervise and monitor the progress of project implementation. 60. In most cases, health facilities in each governorate manually collect and report data on the target populations to the respective governorate health office which review and submit the data to MOH. The MOH centrally consolidates data and publishes the results annually. Disaggregated data for the target population are similarly aggregated at the central level from facilities. MOPIC will work closely with relevant departments at MOH to ensure that disaggregated data collected will be reported to the World Bank and the IsDB on a six-month basis. At present, disaggregated data on the gender of poor Jordanian beneficiaries is not collected, but with the continued roll out of the electronic medical record, HAKIM, more data should become available. 61. The World Bank will conduct implementation support missions biannually in close coordination with IsDB and MOPIC to review progress, as well as discuss and resolve any bottlenecks to ensure smooth implementation and disbursement. Specifically, the missions will: (i) capture progress towards the achievement of the PDO and the most recent data for the identified indicators; (ii) support GOJ on any implementation issues that may arise; (iii) provide technical support for implementation, in particular for component 2; (iv) identify and help mitigate any risks to the project; and (v) monitor progress through progress reports, audit reports, and field visits. C. Sustainability 62. Given that the project will be implemented over a two-year period, it is designed with emphasis on sustainability as demonstrated in three ways. 63. First, the project is in line with the overall medium to long-term vision of GOJ and the vision of MOH to provide universal health coverage (UHC) to all residents of Jordan. This project will help support the provision of essential health services to the target population and thus help with the provision of UHC. 64. Second, the project maintains the current level of health service coverage which is already costed and included in the budget. By maintaining the current level of services which are already costed in the current MOH budget and not adding additional services the project design ensures that, even after the project is completed, GOJ should be able to maintain this level of coverage. 65. Third, the second component of the project focus on improving the efficiency of the health system. In Page 26 of 47 The World Bank Jordan Emergency Health Project (P163387) the medium to long term this should help eliminate unnecessary spending, create more fiscal space, and ensure that GOJ can get more health for the same level of wealth, thus creating a more sustainable system. D. Role of Partners 66. A number of donors and international NGOs have stepped up their engagement in the Jordanian health sector to mitigate the impact of the influx of Syrian refugees . For instance, UNFPA is supporting a package of maternal and child health services for Syrian refugees. In addition, the European Commission’s Civil Protection and Humanitarian Aid Operations directorate (ECHO) has contributed more than €271 million, providing services such as health, food, and basic needs assistance, psychosocial support, to refugees in camps, urban settings, and at the Berm. Meanwhile, UNHCR is reimbursing the copayment that Syrians incur if referred through their primary care NGO, JHAS, to secondary care MOH facilities. Several NGOs, such as MedAir, International Rescue Committee, International Medical Corps, and Médecins Sans Frontières are also providing free health care to Syrian refugees and to uninsured poor Jordanians. 67. With regard to technical assistance, several partners are supporting GOJ in strengthening the health system and improving its institutional capacity. For instance, USAID’s five-year Jordan Health Finance and Governance activity supports GOJ’s efforts to increase spending efficiency of public resources and strengthen health sector governance. WHO’s support focuses on improving the quality and efficiency of the health system. The World Bank team is in contact with these groups and will coordinate with them on component 2 to avoid duplication and maximize impact through relevant partnerships. 68. Currently, no partner is directly covering the cost of service delivery borne by GOJ at MOH facilities for target population. Therefore, the proposed project will fill a critical gap in ensuring public health care provision to these vulnerable target groups and strengthen the existing system in line with GOJ’s overall vision for the health sector. V. KEY RISKS A. Overall Risk Rating and Explanation of Key Risks 69. The overall risk to the achievement of the project’s objective is rated “Substantial”. The key risks that may impede the implementation of the project are: macroeconomic risks, fiduciary risks, stakeholders’ risks, and other risks linked to geographic and regional context which are described in detail below. These risks are largely project specific and do not apply to the country as a whole. In fact, it is important to note that some risks have decreased over time with the 2013 “Emergency Project to Assist Jordan Partially Mitigate the Impact of the Syrian Conflict” having an overall implementation risk rating of “high” as compared to the present risk of “substantial”. This project was successfully implemented within a similar two-year period, resulting in it closing with a Borrower rating of “moderately satisfactory” and overall project rating of “moderately satisfactory”. Several risks for this project are considered moderate (M) or low (L) and include risks due to political and governance (M), sector strategies or policies (M), technical design of project (M), institutional capacity for implementation and Page 27 of 47 The World Bank Jordan Emergency Health Project (P163387) sustainability (M), environmental and social aspects (L). This section describes the risks which are substantial or high and associated risk mitigation measures. 70. Macroeconomic risk is substantial. Economic growth has been slowing down as a result of many shocks, with some recent pressures on Jordan’s external position. Nevertheless, the Government has demonstrated an ability to manage these impediments. The macroeconomic stability objective is supported by several programs and donors, including the Extended Fund Facility approved by the IMF Executive Board in August 2016. So far, the Government has been covering the cost of health care for the refugees (100 percent from 2012-2014, 80 percent since 2014), but given that GOJ is under significant fiscal pressure, current health spending needs to become more efficient which is the aim of Component 2. 71. Fiduciary and stakeholders’ risks is substantial. The proposed project will be parallel financed by the IsDB. IsDB has limited experience in the health sector and this will be the first such project in Jordan. The FM risk is “substantial”, mainly due to: (a) limited prior experience and knowledge of MOH with the World Bank financial management and disbursement guidelines; (b) potential weak coordination between MOPIC and MOH that might cause delay in financial reporting and disbursements; (c) GFMIS being unable to generate the quarterly financial reports as per the World Bank guidelines; (d) potential for incorrect accounting of the health services received by the target population. The following measures are to be taken to mitigate FM-related risks: (a) a qualified FO will be identified within the MOPIC Finance Department to handle FM and disbursement functions; (b) adequate training will be provided to MOH-FO on the World Bank financial management and disbursement guidelines; (c) capacity building and training support will be provided to the AB by an EVE for the expenditure verification portion; the EVE will also provide the first level sign off on the technical quality of the expenditure verification with the AB providing the final sign off; (d) within one month of effectiveness, an EVE and UVE (or one firm who will conduct both functions), acceptable to the World Bank, will be hired in accordance with the TOR acceptable to the World Bank; (e) there will be two verifications completed no later than six months after the first and second advances; (f) the project’s financial statements for the entire length of the project will be audited and presented to the Bank no later than six month after the end of the project; (g) a simplified format using spread sheets will be used to generate the quarterly Interim Financial Reports (IFRs). The World Bank team will supervise the project, particularly early in implementation. Furthermore, implementation missions will be conducted in coordination with IsDB biannually. 72. Other risks, such as geopolitical and regional risks are high. Jordan’s high degree of integration with its neighbors in a volatile region poses a significant risk to the project. The ongoing Syrian conflict, insecurity due to terrorist groups, violence in Iraq, and Israeli-Palestinian tension compound the risks to Jordan in terms of a potential destabilizing impact, toll on the economy, and provision of public services. Keeping these risks in mind, the project has been designed to be simple and fast disbursing against health services delivered. VI. APPRAISAL SUMMARY A. Economic and Financial (if applicable) Analysis Page 28 of 47 The World Bank Jordan Emergency Health Project (P163387) 73. Public health services are well suited to cover the project’s target populations. The project focuses on two highly vulnerable populations: Syrian refugees (who live mostly below the poverty line) and uninsured Jordanians, who are typically unemployed or out of the labor force. International experience has shown private insurance is often not able to provide adequate coverage to poor and informal workers so public intervention is warranted.55 In addition, Jordan’s public health system provides over 60 percent of hospital beds, and practically all primary care services.56 Therefore, the public system has been in a unique position to respond to the refugee crisis, which requires a large infrastructure to cater to a rapidly growing population. Furthermore, the World Bank has long experience in assisting countries in managing emergencies, including in various MENA countries such as Yemen and Lebanon.57, 58 The World Bank has also substantial experience in health care reform and efficiency improvement, which constitute the second component of the proposed project. 74. The proposed project will improve the MOH’s short-term fiscal sustainability. MOH has limited fiscal space to maintain current service levels to the target population. This results from macroeconomic pressures (including lower GDP growth and higher debt to GDP ratios), high public spending in health (11 percent the government budget or 7 percent of GDP), and increased health care demand. 59 Using concessional financing, the proposed operation will improve the short-term sustainability of public services, without creating an undue debt burden in later stages. 75. The project’s impact has been assessed through a cost-benefit analysis (CBA). This analysis estimates the Project’s Net Present Value (NPV) as a function of its costs and benefits, where NPV=Benefits -Costs. The benefits are calculated in terms of the lives of women and children saved by the Project. Following an established methodology, these are expressed in terms of Value of Statistical Life (VSL), which denotes how much society would be willing to pay to save a life.60 The costs correspond to the Project’s total costs (US$150 million). A positive NPV reflects that the project is justified in economic terms. The analysis assumes a three-year time frame (one year retroactive and two-year project time line), and a discount rate of three percent for the time value of money. 76. The project is expected to help GOJ maintain the provision of the current package of services to the target population. Since the package of services provided includes key maternal and child health interventions such as antenatal care, skilled deliveries, and well child visits, the economic analysis is focused on the effectiveness of these interventions. This is likely to underestimate the project’s impact as MOH is providing many other services (such as adult health) that also save lives.61 The literature 55 Bitran, R. Couverture maladie universelle et le défi de de l’emploi informel : enseignements tirés des pays en développement. Publication autorisée, January 2014. 56 Ajlouni, M. Jordan Health System Profile 2010. World Health Organization – Eastern Mediterranean Office Region (EMRO). Amman (Jordan), 2011. 57 International Bank for Reconstruction and Development. Project Appraisal Document on a Proposed Grant in the Amount of SDR 37.5 million (US$50 million) to the United Nations Development Programme for a Yemen Emergency Crisis Response Project. Washington DC, 2016. 58 International Bank for Reconstruction and Development. Project Appraisal Document on a Proposed Grant in the Amount of $15 million to the Lebanese Republic for an Emergency Healthcare Restoration Project. Washington DC, 2015. 59 Hashemite Kingdom of Jordan – High Health Council. Jordan National Health Accounts: Technical Report no.6. Amman, 2016. 60 Ozawa S, Stack ML, Bishai DM, et al. During the “decade of vaccines,” the lives of 6.4 million children valued at $231 billion could be saved. Health Aff (Millwood). 2011; 30:1010–1020. 61 Ministry of Health – Ministry of Planning and International Cooperation. Annual Utilization of MOH Facilities by Syrian Page 29 of 47 The World Bank Jordan Emergency Health Project (P163387) suggests that primary care and targeted maternal and child interventions can reduce maternal and child mortality rates by 5 to 40 percent.62,63,64 Given this range, the original 15 percent effect assumption is conservative. The analysis then further takes into account that the project finances only 77 percent of the cost of delivering a health service to the target populations (i.e. it does not cover medical costs which are 23 percent of service costs). Extrapolating from figures for the whole country, and assuming that these proportions would also hold in the target populations, the 2015 MOH actual budget shows that US$153 million were spent on primary care services; US$273 million in secondary care; and US$126 million in medicines and consumables. As the proposed project covers only the first two, it covers 77 percent of delivery costs, and the original effectiveness estimate was adjusted by this amount. Therefore, the proposed interventions are assumed to reduce maternal and child mortality rates by 11.5 percent (0.77*0.15). 77. A sensitivity analysis assessed the robustness of the findings under various effectiveness scenarios. As in any intervention, the project’s effectiveness can vary due to design and implementation factors. Therefore, the team evaluated the project’s net present value under 10 percent effectiveness (7.7 percent adjusted) and 20 percent effectiveness (15.4 percent adjusted). A positive net present value in all cases would indicate that the project is well-justified in economic terms. 78. The analysis assumptions are based on country-specific estimates. Due to their different sizes and characteristics, the project’s benefits were calculated separately for the Jordanian and Syrian populations. The analysis assumes an uninsured Jordanian population of 2.1 million.65 It also assumes that the under-five and maternal mortality ratios for uninsured Jordanians are the average in the country. These are 17.8 per 1,000 births (under-five mortality) and 50 per 100,000 births (maternal mortality). 66 These are again conservative estimates as uninsured populations tend to be poorer and poverty is closely linked to poor health outcomes. For Syrians, calculations are based on 331,000 registered refugees.67 As 86 percent of refugees live below the poverty line,68 the analysis assumes that under-five mortality in Syrians is that of the lowest income quintile in Jordan, which is 29 per 1,000 births.69 79. The Value of Statistical Life (VSL) in Jordan was calculated per a standard methodology. The analysis uses a VSL value of US$510,366 for Jordan. This amount is based on the benefits transfer formula proposed by Ozawa, where VSLj = VSLUSA × (GNIj/GNIUSA) ^ ξ. 70 In this formula, the subscript j refers to Refugees, 2012-2016. Unpublished. 62 Bhutta, Zulfiqar A., et al. Alma-Ata: rebirth and revision 6: Interventions to Address Maternal, Newborn, and Child Survival: What Difference Can Integrated Primary Health Care Strategies Make? The Lancet 372.9642 (2008): 972. 63 Rosero-Bixby, Luis. Infant mortality in Costa Rica: explaining the recent decline. Studies in family planning 17.2 (1986): 57-65. 64 Macinko, James, Frederico C. Guanais, and Maria De Fátima Marinho De Souza. "Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990–2002." Journal of Epidemiology and Community Health 60.1 (2006): 13-19. 65 Department of Statistics (Kingdom of Jordan). General Population and Housing Census, 2015: Main Results. Unpublished. 66 World Health Organization. Health System Profile: Jordan. Cairo (Egypt), 2015. 67 United Nations High Commissioner for Refugees. Syrian Regional Refugee Response (Inter-Agency Information-Sharing Portal). Available http://data.unhcr.org/syrianrefugees/country.php?id=107. Last checked March 9, 2017. 68 Amnesty International. Living in the Margins: Syrian Refugees in Jordan Struggle to Access Health Care. Amman, 2017. 69 Ravishankar, N.; Gausman, J. Analysis Equity in Health Utilization and Expenditure in Jordan with Focus on Maternal and Child Services”. Amman, 2016. 70 Ozawa S, Stack ML, Bishai DM, et al. During the “decade of vaccines,” the lives of 6.4 million children valued at $231 billion Page 30 of 47 The World Bank Jordan Emergency Health Project (P163387) the country of study (i.e. Jordan), and the VSL value for the United States is US$6.2 million (2011).71 The variable ξ denotes percentage change of VSL in terms of GNI; based on Ozawa’s contribution, the current evaluation uses a 1.5 VSL income elasticity in the United States compared to that of developing countries. Hence ξ=1.5. 72 Following standard practice, PPP-adjusted amounts were used for GNI per capita.73 80. The project is estimated to generate a Net Present Value of US$82.2 million. Under the base case of 15 percent effectiveness, the health benefits for Jordanians (based on VSL calculations) accrue to US$185.4 million and the health benefits for Syrian refugees add up to US$44.6 million. When subtracted from US$147.8 million project costs (the discounted total cost of the project), the project’s NPV is US$82.2 million. The benefit to cost ratio is 1.6, which means that for every dollar invested in the project, 1.6 dollars are returned in terms of lives saved. The sensitivity analysis further shows that the project’s net present value stays positive under alternative scenarios. Assuming a very low 10 percent effectiveness, the project still breaks even (NPV=US$5.5 million) and under a higher effectiveness of 20 percent, NPV=US$159 million. These analyses show that the project’s health benefits outweigh its costs -- even in the most unfavorable circumstances. B. Technical 81. The proposed project is designed to strike a balance between the urgent needs of the health sector and building a foundation for the medium-term objectives of strengthening capacity of the system and improving its efficiency. This approach will ensure both quick health gains during the project’s life, as well as positive efficiency outcomes beyond the project. The implementation and financing mechanisms under the project take into consideration the urgent needs in the sector, the implementation capacity of MOH, as well as the epidemiological and demographical profiles of the target population. Using the government systems to provide the identified primary and secondary services is deemed as the most cost-effective, fit-for-purpose implementation arrangement for the project. 82. The proposed project features several ingredients for success. These include: government commitment to universal health coverage and equity principles for the health system, as well as inclusive policies for refugees to access the same package of services available to Jordanian nationals delivered at MOH facilities; the strong record of MOPIC in managing World Bank-financed projects; reliance on government health system structures with regard to financing and service provision; a streamlined financial management system with limited procurement to allow for quick disbursement. 83. The proposed project design builds on global and country experiences. Maintaining the provision and utilization rates of primary and secondary care services for the vulnerable groups in the country at this could be saved. Health Aff (Millwood). 2011; 30:1010–1020. 71 Trottenberg, P.; Rivkin R. Treatment of the Economic Value of a Statistical Life in Departmental Analyses. July, 2011. 72 Ozawa S, Stack ML, Bishai DM, et al. During the “decade of vaccines,” the lives of 6.4 million children valued at $231 billion could be saved. Health Aff (Millwood). 2011; 30:1010–1020. 73 The World Bank. GNI per Capita, PPP (current international $). World Development Indicators. Available http://data.worldbank.org/indicator/NY.GNP.PCAP.PP.CD. Last checked March 8, 2017. Page 31 of 47 The World Bank Jordan Emergency Health Project (P163387) transitional period in Jordan is expected to enable the GOJ to continue to provide critical health services and cope with the new sectoral challenges. The project will identify the different obstacles and options for reform, consolidate financial management, and allocate resources efficiently. This will be supported by World Bank technical assistance and cooperation during and beyond the project. C. Financial Management 84. The World Bank assessed the financial management systems within MOH and updated those at MOPIC. The assessment concluded that, with the implementation of agreed-upon actions, the proposed FM arrangements will satisfy the minimum requirements under OP/BP 10.00. The FM risk is “Substantial”. 85. MOPIC will be managing the FM and disbursement functions of the Project. A dedicated Financial Officer (FO) from MOPIC Finance Department will follow the Project’s FM and disbursement issues. In addition, a FM Coordination Officer will be designated by MOH and work in close coordination with MOPIC/FO on providing necessary financial information and documentation. MOPIC has extensive experience with the World Bank FM and disbursement policies, built during the implementation of ongoing and previous World Bank-financed projects, while MOH has limited experience and knowledge with the World Bank FM and disbursement guidelines. Adequate training will be provided to the MOH FM Coordination Officer in order to ensure full understanding of the World Bank financial management and disbursement policies and procedures. This shall ensure capacity to provide complete financial information and documentation to the MOPIC/FO. 86. Planning and Budgeting through the use of the existing GFMIS system. MOPIC and MOH uses systems for budget classification and a Chart of Accounts (COA) that conform to international standards and deploys a basic, but effective results-oriented budgeting framework, which provide the means to track government spending. Line ministries, including MOH, have a robust classification system broadly consistent with Government Finance Statistics Manual (GFSM) 2001.74 This system includes administrative, economic, functional, geographical, and program classifications. These classifications are included in the current COA allowing for all transactions to be reported in accordance with the appropriate standards. A Government Financial Management Information System (GFMIS) is used for budget preparation. 87. Accounting and Financial Reporting through quarterly IFRs. Much like other line ministries in Jordan, MOH has a cash basis for accounting. The Government adopts a COA that is compatible with GFSM 2001. The Ministry of Finance (MOF) has rolled out GFMIS to all line ministries in Jordan, including MOH and MOPIC. The current GFMIS implementation utilizes a subset of the functionalities of the underlying application software. The current core application software comprises: (i) Hyperion for budget preparation; (ii) ORACLE financials for budget execution; and (iii) software for interfacing with other software for Debt Management, Payroll, Bank Reconciliation, and Revenue Management. GFMIS is fully utilized for budget execution. Yet for budget preparation, there are manual interventions with various ICT tools being used. MOPIC will be responsible for preparing the quarterly IFRs and annual project 74 Government Finance Statistics Manual – IMF. Page 32 of 47 The World Bank Jordan Emergency Health Project (P163387) financial statements. For purposes of annual financial reporting of the project, it is proposed to rely on existing arrangements to capture the financial transactions. However, annual and quarterly financial reporting will be generated using excel sheets. The IFRs will be submitted by MOPIC to the World Bank within 45 days after the end of the concerned period. 88. IsDB will provide parallel financing. In order to avoid double financing under component one, the financing periods are divided between the two agencies. For instance, the first disbursement will be the retroactive financing for the eligible expenditures made prior to the signing of the loan agreement but on or after June 29, 2016. This will cover up to 40 percent of total financing costs, or up to US$20 million, against the verified primary and secondary health expenditures and services delivered to the target population at MOH facilities, without any financing by IsDB. For prospective periods, IsDB is expected to cover primary and secondary health services delivered to the target population during the period from June 2017 – December 2017, while the World Bank will pay for health services delivered during the period from January 2018 to June 2018. All remaining subsequent periods will be financed fully by IsDB. 89. The unit cost of delivering one primary or secondary health service will be calculated by dividing the total actual costs paid by MOH by the number of health services delivered to target populations at MOH facilities. The cost of primary and secondary health services provided to the target population will be estimated by multiplying the cost per unit of services by the number of primary and secondary care services delivered at MOH facilities. Payments will be made through a transfer to the Government Unified Treasury Account being the Single Treasury Account (STA) at the CBJ in local currency. Internal Controls and Internal Audit 90. Budget execution controls are implemented and applied consistently by MOPIC and MOH in accordance with the applicable Financial By-law (1994) and its Amendment (2015) and the Financial Control By-law (2011) and its Amendment (2015). The budget execution systems at MOPIC and MOH implement prescribed controls, which include: (i) technical approval by the beneficiary department; (ii) finance staff checking and approval; (iii) periodic, ad hoc reviews by resident Internal Auditors; and (iv) exercise of an expenditure controlling function by MOF’s Financial Controllers assigned to respective spending units. MOF assigned Financial Controllers oversee transaction-based compliance controls over payments, recording of transactions, and production of periodic and final accounts by responsible entities. In practice, no payments can be authorized and processed before Financial Controllers verify and signoff on payment vouchers. In addition to resident Financial Controllers from MOF, MOPIC, and MOH have Internal Auditors who mainly perform the job of internal/financial controllers. Internal Audit activities are primarily confined to ex-ante review of receipts, expenditure vouchers, and disbursements. Ex-ante controls are performed by Financial Controllers and Internal Auditors. Payroll 91. Due to the fact that salaries and wages make up a significant part of the cost of primary and health services provided by MOH and financed by the project, a review of diagnostic PFM reports and an assessment of MOH payroll system was conducted. As per the 2017 Public Expenditure and Financial Accountability (PEFA) assessment for Jordan, the controls over payroll were rated as “A”, with a key role Page 33 of 47 The World Bank Jordan Emergency Health Project (P163387) being played by the Internal Control Unit (ICU) in each ministry, including MOH. The ICU exercises a pre- audit role that involves the review of individual salaries and ensures compliance with the By-Law. It submits four reports per annum to the MOF and the Audit Bureau (AB) and informs the Civil Service Bureau (CSB). Payroll audits are carried out by both the CSB and the AB. The CSB’s role relates to administrative matters such as whether MOH is following the performance appraisal system correctly and matching job descriptions correctly to posts. Employing the International Organisation of Supreme Audit Institutions (INTOSAI) standards, the AB carries out an annual payroll audit of all ministries including MOH using a specially developed audit program that incorporates a system review, sampling, and review of the regulatory framework. 92. The payroll system in place has a good degree of integration and reconciliation between the position controls, personnel records, and payroll registers. The payroll system at MOH follows the CSB instructions and is in line with the national financial law and internal controls regulation, in addition to instructions issued by the MOF. The Human Resources (HR) department at MOH is responsible for receiving and entering the information for the appointed employee into the automated HR database system. The HR department safeguards the information and the data entry through an automated system with record archival both in the system and in paper files. HR input in the system is subject to both automated and human checks. A payroll schedule is prepared on a monthly basis and subject to several layers of approvals (Payroll Officer, Head of Payroll unit, Department Manager (budget holder), Internal Control Department, MOF Financial Controller and FM Manager). Salaries are transferred to employees’ personal bank accounts. Monthly reconciliations are prepared in the system and shared with the Internal Control unit and MOF representative. Daily time attendance sheets, based on an automated attendance register, are maintained by the Attendance Supervisor, who reports absences to HR and the responsible department. Supervisors confirm that they strictly ensure all employees are in place and functional. 93. For additional assurance over payroll, the external auditor hired for the project will also provide an opinion on the internal controls over payroll at MOH, and MOH hospitals and centers that provide primary and secondary services financed by the loan. External Verification and Auditing 94. The project will have three types of audits: (i) an expenditure verification to check the eligibility of expenditures made, which will be carried out by AB with capacity building support provided by an EVE, due within six months of each Advance; (ii) a utilization verification to track the delivery of health services to the target beneficiaries, which will be carried out by an UVE, due within six months of each Advance; and (iii) a financial statement audit due at the end of the project to cover the entire period during which withdrawals from the Loan Account were made, which will be carried out by an external auditor. It is likely that the same independent verification entity will verify utilization data and provide capacity building to AB on expenditure verification. 95. A private sector external auditor, acceptable to the World Bank, will be appointed based on the TOR acceptable to the Bank to audit the project’s financial expenditures under components one and two. MOPIC will be responsible for preparing the TOR for the auditor and submitting them to the Bank for clearance. The auditor’s scope of work will also include providing an audit opinion on the internal Page 34 of 47 The World Bank Jordan Emergency Health Project (P163387) controls over payroll at MOH, and MOH hospitals and centers that provided primary and secondary services financed by the loan. 96. The project’s audited financial statements will cover the entire period during which withdrawals from the Loan Account were made. The audited Financial Statements for such period shall be furnished to the Bank not later than six months after the end of such period. The final payment for the auditor after the closing date will be transferred from the loan account to an escrow account. According to the World Bank Policy on Access to Information issued on July 1, 2010, the audit report with audited financial statements of the project will be made available to the public. Funds Flow and Disbursement Arrangements 97. Three Designated Accounts (DAs) will be set up—two for the World Bank funds and one for IsDB. The project will be financed in parallel by IsDB (US$100 million). Three separate US Dollar DAs will be opened at the Central Bank of Jordan (CBJ) to receive the loan proceeds—two DAs will be for the World Bank amounts and one for the IsDB amount. For the World Bank DAs, the first DA (DA-A) will be used for component 1 and the second DA (DA-B) will be used for the TA component. 98. For component 1, up to US$20 million will be provided as part of the retroactive financing for the eligible expenditures made prior to the signing of the loan agreement but on or after June 29, 2016. Prospective disbursements will finance the actual costs of primary and secondary health services provided to the target population borne by MOH for the period January 1, 2018 to June 30, 2018. All loan funds under component 1 will be transferred to MOF Treasury Account at CBJ. 99. The proceeds of the loan will be disbursed in accordance with the World Bank's disbursements guidelines. This will be outlined in the Disbursement Letter and in accordance with the Bank Disbursement Guidelines for Projects. The Project will follow transaction-based disbursement. Accordingly, requests for payments from the loan will be initiated through the use of withdrawal applications (WAs) either for direct payments, reimbursements, and replenishments to the DA. All WAs will include appropriate supporting documentation. The documentation supporting expenditures (including the financial audit report of retroactive financing) will be retained at MOH and readily accessible for review by the external auditors and Bank supervision missions. All disbursements will be subject to the conditions of the Loan Agreement and disbursement procedures as defined in the Disbursement Letter. 100. Under component 1, there will be two disbursements, one disbursement against each output. The two outputs are: (1) health services delivered to the target population for time period prior to the date of the loan agreement but on or after June 29, 2016; and (2) health services delivered to the target population for time period January 1, 2018 to June 30, 2018. Each output will need to be verified by AB and UVE within six months following the payment of each advance. The verification agents will verify the outputs and the actual amount due and will submit their report to the Bank. 101. E-Disbursement. The World Bank has introduced an e-Disbursement system for all projects in Jordan. Under e-Disbursement, all transactions will be conducted and associated supporting documents and IFRs scanned and transmitted online through the World Bank’s Client connection system. The use of e- Page 35 of 47 The World Bank Jordan Emergency Health Project (P163387) Disbursement functionality will streamline online payment processing to: (i) avoid common mistakes in filling out WAs; (ii) reduce the time and cost of sending WAs to the World Bank; and (iii) expedite the World Bank processing of disbursement requests. D. Procurement 102. Limited procurement needs. Each financier – World Bank and IsDB - will be liable for its own financing. However, very limited procurement is expected under component 2 financed by IBRD only. 103. Procurement capacity assessment. The World Bank undertook an assessment of the procurement system and capacity in place at the MOPIC, the implementing agency of the proposed project which has been filed in Procurement Risk Assessment and Management System (P-RAMS). MOPIC will be in charge of selecting competent consultant(s), and auditor(s) for Component 2. 104. The procurement capacity assessment identified that MOPIC has clear regulations in place with regard to procurement responsibility. However, most of MOPIC’s procurement activities involve MOPIC supply of goods by the Supplies and Purchasing Section under the Financial and Administration Department. Additionally, MOPIC has acquired experience in channeling foreign international aid and implementing donor-funded projects. MOPIC also has a strong track record in working with consultants, NGOs, and community based organizations through self or donor-funded projects. 105. The applicable procurement regulations for the project is the World Bank new procurement framework (NPF), effective since July 2016. Since this framework is new, and despite limited procurement involved, initially it is anticipated that there may be a gradual learning curve. Additionally, the Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants (dated October 15, 2006 and revised in January 2011 and as of July 1, 2016) will apply to the project. 106. The overall procurement risk rating is Moderate. The overall procurement implementation risk of this project, having very limited procurement activities, is Moderate. The following measures are proposed to mitigate procurement-related risks: (i) utilizing a procurement plan as a monitoring tool for processing timely activities; (ii) preparing a procurement section in the Project Operations Manual (POM; to be finalized no later than one month after effectiveness) to integrate procurement processing; (iii) systematizing record keeping, and initiating electronic archiving of procurement processing; (iv) enhancing capacity for appropriate support (staff, training, tools); and (v) preparing in advance the TORs for the required consulting services. Market Analysis Summary 107. Consultants. The required consultants for auditing are mainly specialized verification consulting firms. Jordan has a good number of experienced independent verification firms for the tasks. Any additional consultancy contracts are expected to be small contracts, mostly for individual consultants, where both local and international capacity may be tapped as needed. 108. Procurement arrangements are envisaged as described below. Page 36 of 47 The World Bank Jordan Emergency Health Project (P163387) 109. Methods of Procurement. Selection methods and arrangements: a. Goods and non-consulting services: The Project is not expected to purchase equipment or goods. However, if small items were needed, a Request for Quotations (or Shopping); and Direct Selection (old Direct contracting) will be used. b. Consulting Services: The Project is expected to use request for proposals with the following methods: (i) Quality- and Cost-Based Selection (QCBS); (ii) Fixed Budget-based Selection (FBS); (iii) Least Cost-based Selection (LCS); (iv) Selection Based on Consultants’ Qualifications (CQS); (v) Direct Selection (old single sourcing); and (vi) Selection of Individual Consultants. 110. Prior review thresholds. Based on the procurement assessment risk rating, the Project shall be subject to moderate risk prior review thresholds as defined under NPF. Therefore, all contracts, with exception of TORs, are expected to be post review. Hands on assistance will be provided by Bank staff as needed. 111. The procurement plan for the life of the project will be developed by MOPIC through the Systematic Tracking of Exchanges in Procurement (STEP). It will define the market approach options, the selection methods and contractual arrangements, and determine the World Bank’s prior/post reviews. The initial procurement plan will be attached to the legal agreement. Packages shall be determined to process activities efficiently. 112. Frequency of post procurement review. The frequency of post procurement review is foreseen to be once a year. In the post procurement review, a minimum sample of ten percent of contracts or at least one contract eligible for post review shall be covered. E. SoE. Social (including Safeguards) 113. The project is expected to contribute to positive social outcomes. It is not expected to pose social safeguard risks; however, there are non-safeguard (social) risks that may negatively affect implementation of the project. The Involuntary Resettlement OP/BP 4.12 is not triggered. The first risk will be ineffective targeting of vulnerable Jordanians, such as the elderly, disabled, single headed households, the uninsured, and those who may be discouraged from seeking health care due to recent increases in out of pocket payments. For the same reason, Syrian refugees, particularly those not registered with MOI, may also be difficult to identify. The second risk is interlinked with the first. Access to care may be perceived as favoring the insured thus, deterring the target population from seeking public coverage. Peoples’ perceptions of key issues matter in mitigating risks to social cohesion. This includes perceptions of how humanitarian aid is delivered and to whom. Such public perception aspects and their potential impact on relationships between refugees and host communities place a premium on communication and outreach within the purview of the project. 114. The mitigation measure, therefore, is to support current MOH outreach and communications activities, in collaboration with other relevant local stakeholders (i.e., Health Directorates, UNHCR, health centers in locations with high presence of Syrian refugees, and local NGOs) to disseminate information about the rights of Jordanians and Syrian refugees including on access to health services. This would include: where and how to access health services; changes introduced with regards to copayments; and where and how to submit a grievance. Page 37 of 47 The World Bank Jordan Emergency Health Project (P163387) 115. Findings from the extensive consultations with relevant beneficiaries and stakeholders were integrated into project design. These included discussions with women and girl beneficiaries; patients and health providers; UNFPA supported maternal and child health center in Za’atari refugee camp; a pediatric hospital in Irbid with a high volume of poor uninsured Jordanians and Syrian refugees; a maternal health outpatient center at a Comprehensive Primary Health Care Center in Amman; and heads of maternal health and gender based violence departments at the Ministry of Health, UN Agencies (UNFPA and UNICEF), and NGOs providing gender oriented services including International Medical Corps, Médecins sans Frontières, MedAir, and Médecins du Monde. 116. The project’s design is gender sensitive and aligns well with the new World Bank Gender Strategy which focuses, among other things, on improving gaps in human endowments. The gender-based analysis plus (GBA+) examined gaps in access to healthcare and the intersection of gender with income to identify the most vulnerable subpopulations in Jordan revealing that Syrian refugees and the poor uninsured Jordanians are the most vulnerable. To support them with a gender sensitive package of health services for both men and women, the project will provide free antenatal care services or deliveries for women and support treatment of non-communicable diseases (some of which disproportionately affect men), at a very subsidized rate. A capacity building component will be rolled out to provide training on gender based violence and barriers to access, as well as supporting the collection, use, and analysis of more gender disaggregated health data over the medium to long term. In particular, the following processes will be strengthened and/or tracked: (i) collection of gender disaggregated data on utilization of different types of health services as part of the verification process, enabling tracking of indicators; (ii) gender sensitive analysis and capacity building on gender streamlining across different health interventions, and (iii) training and development of protocols on GBV and reproductive health (in partnership with other donors and UN Agencies). F. Environment (including Safeguards) 117. According to the OP 4.01 on Environmental Assessment, this project is classified as Environmental Category "C". Activities supported by this project are expected to have minimal to no direct environmental impacts. The project will not fund any medical consumables (e.g. vaccination kits, vials, syringes), nor fund the purchase of any equipment, goods, or works. If the procurement plan is revised to include any of the above, then the project is subject to environmental assessment (EA) reclassification, which would then necessitate a project restructuring. In terms of both social and environmental safeguards, each financier – World Bank and IsDB -- will be liable for its own financing. 118. In terms of accreditation, there is a Health Care Accreditation Council (HCAC), which is Jordan’s only non-profit health accreditation, that assesses how health care services address environmental and social risks inherent to health service delivery. HCAC is a member of the International Society for Quality in Health Care (ISQua) Federation. HCAC surveyors are required to use the measurable elements in the standards to determine whether the institution has met, partially met, or did not meet the standard requirement. The fifteen standards clusters are as follows: (1) patient and family rights; (2) access and continuity of care; (3) patient care; (4) diagnostic series; (5) mediation use; (6) infection prevention and control; (7) environmental health and safety; (8) support services; (9) quality improvement and patient safety; (10) medication records; (11) human resources management; (12) Page 38 of 47 The World Bank Jordan Emergency Health Project (P163387) management and leadership; (13) medical staff; (14) nursing series; and (15) patient and employee education. 119. Standards within each cluster are classified as critical, core, and stretch. Critical standards are standards which, if not met, could cause injury or death to patients, staff or visitors and are required by law. The facility must meet 100 percent of the critical standards. Core standards relate to the systems and processes of the facility. During the first survey, 60 percent of the core standards must be met, and 70 percent of the core standards must be met at the second survey. Stretch standards are more difficult to meet, sometimes due to a lack of resources or to the significant change required in culture or thinking within the organization. The organization must meet 30 percent of the stretch standards during the first survey and 40 percent during the second survey. If a “seminal event” occurs which demonstrates a failure of any critical standards, the facility must report this event or risk loss of accreditation. Standards are reviewed and revised every two years. The HCAC accreditation awards are also valid for two years. 120. HCAC Accredited MOH Primary Health Care (PHC) Centers in Jordan currently include 120 out of 240 facilities. HCAC, together with MOH and the Royal Court, have set National Quality and Safety Goals (NQSG) to increase the number of HCAC accredited centers. HCAC is relatively new. The process of standards setting started in 2007, with 20 and 42 PHC centers accredited in 2010 and 2013, respectively. MOH Quality Assurance Directorate regulates MOH-operated PHC centers so that they are meeting national standards. This provides a “safety net” for health care quality, whereas the HCAC system is pushing Jordanian medical facilities to achieve quality on par with international standards. 121. The primary constraint to more facilities becoming accredited is lack of necessary financial resources to host accreditation site visits and work on accreditation-related capacity building needed to close identified gaps. There is a goal to accredit 20 new PHC centers per year, and MOH has been consistently that target. MOH has an Occupational Health and Safety department, which assists MOH-funded as-yet- unaccredited facilities to meet HCAC standards for infection prevention and control as well as environmental health and safety. 122. As part of the Jordan Response Plan, the Royal Court is providing funding, as well as coordinating with HCAC, to prepare additional MOH-run facilities for HCAC accreditation. USAID, which supported Jordan in establishing health care accreditation systems, is now focusing on quality care improvement in field-based health facilities working with Syrian refugees and other vulnerable groups. 123. Based on the strength of health care quality systems as noted above, the environmental and social risk profile of this project is assessed to be low, commensurate with an Environmental Assessment category classification of C. The TA component of this project is expected to incorporate health care accreditation as part of the sector roadmap. G. Other Safeguard Policies (if applicable) N/A Page 39 of 47 The World Bank Jordan Emergency Health Project (P163387) H. World Bank Grievance Redress 124. Communities and individuals who believe that they are adversely affected by a World Bank (WB) supported project may submit complaints to existing project-level grievance redress mechanisms or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org. . Page 40 of 47 The World Bank Jordan Emergency Health Project (P163387) VII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY : Jordan Jordan Emergency Health Project Project Development Objectives The Project development objective (PDO) is to support the Government of Jordan in maintaining the delivery of primary and secondary health services to poor uninsured Jordanians and Syrian refugees at Ministry of Health facilities. Project Development Objective Indicators Unit of Responsibility for Indicator Name Core Baseline End Target Frequency Data Source/Methodology Measure Data Collection Name: Maintaining number Number 1238.00 1238.00 Every 6 months Governorate health Directorate of of health services delivered (Thousand) directorates Primary Health at MOH primary health care Care, MOH facilities to target populations Number of health services Number 513.00 513.00 Every 6 months Governorate health Directorate of Primary delivered at MOH primary (Thousand) directorates Health Care, MOH health care facilities to poor uninsured Jordanians, male Number of health services Number 556.00 556.00 Every 6 months Governorate health Directorate of Primary delivered at MOH primary Page 41 of 47 The World Bank Jordan Emergency Health Project (P163387) Unit of Responsibility for Indicator Name Core Baseline End Target Frequency Data Source/Methodology Measure Data Collection health care facilities to (Thousand) directorates Health Care, MOH poor uninsured Jordanians, female Number of health services Number 69.00 69.00 Every 6 months Governorate health Directorate of Primary delivered at MOH primary (Thousand) directorates Health Care, MOH health care facilities to registered Syrian refugees, male Number of health services Number 100.00 100.00 Every 6 months Governorate health Directorate of Primary delivered at MOH primary (Thousand) directorates Health Care, MOH health care facilities to registered Syrian refugees, female Description: Name: Maintaining number Number 904.00 904.00 Every 6 months Governorate health Directorate of of health services delivered (Thousand) directorates Primary Health at MOH secondary health Care, MOH care facilities to target populations Number of health services Number 381.00 381.00 Every 6 months Governorate health Directorate of Primary delivered at MOH (Thousand) directorates Health Care, MOH secondary health care facilities to poor uninsured Page 42 of 47 The World Bank Jordan Emergency Health Project (P163387) Unit of Responsibility for Indicator Name Core Baseline End Target Frequency Data Source/Methodology Measure Data Collection Jordanians, male Number of health services Number 413.00 413.00 Every 6 months Governorate health Directorate of Primary delivered at MOH (Thousand) directorates Health Care, MOH secondary health care facilities to poor uninsured Jordanians, female Number of health services Number 52.00 52.00 Every 6 months Governorate health Directorate of Primary delivered at MOH (Thousand) directorates Health Care, MOH secondary health care facilities to registered Syrian refugees, male Number of health services Number 58.00 58.00 Every 6 months Governorate health Directorate of Primary delivered at MOH (Thousand) directorates Health Care, MOH secondary health care facilities to registered Syrian refugees, female Description: Name: Completion and Yes/No N Y Every year MOH MOH dissemination of a health sector roadmap to improve the efficiency of services delivered Page 43 of 47 The World Bank Jordan Emergency Health Project (P163387) Unit of Responsibility for Indicator Name Core Baseline End Target Frequency Data Source/Methodology Measure Data Collection Description: Intermediate Results Indicators Unit of Responsibility for Indicator Name Core Baseline End Target Frequency Data Source/Methodology Measure Data Collection Name: Grievances registered Percentage 100.00 100.00 Every 6 months Directorate of Controls and MOH related to delivery of project Internal Auditing, MOH benefits that are actually addressed Description: Page 44 of 47 The World Bank Jordan Emergency Health Project (P163387) Target Values Project Development Objective Indicators FY Indicator Name Baseline YR1 YR2 End Target Maintaining number of health services delivered at MOH 1238.00 1238.00 1238.00 1238.00 primary health care facilities to target populations Number of health services delivered at MOH primary health 513.00 513.00 513.00 513.00 care facilities to poor uninsured Jordanians, male Number of health services delivered at MOH primary health 556.00 556.00 556.00 556.00 care facilities to poor uninsured Jordanians, female Number of health services delivered at MOH primary health 69.00 69.00 69.00 69.00 care facilities to registered Syrian refugees, male Number of health services delivered at MOH primary health 100.00 100.00 100.00 100.00 care facilities to registered Syrian refugees, female Maintaining number of health services delivered at MOH 904.00 904.00 904.00 904.00 secondary health care facilities to target populations Number of health services delivered at MOH secondary health 381.00 381.00 381.00 381.00 care facilities to poor uninsured Jordanians, male Number of health services delivered at MOH secondary health 413.00 413.00 413.00 413.00 care facilities to poor uninsured Jordanians, female Number of health services delivered at MOH secondary health 52.00 52.00 52.00 52.00 care facilities to registered Syrian refugees, male Page 45 of 47 The World Bank Jordan Emergency Health Project (P163387) Indicator Name Baseline YR1 YR2 End Target Number of health services delivered at MOH secondary health 58.00 58.00 58.00 58.00 care facilities to registered Syrian refugees, female Completion and dissemination of a health sector roadmap to N N Y Y improve the efficiency of services delivered Intermediate Results Indicators FY Indicator Name Baseline YR1 YR2 End Target Grievances registered related to delivery of project benefits 100.00 100.00 100.00 100.00 that are actually addressed Page 46 of 47 The World Bank Jordan Emergency Health Project (P163387) Page 47 of 47