Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB1804 Project Name Zambia Malaria Booster Project Region AFRICA Sector Health (100%) Project ID P096131 Borrower(s) GOVERNMENT OF REPUBLIC OF ZAMBIA Implementing Agency Government of Republic of Zambia Ministry of Finance and National Planning Box 50062 Zambia Tel: 260-1-253512 Fax: 260-1-251078 Ministry of Health Ndeke House Zambia Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared September 7, 2005 Date of Appraisal Authorization September 7, 2005 Date of Board Approval November 15, 2005 1. Country and Sector Background Poverty has been persistent and worsening in Zambia. In 2002-03, the Central Statistical Office reported 67.0 percent of the Zambian population as poor. Although poverty remains centered in rural areas, with as much as 83.1 percent of rural households poor, the incidence of urban poverty has increased from 48.6 percent in 1991 to 56.0 percent in 1998. The worsening situation in Zambia is captured in the decline of the UNDP Human Development Index from 0.48 in 1985 to 0.43 in 2000. Social services have not grown commensurate with need, mainly because the Zambian macroeconomic situation remains very fragile. The Zambian health sector is facing numerous problems principally caused by the double burden of declining resources in real terms and an escalating disease burden. Total expenditures on health as percent of GDP have fallen from 6.0 percent in 1997 to 5.7 percent in 2001. Similarly, per capita total expenditures on health have fallen from US$24 in 1997 to US$19 in 2001. (WHO World Health Report 2004) Few health indicators have improved in Zambia over the last ten years and some have even deteriorated. Life expectancy at birth has dropped to 37 years, the under-five mortality rate has increased to 168 in 2001/ 02 and the infant mortality rate has remained high at 95 per 1000. The maternal mortality rate is 729 per 100,000 in 2001/02. Zambia is the fifth worst affected country Page 2 in HIV/AIDS, with an infection rate of 20 percent in the 15-45 age group. Combating malaria, the third of the Millennium Development Goals (MDG) in health, is a large challenge in Zambia, where it is the leading cause of morbidity and the second highest cause of mortality, especially among children and women (World Bank, 2005). Malaria accounts for 50,000 deaths a year in the country, and 37 percent of all outpatient hospital visits (CSO DHS, 2003). Malaria incidence rates have tripled in the past three decades from 121 cases per 1,000 in 1976 to 376 cases per 1,000 in 2004 (HMIS). The Government of Zambia has given high priority to dealing with the high morbidity and mortality associated with malaria. A 5-year national Roll Back Malaria strategic plan has been developed by the National Malaria Control Centre (NMCC), focusing on expanding the coverage and utilization of effective prevention and treatment interventions for malaria. There are several challenges in improving malaria control in Zambia that will need to be addressed: · Integrated vector management: low coverage and use of insecticide treated bed-nets especially among the poor and low coverage of indoor residual spraying interventions. · Scaling up of prompt and effective case-management, including Intermittent Presumptive Treatment (IPT) of malaria in pregnancy and improved malaria diagnosis, referral and treatment · Addressing the human resource capacity constraints in the health sector. 2. Objectives The project is designed to operate within the national program context. The development objectives of the project are therefore the specific objectives of the program that will be achieved in the four years coinciding with the project implementation period. The overall project development objective is to increase access to, and use of, interventions for malaria prevention and treatment by the target population. The target population is the population of Zambians living in all the 72 malarious districts of the country. However the priority groups among this target population will be children under the age of five years, pregnant women and all those infected with malaria. The specific objectives of the project are to: (i) increase the percentage of children under 5 years of age who sleep under a treated bed net from 30% to 60% by 2008, (ii) increase the percentage of pregnant women who receive a complete course of intermittent presumptive treatment for malaria from 45% to 70% by 2008, (iii) increase the percentage of people in IRS-eligible districts areas who sleep in appropriately sprayed structure from 40% to 80% by 2008, and (iv) increase the percentage of people with fever who receive effective treatment within 24 hours of onset of illness from 60% to 80% by 2008. These objectives are derived from the overall objectives of the national malaria program, to which the project contributes. The baselines for these specific objectives will be finalized before project approval. The existing monitoring and evaluation tools, such as the Health Management Page 3 Information System, and other tools that would be developed for the program, would provide the basis for monitoring and evaluation during implementation of the project. The Government of Zambia is determined to intensify its efforts on malaria control during the next 6-year planning cycle covered by the National Development Plan 2006-2011. The stated vision of the Government is a “Malaria-free Zambia”. The National Health Strategic Plan, which is synchronized with the NDP, has as its main theme “Working towards achieving the MDGs”. The reduction of malaria morbidity and mortality is one of the key MDGs for reducing the burden of communicable diseases. In response to the magnitude of the malaria problem in Zambia, the country's Poverty Reduction Strategy Paper (PRSP), which preceded the NDP, highlighted the importance of addressing malaria as a priority area within the framework of an integrated approach to health care and as part of the Roll Back Malaria Initiative. The proposed project is directly supportive of the Bank’s results-based Zambia Country Assistance Strategy (CAS) 2004. The project is aligned with the CAS strategic pillar 2, which is focused on improving lives and protection of the vulnerable. The project will contribute towards achieving the MDG goals of reducing infant and child mortality, maternal mortality and control of communicable diseases. 3. Rationale for Bank Involvement There are compelling reasons for the Bank’s involvement in malaria control. Malaria accounts for a high proportion of burden of disease and preventable mortality, thereby impairing human development. The economic burden of malaria, being a major cause of absenteeism from work and school and the cost associated with seeking for care, suggests that malaria control would provide positive returns in economic development. The link between malaria disease burden and poverty is a close and bidirectional one. The cost to households that is associated with malaria prevention is not affordable to the poor, who live on less than $1 per day, and when infected the poor are less likely to seek effective care and suffer more from wages lost as a result of illness and care seeking. The Bank’s involvement in malaria control has clear advantages. The Bank is well positioned to forge the necessary linkages between the macroeconomic context and the malaria program; the World Bank health team provided support to the targeting and achievement of the HIPC triggers on malaria control. The multi-sector impact of malaria necessitates a multi-sector effort, and the Bank can play a substantial convening role for the partners involved. The Bank has global and regional experience with health system development, health sector budgeting and planning, dealing with cross-cutting issues such as human resource crisis and experience in the implementation of multi-sector operations. The Bank’s involvement in financing the national HIV/AIDS program also provides opportunity to tap into synergies between HIV/AIDS and malaria control efforts in Zambia. The Bank’s strategic access, and support, for the process of developing the national development plan and the medium-term expenditure framework will improve prospects for long term program sustainability. The World Bank funding will fill critical gaps in the national malaria program to ensure achievement of desired outcomes and Page 4 impact. Many of these gaps are not included in financing provided by the Global Fund and other financiers. 4. Description The project’s contribution to the national malaria program will be organized in three components, which comprise elements derived from the malaria strategic plan. Component 1 (a) : Strengthening the health system to improve service delivery : This component will deal primarily with health system strengthening activities through the district basket pooled funding arrangement whereby all 72 district health management teams will receive incremental fund allocation to improve their malaria service delivery. The component will deal with the supply-side constraints for expanding coverage of malaria interventions, such as Insecticide Treated Nets (IRS), Indoor Residual Spraying (IRS) with insecticide, Rapid Diagnostic Tests (RDTs) and other laboratory equipment, and contribute to alleviating the dire human resource situation in the health sector through support for non-monetary compensation to retain critical staff. The project will finance the expansion of supply and distribution of insecticide treated bed nets, increase the coverage of Indoor Residual Spraying led by the District Health teams, provision of the rapid diagnostic tests (RDTs) and microscopes, and the training of microscopists and other front-line health workers in the use of RDTs. The implementation of this component will be primarily through the district basket mechanism, whereby funds will be pooled with other partners to finance incremental operating costs for the districts. Large ticket items such as ITNs, IRS equipment and supplies, and laboratory supplies will be centrally procured and distributed to the DHMTs as contributions to the basket “in kind”. The project will also support expansion of the Community-Based Malaria Control Program (CBMCP) through this window, linked to the DHMTs. Component 1 (b ): Improved environmental health management : This sub-component of the project will finance activities aimed at improving the management of health care waste associated with malaria control and the environmental monitoring for impact of insecticide use. The project will support activities to address the weaknesses identified in the WHO assessment of the vector management program in Zambia. Component 2 (a ): Program Management : This component will support strengthening the National Malaria Control Centre to provide technical leadership for the malaria program, coordination and implementation of the program, human resource capacity strengthening, strengthen monitoring and evaluation of the malaria control program including support to establishment of M&E systems, strengthen the capacity to conduct operational research i.e conduct of specific studies for data gathering, analysis and dissemination including knowledge management. At provincial and district level, the MOH entities responsible for coordination and harmonization of malaria prevention and control interventions will be eligible for financial support provided on the basis of costed annual work plans agreed during annual joint program reviews. The eligible activities will be consistent with the agreed national malaria strategic plan. The support will be Page 5 complementary to the support from partners supporting the RBM program in Zambia, since the work programs will be appraised and agreed on annual basis. Once the MTEF process is established in the health sector, these work programs will be integral to the sector MTEF. Financial management, procurement and disbursement functions of the project will be integrated within the MoH departments/units responsible for these functions. Reports from all stakeholders on resources and their use, implementation progress and procurement plans and progress will be consolidated by NMCC in collaboration with responsible departments and units within MoH. The capacity of the appropriate MOH staff will be strengthened to ensure they can manage the implementation of the program. Component 2 (b ): Multi-sector response: This sub-component will support mainstreaming of malaria-related activities into the work programs of key line ministries and government departments, the private sector and large NGOs, depending on their comparative advantages. Each of the relevant line ministry and government department will be eligible to receive funding based upon agreed annual work plans for the multi-sectoral efforts to combat malaria. These ministries include the Ministries of Education; Defense; Information and Broadcasting Services; Local Government and Housing; Agriculture, Tourism and Environment including the Zambia Tourist Board and Environmental Council of Zambia. The project will also support public- private partnerships between the NMCC and the Konkola Copper Mines, Mopani Copper Mines, Zambia Sugar, and private health care providers to support specific interventions, and the possible use of NGOs with expertise as service providers for certain malaria control and prevention activities including IEC, training, ITN distribution, and program monitoring. Component 3 : Community Booster Response to Malaria (COMBOR ): This component will deal with the demand-side constraints to effective malaria control programming. For example, while ITN ownership by households in rising, actual use is lagging behind. This project component will support community demand-driven interventions: (i) directly through financing of sub-projects by community based organizations, and (ii) through the facilitation of interventions by communities and local leaders to strengthen the malaria control activities of other implementers. The community response to malaria will help to both extend the geographic coverage of malaria interventions, particularly in the rural communities, and increase the use of the interventions. It will involve the communities to promote the behavior change that is necessary for malaria interventions to be effective within them. The component will be piggy- backed on the brand name and network infrastructure of the CRAIDS demand-driven fight against HIV/AIDS. This community demand-driven component (COMBOR) will complement the more supply-oriented CBMPCP, which is under Component 1. The activities to be supported under the COMBOR component will focus particularly on behavior change communication, advocacy on the appropriate usage of malaria prevention interventions, and capacity building for malaria prevention and control at the community and district level. 5. Financing Source: ($m.) BORROWER/RECIPIENT 0.0 INTERNATIONAL DEVELOPMENT ASSOCIATION 20.0 Total 20.0 Page 6 6. Implementation Malaria Partnership arrangements Since the launch of the RBM initiative in 1998, the government of Zambia has been working closely with the RM partnership in the implementation of the malaria control program through the Zambia RBM strategy for the last five years. The in-country partnerships and multi-sectoral coordination mechanisms have been developed at various levels of health care and have supported coordination and implementation of the national program. National Level: The following partnerships exist at national level: 1. The National Malaria Task Force : Membership comprises deputy ministers from all the line ministries, WHO and UNICEF and is chaired by the Deputy Minister of Health. The Task force reports to Vice –President and to Cabinet through the Minister of Health. The Task force provides a platform for higher political commitment and monitors the implementation of the RBM strategy to ensure that the Abuja targets are being met. The NMCC facilitates and provides secretariat to the biannual meetings of the National Malaria Task Force. 2. Health Sector Committee : involves the MOH and its partners in health SWAP. This partnership provides implementation support of the RBM strategy, coordinates resource allocation and approves disbursement of resources to hospitals and districts, and monitors and evaluates RBM national program. 3. National Malaria Control Centre Technical Working Groups : The technical working groups meet monthly to provide guidance in implementation of program activities, monitor progress and assist the development of guidelines. Membership includes NMCC staff and RBM partners from civil society, public and private institutions. The chair of each TWG is appointed among the members. The TWGs include Vector Control, Case Management, IEC and Monitoring and evaluation. The NMCC facilitate the reporting on progress implementation of malaria activities to the Health Sector Subcommittees, the Resource Allocation Subcommittee and the Sector Advisory Groups. Provincial Level: Although there is a provision for Provincial Malaria Task Forces, these have not been established in all provinces, and where they exist they are not fully functional. Page 7 District Level: The District Malaria Task Forces oversees and monitors the implementation of malaria activities at the district level, as part of the District Health Management Team. Membership includes all government departments and NGOs. The Task Force is chaired by the Director of the District Health Management Team. Community Level: The Malaria Control Committee (MCC) is linked to the Health Centre Committee at each Health Centre. Membership comprises the community members, health centre staff and NGOs where they exist. The committee is responsible for coordinating malaria control activities in each health centre catchment population. The project will support strengthening of partnerships at provincial, district level and to a certain extent the central level. Project implementation will be embedded within the implementation of the National Malaria Control Program. It will build on existing institutional capacity within the Ministry of Health, both at national and district levels, as well as implementing agencies (governmental and non- governmental) or partners with proven track record. At the national level, the project will be located under the Ministry of Health (MOH) which will be responsible for overall coordination, monitoring and evaluation. The MOH will also provide procurement and financial management support, and oversight to various implementing agencies within the project. Within the MOH, the malaria program coordination and management functions are delegated to a specialized unit in the public health directorate of the CBOH, namely the National Malaria Control Center (NMCC). As currently constituted, NMCC has technical responsibility for provision of guidelines and guidance on malaria control, and coordination of malaria control activities of the various RBM partners. The NMCC serves as the Secretariat for activities for RBM and links the service delivery points with the RBM partners. Hence, the NMCC will coordinate the implementation of components of the project within the context of the national malaria control program and provide strategic direction, technical support and quality control. Specific technical functions of the NMCC will include: policy formulation and resource mobilization, development of district and national strategic plans; development of guidelines on malaria programmatic areas; preparation, and dissemination of IEC materials; guidance to the CCM and RBM partners on Program implementation; assistance to District Health Management Teams (DHMTs) in implementation of malaria control activities and conducting monitoring and evaluation, including operational research. NMCC will provide quarterly reports to the MOH and to IDA on implementation progress of the national malaria program and the IDA supported malaria booster program. The MOH is currently undergoing reorganization. The proposed restructuring aims to integrate the CBoH, and its subsidiaries, into the MOH, which would assume both program and fiduciary responsibilities. Under the new organization, the NMCC would continue to perform its mandate of technical leadership for the malaria program. In light of the discussions with the Ministry of Page 8 Health, any substantial change vis- à-vis the national malaria control program responsibilities or disruption is not expected. The Community Booster Response to Malaria, will be implemented through the already existing Community Response to HIV/AIDS (CRAIDS) component of the Zambia HIV/AIDS project. CRAIDS has existing staff capacity and a decentralized organizational structure to mobilize communities, generate, appraise, approve and supervise community based interventions (sub- projects). CRAIDS has 9 regional offices which provide support to district technical teams. CRAIDS will provide grants to community based groups, NGOs and private sector organizations for malaria prevention interventions in line with the existing national guidelines. CRAIDS will be responsible for outreach, information dissemination, mobilization and technical support to communities. CRAIDS and District Facilitating Teams will work closely with the civil society in the preparation and implementation of the interventions (sub-projects). Sub-projects will be approved by the District Facilitating Teams, which include the District Health Management Teams, and ratified by the District Development Coordinating Committee. Approval thresholds for different groups to implement sub-projects at the district level have been agreed to by the Government and the Bank and included in the project operational manual. NMCC will provide overall technical guidance and support to CRAIDS. CRAIDS will provide quarterly reports to NMCC on physical and financial implementation progress. The malaria booster project will strengthen and use the existing MOH systems for procurement, financial management, and monitoring and evaluation. It is envisaged that there will be two special accounts which will be administered by MOH on behalf of the NMCC and CRAIDS. All the Components will be supported through one Special Account to be managed by the Ministry of Health. Funds for interventions to be implemented by DHMTs will be directly transferred to district accounts in tranches following the district basket fund guidelines and timetable. Disbursements for centrally managed activities will be transaction based. Disbursement of funds for Component 3 activities out of the Special Account will be against approved sub-projects and directly into approved community accounts. Audit arrangements have been finalized. Procurement will be handled through the MOH Central Procurement Unit in accordance with the World Bank Guidelines on Procurement for Goods and Services and the Selection of Consultants, and as stipulated in the Legal Agreement. A draft procurement plan for the first 18 months of implementation, which provides information on the procurement schedule and methods to be followed, has been prepared and will be updated annually to reflect changes in project needs. 7. Sustainability The Government’s commitment to the malaria program has been sustained through the first phase of the RBM partnership program 2000-2005. The evidence for the government’s ownership of the malaria control strategy include the enactment of a legislation to waive taxes Page 9 and tariffs on impregnated bed nets and insecticides and a change of anti-malarial treatment policy to use more effective drugs. The project’s support of the district basket pooled funding arrangement will strengthen the health system to address structural weaknesses as human resources, management and monitoring and evaluation. District level planning for malaria activities will be integrated with the district MTEF planning process to ensure that future funding flows through the Government will finance recurrent costs to sustain program activities at the district level. The recurrent cost required for the program has been estimated using the costing tool developed by the RBM partnership. The change of the malaria drug-policy in Zambia to the first-line use of Artemisinin-based combination therapy (ACT) comes at a significantly increased cost. ACT’s are financed through the Global Fund and are now widely available in the public sector. In the short and medium term the financing of ACTs is therefore not expected to be a problem. In the long-term the price of ACT is expected to decrease considerably making them more affordable and a sustainable choice for the treatment of malaria. 8. Lessons Learned from Past Operations in the Country/Sector a) Institutional development and human resource management : The intensive learning Implementation Completion Report (ICR) for the last World Bank financed health project in Zambia, Health Sector Support Project (1995-2002), highlighted decentralization of health services delivery by the establishment of functional district health teams funded through a novel “basket” arrangement as an important achievement. However, the ICR identified key lessons for the Bank, including: (i) Weak institutional capacity on procurement and financial management within the Ministry of Health (MOH), which led to delays in project implementation. (ii) the need to emphasize human resource development so that staff in the health sector has proper incentives, have access to continued professional development, and are retained in the health system in a productive manner, and (iii) the importance of establishing base-line indicators and a system for monitoring progress towards goals. The experience from the World Bank Africa region Multi-Country AIDS Program (MAP) has showed that it is vital that existing institutions are strengthened where they work, rather than creating completely new untested institutions. b) Coordination: In the context where there is already a multitude of partners, and new ones are coming in, it is critical that a sound partnership framework is developed and agreements on joint programming, procedures and monitoring systems developed. This will ensure that duplications are minimized and that activities are prioritized. The malaria booster project chose to operate with the program approach so that IDA contribution as donor of last resort is tailored towards priority gaps. The national malaria strategic plan forms the basis for IDA financing. c) Specific lessons from malaria control experience in Zambia: (i) cost sharing approach in distribution of ITNs has posed a barrier to access by some households, (ii) limitation of inputs has constrained scale-up efforts, (iii) there is need to improve infrastructure for diagnosis, (iv) more attention should be given to financial sustainability of new interventions, (vi) urgent need to address human resource constraints, and (vii) operations research is needed to examine what works, when and why. Page 10 9. Safeguard Policies (including public consultation) Two safeguards are triggered by this project: Environment Assessment (OP/BP/GP 4.01) and Pest Management (OP 4.09). Please see Section 5 and Annex 10 of the PAD for information on the Environmental Assessment, Vector Management Plan, and Medical Waste Management Plan. Safeguard Policies Triggered by the Project Yes No Environmental Assessment ( OP / BP / GP 4.01) [X] [ ] Natural Habitats ( OP / BP 4.04) [ ] [ X] Pest Management ( OP 4.09 ) [X] [ ] Cultural Property ( OPN 11.03 , being revised as OP 4.11) [ ] [X ] Involuntary Resettlement ( OP / BP 4.12) [ ] [X ] Indigenous Peoples ( OD 4.20 , being revised as OP 4.10) [ ] [X ] Forests ( OP / BP 4.36) [ ] [X ] Safety of Dams ( OP / BP 4.37) [ ] [X] Projects in Disputed Areas ( OP / BP / GP 7.60) * [ ] [X ] Projects on International Waterways ( OP / BP / GP 7.50) [ ] [X ] 10. List of Factual Technical Documents Documents in Project File Environmental Assessment 1. Integrated Vector Management Action Plan 2. DDT Indoor Residual Spraying: Guidelines for Health Workers 3. WHO Report of Vector Control Needs Assessment in Zambia, May 2005 4. ZANARA Medical Waste Management Plan 5. Malaria Medical Waste Management Plan (Addendum to ZANARA MWMP) Social Assessment 6. Rapid Qualitative Social Assessment of Malaria (De Soto & Makono, August 2005) 7. The Behavioral and Social Aspects of Malaria and its Control (TDR document) 11. Contact point Contact: Muhammad Ali Pate Title: Public Health Spec., HQ Tel: (202) 473-4463 Fax: Email: mpate@worldbank.org * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas Page 11 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop wb252543 C:\Documents and Settings\wb252543\My Documents\Malaria\PID - Appraisal Stage.doc 09/08/2005 10:45:00 AM