The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) Note to Task Teams: The following sections are system generated and can only be edited online in the Portal. Please delete this note when finalizing the document. Project Information Document/ Integrated Safeguards Data Sheet (PID/ISDS) Concept Stage | Date Prepared/Updated: 06-Jun-2018 | Report No: PIDISDSC23713 Apr 15, 2018 Page 1 of 10 The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) BASIC INFORMATION A. Basic Project Data OPS TABLE Country Project ID Parent Project ID (if any) Project Name Comoros P166013 Health and Nutrition Systems Support for Quality Services (P166013) Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) AFRICA Oct 15, 2018 Dec 14, 2018 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing MINISTRY OF FINANCE AND MINISTRY OF HEALTH, BUDGET SOLIDARITY, SOCIAL PROTECTION AND GENDER PROMOTION Proposed Development Objective(s) Improve access to quality maternal and child health and nutrition services in selected geographical areas of the country PROJECT FINANCING DATA (US$, Millions) SUMMARY-NewFin1 Total Project Cost 10.00 Total Financing 10.00 of which IBRD/IDA 10.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 10.00 IDA Credit 10.00 Environmental Assessment Category Concept Review Decision Apr 15, 2018 Page 2 of 10 The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) B - Partial Assessment Track II-The review did authorize the preparation to continue Note to Task Teams: End of system generated content, document is editable from here. Please delete this note when finalizing the document. Other Decision (as needed) B. Introduction and Context Country Context The Union of Comoros is a small volcanic archipelago, made up of three islands, located off the coasts of northeastern Mozambique and northwestern Madagascar: Grande Comore (Ngazidja), Anjouan (Ndzouani), and Moheli (Mwali). At the heart of the triangle, south-Tanzania / north-Mozambique / northwestern Madagascar, Comoros is considered the second triangle of reef biodiversity in the world, after Indonesia. Comoros has about 1,800 square kilometers of land, with an estimated population of 800,0001 and off-shore it controls an Exclusive Economic Zone (EEZ) of 160,000 Km or 70 times the size of the country’s land area. About half of the population lives on the largest island, Grande Comores, which is also home of the Union capital Moroni. As in other low income and SSA economies, the primary sector plays a key role in the Comorian economy. Endowed with fertile volcanic soil, abundant land and good precipitation, the economy of Comoros has traditionally been dominated by agriculture. Currently, agriculture is the second-largest sector and employer (after the retail services sector). Thus, the agriculture sector (mainly subsistence agriculture, a few cash crops and fisheries) is an important source of livelihoods, and represents about one-half of the country’s GDP, with retail services representing one-fifth. The third largest sector is government services, representing about 10 percent of GDP. With longstanding migration, the country benefits from large and growing remittances (close to 20 percent of GDP) from the Comorian diaspora that is mainly based in France. Compared to over a decade ago, the poverty incidence has slightly improved, but progress has been uneven. Comoros’ gross domestic product (GDP) per capita was US$645 in 2015, and the country ranks 159 out of 188 countries on the 2015 Human Development Index. The reduction in the poverty headcount was achieved in both rural and urban areas, but the poverty incidence is typically higher in rural areas and on the island of Anjouan. Recent urban migration may have further exacerbated poverty in crowded urban suburbs. According to recent poverty estimates, around 42 percent (2014) of the population is classified as poor based on the national poverty line, and around 17.2 percent of the population lives below the international poverty line of US$1.90 per capita per day.2 Internationally, this puts Comoros ahead of other Low Income (LIC) and Sub-Saharan African (SSA) countries. However, compared to some of the richer Island Nations in the region, such as Mauritius or Seychelles, Comoros’ poverty rate is still high. 1 United Nations Statistics Division, 2016. 2 At the 2011 Purchasing Power Parity exchange rate Apr 15, 2018 Page 3 of 10 The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) Sectoral and Institutional Context Health outcomes in Comoros have improved since 2012, surpassing averages for SSA but lagging those of other small island states. Life expectancy in Comoros is today above the average for the SSA region (62 compared to 56), but compared to other small islands and aspirational peers the country is below the average (62 compared to 71)3. Progress was also made towards reducing the maternal mortality ratio (MMR) from 440 to 172 deaths per 100,000 live births between 1990 and 2012 (SDG 3.1 goal at less than 70 per 100,000 births). At 172 deaths per 100,000 births in 2012, the maternal mortality ratio is significantly lower than the average for sub-Saharan Africa, which stood at 547 deaths per 100,000 births in 2012. However, Comoros appears worse off when compared to its international peers and small states (Figures I and II). Significant progress was also made in under-five mortality, where the rate declined from 124 in 1990 to 74 per thousand live births in 2012 (SDG 3.2.1 target value at least as low as 25 per thousand live births).4 More progress is needed to bring the neonatal mortality rate, which is currently estimated at 24 per thousand (SDG 3.2.2 target of 12 per thousand by 2030). Figure I: Mortality rate, under-5, 2012 (per 1,000 Figure II: Maternal mortality ratio, 2012 (per live births) 100,000 live births) Sub-Saharan African 86 Sub-Saharan African 547 Comoros 74 Comoros 172 Small States 48 Small States 272 Cape Verde 25 Mauritius 54 Fiji 22 Samoa 51 Samoa 18 Cape Verde 42 Mauritius 14 Fiji 30 0 20 40 60 80 100 0 200 400 600 Source: DHS 2012 and WDI estimates for 2012. Poor results on stunting suggest the existence of long-term or chronic nutrition inadequacies. Stunting, defined as low height for age, is an indicator of persistent nutritional insufficiencies and/or frequent illness among young children. This seems to be a particular driver in Comoros, since stunting appears more prevalent among children between 2 and 4 years old – 24 to 60 months. (This stands in contrast to stunting among infants that might be caused by poor maternal health, since stunted women are more likely to give birth to low-birth-weight babies). These poor results are also explained by the absence of nutrition interventions and a low rate of exclusive breastfeeding (at 12% in 2012 and on decreasing trend during the last five years). Communicable diseases are still the main causes of illness in Comoros. Comoros has a high prevalence of diarrheal diseases and ARI among children under 5 years old, aggravated by malnutrition (4.4% of which were severely underweight and 30% being stunted). With around USD 57 per capita, total health expenditure is lower in Comoros than the average of SSA (USD98), but higher than LIC (USD37); 33 percent of per capita amount is from public sources. Public financing for health comprises 8.7 percent of public expenditure (World Development Indicator, 2014). 3 Aspirational peers: Mauritius, Samoa, Cape Verde, and Fiji - http://www.who.int/gho/publications/world_health_statistics/2017/en/ 4 As of SDG 3.2. 1 under-five mortality should be at least as low as 25 per 1000 live births by 2030 Apr 15, 2018 Page 4 of 10 The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) Out of pocket (OOP) spending is high at 45% of total health expenditures and considerably above the WHO- recommended threshold of 20%. Government spending on health represents one-third of total health expenditure (World Development Indicator, 2016). High OOP spending causes patients to fall into poverty (World Bank, Sub-national analysis of systemic differences in health status and the access to and funding of health service, 2016) Existing social and financial protection systems are limited and cover only a small part of the population. For example, health mutuals cover only 3.3 percent of the population as of 2012 (Politique Nationale de Protection Sociale en Union des Comores, July 2014) Comoros faces the emergence of non-communicable diseases (NCDs) related to lifestyle behaviors. Deaths due to NCDs, such as cardiovascular disease, diabetes and cancer, represent 40% of the total death in Comoros in 2015 compared with 28% in Sub-Saharan Africa. Relationship to CPF The proposed project is fully aligned with the World Bank Group’s Comoros Country Partnership Strategy (CPS) for FY14 - 17 (Report No. 82054-KM) that was discussed by the World Bank Executive Directors in April 2014. The Bank-supported program is structured around two pillars: (1) increased public sector capacity, and (2) shared growth and increased employment, and contributes directly to the objectives of reducing extreme poverty and increasing shared prosperity in Comoros. The CPS’s strategic priorities are aligned with the GoC’s Strategy for Accelerated Growth and Sustainable Development (SCADD) for the period 2015-2019. The Project will contribute directly to the achievement of Pillar 1 of the CPS, and specifically to Results Area 4 which seeks to strengthen programs to assist the poor and vulnerable. It will do so by helping to improve access of poor populations to quality health services. It will also support the Government in its pursuit of UHC and development of an efficient and equitable health system. The Project objectives are also aligned with the SCADD Core Strategy 3 “strengthening access to basic social services and household resilience� and to the GOC’s national health policy. C. Proposed Development Objective(s) Note to Task Teams: The PDO has been pre-populated from the datasheet for the first time for your convenience. Please keep it up to date whenever it is changed in the datasheet. Please delete this note when finalizing the document. Improve access to quality maternal and child health and nutrition services to support the government of Comoros in its pursuit of UHC Key Results (From PCN) 1. Pregnant/lactating women, adolescent girls and/or children under age five reached by basic health and nutrition services (number) * (to be defined) 2. Patients using medical transport where reference to a higher level of care is needed (number) 3. Health facilities renovated, and/or equipped (number) Apr 15, 2018 Page 5 of 10 The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) D. Concept Description Based on discussion with government counterparts, the following four components have been identified to achieve the proposed development objectives. Component 1 – Performance Based Financing and Technical Assistance to support quality services and health financing reforms (US$3mln) This component seeks to provide technical assistance to the GoC regarding health financing reform and the Performance Based Financing with a focus on supply side. The following activities have been identified: 1.1 Performance Based Financing mechanism to ensure quality of health and nutrition services (US$2.3mln) through financing results, based on quality of services produced by health facilities and district level. PBF will be used to finance activities contributing to the improvement of quality of care as well as increasing services to be provided and to pay performance bonuses to the health personal based on an indices tool. 1.2 Support to the development of: (a) health economic /analytical unit of the AMG within the MoH; (b) the “national technical platform" to inform the development of the health financing and UHC strategies (US$0.05mln) 1.3 TA to advise on the proposed national health insurance, including developing a basic benefit package (BBP) incorporating quality aspects, projections on beneficiaries, financial analysis, and regulatory aspects (US$0.35mln) 1.4 Support on the purchasing function on government and provider side to set up the administrative, management and financial system (US$0.30mln) Component 2 – Improve access to and quality of health care and nutrition services through provision of medical equipment, health infrastructure renovations and capacity building of health care providers (US$6mln) The aim of this component is to ensure the quality of health and nutrition services, as well as the technical and managerial capacity of health providers. The following activities have been identified: 2.1 Improvement of availability of medical equipment and patient transportation (US$4mln) Basic medical equipment, essential drugs, standard laboratories, and equipment maintenance management Referral and counter-referral system, patient medical transport, 2.2 Support to develop quality control system of health facilities and a system to strengthen pharmaceutical procurement (US$1.5mln) 2.3 Managerial and Technical Capacity Building of health providers (US$0.5mln): including training on quality of care for medical staff, activities to strengthen the MoH’s capacity to develop and implement basic and complementary health services package at primary and secondary health facility levels Component 3 – Project Management, Capacity building, Social communication and M&E (US$1mln) This component will finance operational costs of the project implementing agency, capacity building, social communication and monitoring and evaluation plan to ensure satisfactory management and implementation of Apr 15, 2018 Page 6 of 10 The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) components 1 and 2. The following activities will be supported: 3.1 Operational and staff cost for the PIU (US$0.3mln) 3.2 Project Management Training and Training of District management teams (organization, management of services, hospital hygiene, administrative management of health establishments, etc.) (US$0.25mln) 3.3 Monitoring and Evaluation cost (US$0.25mln) 3.4 Support to Early Years and Obesity Campaign through BCC (US$0.20mln) Component 4 - Contingent Emergency Response Component (CERC) • The CERC can be activated to provide swift response in the event of a crisis or emergency. • This component will give the country rapid access to IDA financing for immediate rehabilitation and reconstruction needs. • The CERC will be embedded in the project with zero funds allocated to it. • Once activated, uncommitted funds from the project are reallocated to the CERC and made available for expenditures. Note to Task Teams: The following sections are system generated and can only be edited online in the Portal. Please delete this note when finalizing the document. SAFEGUARDS A. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project will be implemented in selected geographic areas of Comoros. However, targeted sub regions, such as the five poorest sub regions will benefit from more intensive support to ensure equity access to quality health and nutrition services and make optimal use of limited resources. Health facilities will be supported to improve project beneficiaries access to quality services by addressing supply side constraints, and strengthening referral and counter referral systems. It is proposed to renovate and rehabilitate existing health facilities (painting, rehabilitation of sanitary and electrical equipment; ..etc.) . B. Borrower’s Institutional Capacity for Safeguard Policies The Union of the Comoros is currently in finalization of its medical waste management plan. At this stage, it does not have a national strategy for the management of medical waste operational. There is no sectoral policy or formalized medical waste management procedures. The National Health Policy (NSP) document does not give priority to medical waste management. The areas of competence and responsibility of the different institutions involved in the management of medical waste are not noted, particularly in the Ministry of Health, the Ministry of the Environment, municipalities and health facilities. There are no texts on medical waste, nor internal regulations on health facilities, nor even standardized procedures for the collection, transport, storage and treatment of medical waste. The project implementing entity will be discussed and determined during the project preparation. This entity will be set Apr 15, 2018 Page 7 of 10 The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) up with the oversight from the Ministry of Health (MoH) and roles, responsibilities, training and resources for implementing the national Medical Waste Plan, including at district level, will be identified prior to appraisal. C. Environmental and Social Safeguards Specialists on the Team Paul-Jean Feno, Environmental Safeguards Specialist Andrianjaka Rado Razafimandimby, Social Safeguards Specialist D. Policies that might apply Safeguard Policies Triggered? Explanation (Optional) Triggered due to generation of health care waste and potential construction waste produced and potential accident risks during renovating of health facilities. The support to improve health and nutrition service delivery is anticipated to increase the utilization of health services and facilities, which is likely to generate incremental health care waste in participating health facilities which may adversely affect the environment and local populations if not managed appropriately. Small renovation works are mainly planned for existing sanitary installations that could generate construction waste and accident risks during the renovation period. These small renovation Environmental Assessment OP/BP 4.01 Yes works will be painting works, rehabilitation of sanitary and electrical equipment of existing sanitary installations in the selected project areas. These impacts and risks are limited in the health facilities and could be mitigated with specific mitigation measures. The EA category for this project is Category B, owing to the location specific and manageable nature of the potential environmental impacts in the selected health facilities. To this end, the existing draft medical waste management plan will be finalized and a simple ESMP for the implementation of minor renovations planned in health facilities will be prepared. Both documents will be submitted to the Bank for review and approval prior to the DM meeting. Performance Standards for Private Sector The project is not expected to collaborate with private No Activities OP/BP 4.03 investors. The project is not expected to impact on natural Natural Habitats OP/BP 4.04 No habitats. Forests OP/BP 4.36 No The project is not expected to impact on forests. Pest Management OP 4.09 No The project is not expected to impact on pests. Apr 15, 2018 Page 8 of 10 The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) The project is not expected to have an impact on Physical Cultural Resources OP/BP 4.11 No physical cultural resources. Indigenous Peoples OP/BP 4.10 No There are no IPs in the Project area The project will not involve any activities that would result in land acquisition, physical displacement, Involuntary Resettlement OP/BP 4.12 No economic displacement or any other form of involuntary resettlement as defined by the policy. The policy is not triggered since project will not invest Safety of Dams OP/BP 4.37 No in dams nor will any project activities rely on the operations of existing dams. Projects on International Waterways The policy is not triggered since project activities will No OP/BP 7.50 not affect any known International Waterways. The policy is not triggered since project activities will Projects in Disputed Areas OP/BP 7.60 No not affect any known disputed areas E. Safeguard Preparation Plan Tentative target date for preparing the Appraisal Stage PID/ISDS Jul 12, 2018 Time frame for launching and completing the safeguard-related studies that may be needed. The specific studies and their timing should be specified in the Appraisal Stage PID/ISDS To this end, the existing draft medical waste management plan will be finalized and a simple ESMP for the implementation of minor renovations planned in health facilities will be prepared. Both documents will be submitted to the Bank for review and approval prior to the DM meeting. The EA category for this project is Category B, due to the specific and manageable nature of the potential environmental impacts. The project is not expected to have significant negative long-term social and environmental impacts. RSA office recommends that the safeguard responsibility for this project is transferred to the sectoral GP. It is the responsibility of the task team to immediately alert the RSA of any changes in project design or of any new information that could warrant a different approach for safeguards management. CONTACT POINT World Bank Voahirana Hanitriniala Rajoela Senior Health Specialist Borrower/Client/Recipient MINISTRY OF FINANCE AND BUDGET Said Ali Said Chayhane Minister of Finance and Budget Apr 15, 2018 Page 9 of 10 The World Bank Health and Nutrition Systems Support for Universal Health Coverage (P166013) elaziz.elaziz@gmail.com Implementing Agencies MINISTRY OF HEALTH, SOLIDARITY, SOCIAL PROTECTION AND GENDER PROMOTION Rashid Mohamed Mbaraka Fatma Minister of Health, Solidairity, Social Protection and Gende naifata@gmail.com Aboubacar Said Anli Directeur Géneral Santé dgs@sante.gouv.km FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Task Team Leader(s): Voahirana Hanitriniala Rajoela Approved By APPROVALTBL Practice Manager/Manager: Magnus Lindelow 24-Jul-2018 Country Director: Peter Anthony Holland 04-Sep-2018 Note to Task Teams: End of system generated content, document is editable from here. Please delete this note when finalizing the document. Apr 15, 2018 Page 10 of 10