Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB1644 Project Name MR-Health and Nutrition Support Project Region Africa Sector Health (80%);Other social services (20%) Project ID P094278 Borrower(s) GOVT. OF THE ISLAMIC REPUBLIC OF MAURITANIA Implementing Agency Ministry of Health and Social Affairs (MOHSA) and State Secretary of Women Affairs (SSWA) Mauritania Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared Estimated Date of Appraisal Authorization June 8, 2005 Estimated Date of Board Approval April 27, 2006 1. Key development issues and rationale for Bank involvement The Government of Mauritania (GOM) and IDA have been partners in the health sector in Mauritania since the early 9 0s. The Bank’s assistance consisted of (i) a Health and Population Project (Cr. 2311 closed on 08/30/98), and (ii) a Health Sector Investment Project (Cr. 3055 closed on 12/31/04) and a Nutrition Project (Cr. 3187 closing on 04/30/05). The Health and Population Project and the Health Sector Investment Project had satisfactory outcomes and demonstrated the government’s ability and willingness to address complex sectoral and development issues, while the Nutrition LIL has resulted in important lessons learned that have been incorporated into the project design. GOM demonstrated its commitment to poverty reduction and, since early 2001, has been implementing a strategy based on the Poverty Reduction Strategy Paper (PRSP) in Mauritania for the period 2001-2004. Two PRSP Progress Reports have shown that the MDGs remain high on the government’s agenda, but also proved that the country, under current policies and with present financial flows, was highly unlikely to reach the health and nutrition related targets, particularly with regards to the reduction of infant and maternal mortality, malnutrition and the control of infectious diseases. Over the years, financial resources allocated to the sector have consistently been increased and have been used in accordance with the sector requirements. The adoption of a sector investment program approach as well as the actions aimed at reducing gender gap in education, health and socio-economic status provide evidence of the government’s commitment. In the health sector, GOM adopted a new national health policy and a national nutrition policy aiming at accelerating the achievement of the PRSP and MDGs health and nutrition targets, thus demonstrating its ownership of the reform program. The experience of other countries in Africa and elsewhere demonstrated that rapid improvement of national wealth (as the one anticipated in Mauritania due to the exploitation of oil reserves) is not followed by a more equitable distribution of resources and increases the gap between rich and poor. This is also likely to happen in Mauritania and provides the rationale for continuing support to health and other social services with emphasis on the accessibility and affordability of these services for the poor. Page 2 Therefore, it is critical to maintain donor funding to the health sector. In Mauritania, IDA involvement in the financing of the health and nutrition activities will become even more necessary because of the projected decline of support by other donors 1 . Today, the health sector already faces a difficult situation with no direct IDA support for the sector and an interrupted PRSC preparation (it became clear that the Bank will no longer finance this operation which might jeopardize the achievements gained through past IDA support to the sector). Therefore, a project is proposed to support the health and nutrition sector until financing from other sources becomes available. The proposed Health and Nutrition Support Project (FY06) is consistent with the objective of the FY03- 05 CAS, namely to support the GOM in implementing the PRSP, especially regarding (i) human resource development, (ii) increased access of the poor to basic services, and (iii) promotion of institutional development based on good governance. The proposed project will provide support to overcome the key challenges currently confronting the sector. Major sectors issues can be summarized as follows: (i) insufficient and inequitable access to health and nutrition services; (ii) shortages of skilled and motivated health personnel; (iii) persistent problems with drugs and vaccines supply; (iv) inadequate and inequitable financing; (v) inadequate institutional and managerial capacity; and (vi) poor management of health and nutrition services. The proposed Health and Nutrition Support Project is also a follow-up operation to the HSIP and Nutrition Project and draws on the following lessons from those two operations: (i) the health service delivery system would not be able to cope with the burden of diseases, and the country would not reach PRSP targets and MDGs without major changes in the governance of the sector and large funding increases; (ii) concomitant development and strong coordination must occur between various levels of the health sector (primary, secondary and tertiary) in order to ensure greater efficiency of the delivery system; (iii) solving human resources issues in terms of quantity, quality and distribution of staff plays a critical role in improving service delivery and in achieving the MDGs; (iv) nutrition interventions aimed at behavioral change at the community level can be effective in reducing malnutrition among young children (a strong communication program is crucial to this success); (v) implementation of community-based nutrition interventions using women groups is very effective; and (vi) strengthening the link between community development and health and nutrition services is needed to improve effectiveness as well as responsiveness to the population’s needs and their sustainability. These lessons have been taken into account in designing the new project. 2. Proposed objective(s) The HNSP overall objective is to strengthen the health system and its capacity to improve the health and nutrition status of the population, notably of women, children, and the poor, as it will support the implementation of the Government Program for the health and nutrition sectors during the period 2006- 2008. HNSP would have the following more specific objectives: (i) improve access to basic health services in underserved areas; (ii) ascertain the equitable allocation of resources to underserved areas; (iii) strengthen the health sector management to raise efficiency; and (iv) improve and expand community-based communications for improved nutrition. 1 Other donor funding possibilities were explored, but appear highly unlikely at present. Between 1998 and 2003, the contribution of other donor funds as a share in health financing declined from 55 % of the total health budget to 26 %. In addition, AfDB decided to redirect its aid to other sectors, and Germany will channel its aid through budget support. Another important reason was the availability of HIPC resources. Page 3 Progress towards the achievement of these specific objectives would be monitored during HNSP implementation. 3. Project components HNSP would provide support to priority activities for which there is a financial gap, provided that they are consistent with the sector policy and there is agreement on their relevance. However, based on lessons learned from past operations, it was deemed necessary to pre-identify the entire set of civil works and major goods that would be supported from the credit. Also, the implementation of the Health Sector Investment Project demonstrated that a certain focus on key issues is necessary, thus making possible to evaluate outputs in a more specific manner. Focusing on key issues would also allow a more substantial contribution to the achievement of MDGs, which is the fundamental priority of the country. Lastly, and based again on past experience in Mauritania and elsewhere, it was deemed useful to retain a certain flexibility in financing, to monitor progress periodically and to plan in a transparent manner depending upon the ever evolving situation in the sector (in terms of needs, financing and implementation capacity). As a consequence of the above features, activities to receive financial support from the credit would fall into two categories: (i) Civil works and major goods would be identified for the entire duration of the operation, and (ii) Support pertaining to all other disbursement categories would be discussed and agreed upon on an annual basis using the annual progress review and operational planning process already in place. The HNSP funding would remain flexible because part of the credit will be allocated on an annual basis and also because the totality of IDA funded activities will be reviewed every year and adjustments made when and if needed. The proposed HNSP will provide support focusing on the areas identified below. The MOHSA will implement the health package described in paragraphs 4.1-4.4 and SECF will implement the community- based nutrition interventions as described in paragraph 4.5. 4.1 Further develop human resources and improve their geographical distribution. The project would support activities to review staffing norms, train health sector personnel, improve the incentive system, and strengthen the sector capacity to manage human resources. · Review of staffing norms. The project would support review of the staffing norms, especially for outpatient facilities and regional hospitals and update the Human resources development plan, including (a) measures to decrease the disproportionate number of qualified health providers working in the administration and to recruit and train administratively qualified personnel, (b) reasonable projections of staff needs and growth, and (c) benchmarks for staff redeployment to regions. · Training of health sector personnel . Activities to train essential personnel, such as nurses, anesthesiology nurses, midwifes, generalist physicians, general surgeons and obstetricians would be supported. Additionally, the project will support activities to train the health sector personnel in safe medical waste management. · Improvement of the incentive system will be supported to motivate staff to discharge quality services, work in remote areas and be responsive to the needs of underserved groups. The incentive system needs to take into account the potential to generate funds through cost-recovery but also that facilities in remote areas have low utilization rates and should focus, first and foremost, on rendering drugs and services affordable and attractive to the poor. · Additionally, activities will be supported to strengthen the sector’s capacity to manage human resources centrally and at regional level and to harmonize human resources development with infrastructure development, estimate the cost involved and render the planning process realistic. Page 4 4.2 Ensure adequate sector financing and an equitable allocation of resources for the poor and for underserved geographical areas. The project would support activities (i) to improve the existing process and methods for mobilizing the different sources of sector financing and for allocating them more equitably; and (ii) to strengthen measures to ensure financial accessibility to health services, increase utilization of services by the poorest and most vulnerable, and to rationalize the existing cost recovery system. · Mobilization and allocation of sector financial resources. To further support MOHSA's progress since 2003 in improving the annual budget preparation process, the HNSP will provide technical and financial assistance to strengthen ministry capacity to: (i) prepare the annual updates of the medium-term expenditure framework (MTEF) for the sector; (ii) establish criteria for overall budget ceilings and for allocations by level of care, region, type of expenditure, etc.; and (iii) organize annual sectoral expenditure reviews. The project will also finance a national health accounts (NHA) study. · Financial access of the population to health services. Given the increasing financial needs of the sector, the stabilizing of available resources for health, and the relatively low level of budgeted health expenditures over the last three years, the HNSP will support efforts: (i) to subsidize essential health services for the poor and other targeted populations; (ii) to organize payment of health services for the poorest and most vulnerable populations who are unable to afford subsidized services; and (iii) to help those populations interested in and able to establish alternative financing systems (mutuelles) at community level to share risks. In addition, the HNSP will provide support for strengthening the cost recovery system, including revising the regulatory basis for charging and collecting monies and training facility-level management committees. 4.3 Improve health sector management to raise efficiency. This component would finance activities: (i) to support ongoing health sector reforms to improve resource allocation and program effectiveness; (ii) to promote the sector-wide approach; and (iii) to develop the management capacity of health sector personnel at all levels. · Implementation of health sector reforms. HNSP would support MOHSA in achieving ongoing or proposed reforms supported by the National Health and Social Action Policy (PNSAS). This includes support to reinforcing sector management capacity for human and financial resources, reform of the hospital and pharmaceutical sub-sectors, development of capabilities for maintaining health facilities and equipment, and strengthening health service delivery and outreach in particular. · Development of the sector-wide approach. Initiated in 1998 with support from the HSSP, the sector-wide process has advanced, and HNSP would provide support to MOH in the process of formulating a memorandum of understanding clearly establishing the objectives, roles, and relationships of the collaboration. · Strengthening of sector management capabilities. HNSP would concentrate especially on: (i) enhanced coordination of the planning and budgeting process; (ii) increased budget execution through more efficient organization of the procurement process and improved financial management; and (iii) development of measures and modalities for monitoring and evaluating the programmatic interventions. · Monitoring and evaluation . HNSP would monitor and evaluate progress within the overall context of: (i) the poverty reduction strategy through achievement of the MDGs pertaining to health; (ii) the development of a consolidated sectoral program with common measures and procedures for supervising, monitoring, and evaluating results; et (iii) the regular submission of project reports on physical and financial results as well as periodic supervision of HNSP's key performance indicators. Page 5 4.4 Improve the accessibility to quality and affordable health services in underserved areas. This component include activities to (i) improve access to and quality of basic health services, (ii) raise demand for services, and (iii) strengthening of the monitoring and evaluation of the quality of the services. · Construction of approximately 15 health posts in areas of low accessibility to public or private health services and rehabilitation of selected primary health facilities (health centers type A and B and health posts) that are not operational. The sites of these facilities would be chosen based on accessibility criteria, estimated number of population in the catchment area, possible existence of specific health problems, availability of personnel etc.. New and rehabilitated facilities will benefit from maintenance and equipping, including the provision of equipment to ensure effective medical waste management. · Activities to improve access to and quality of services by: (i) the strengthening of outreach activities from health posts, and the revival of the community approach in order to ensure improved access to preventive child, maternal and nutrition interventions for the population in hard- to-reach areas; and (ii) the improvement of the availability of drugs. · Activities to raise the demand for health and nutrition services , with emphasis on prevention, and to induce behavioral changes conducive to health and nutritional improvements; and increase community participation in the management of health services and to render health providers more responsive to the needs of the underserved populations. · S trengthening of the monitoring and evaluation of the quality of the services provided through the enhancement of the integrated formative supervision, and the revitalization of the monitoring system of the primary health care facilities. · Strategies to be supported would include : (i) reduction of child mortality primarily by the extension of the Integrated Approach to Childhood Illness (IMCI); (ii) reduction of maternal mortality by the improvement of the availability, the quality and the utilization of emergency obstetrical and neonatal care; (iii) decrease in the incidence of schistosomiasis 2 ; and (iv) improvement of the nutritional status of children under five years of age and pregnant women, primarily through behavioral change and community based activities. 4.5 Improve and expand community-based communications for improved nutrition: This component would finance activities to: (i) develop and implement a community-based nutrition communication strategy, (ii) provide basic essential health and nutrition services; (iii) support the application of the salt iodization law in close collaboration with UNICEF; and (iv) strengthen the capacity of the SECF to plan, monitor and evaluate nutrition communication program implementation. This will be achieved using community mobilization strategies, training of community agents, and interpersonal communication strategies supported by group and mass communication strategies. Basic essential health and nutrition services refer to essential services that can be provided by trained community agents, e.g., micronutrient supplementation, de-worming, and distribution of bed-nets. Messages about micronutrients would typically be included under the communications program to mobilize the community and raise awareness about the importance. 4. Safeguard policies that might apply Given the project's need for safe medical waste management and the potential environmental and social impacts related to the construction of about 15 health posts and some rehabilitation works in unknown locations, it is proposed that (i) an Environmental and Social Management Framework (ESMF) and 2 Activities for control of other endemic diseases already receive adequate financing from other sources such as The Global Fund for malaria and tuberculosis, or GAVI for vaccination, as well as UNICEF, WHO and the World Bank MAP for HIV/AIDS. However, if needed, these areas would also be eligible for funding from the credit. Page 6 Resettlement Policy Framework (RPF) be prepared; and (ii) relevant provisions of the existing National Medical Waste Management Plan be implemented under the proposed project. This plan, as well as the ESMF and RPF will be disclosed in Mauritania as well as sent to the Bank's Infoshop prior to appraisal, currently scheduled for January 16, 2006. 5. Tentative financing Source: ($m.) BORROWER/RECIPIENT 1 INTERNATIONAL DEVELOPMENT ASSOCIATION 10 Total 11 6. Contact point Contact:Astrid Helgeland-Lawson, Sr. Operations Officer Tel: 473-4818 Email: ahelgelandlawson@worldbank.org Location: Washington DC