Document of The World Bank FOR OFFICIAL USE ONLY Report No: 74281-DJ PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 4.6 MILLION (US$7 MILLION EQUIVALENT) TO THE REPUBLIC OF DJIBOUTI FOR AN IMPROVING HEALTH SECTOR PERFORMANCE PROJECT March 7, 2013 This document is being made publicly available prior to Board consideration. This does not imply a presumed outcome. This document may be updated following Board consideration and the updated document will be made publicly available in accordance with the Bank’s policy on Access to Information. CURRENCY EQUIVALENTS (Exchange Rate Effective December 31, 2012) Currency Unit = Djiboutian Francs (DJF) DJF 176 = US$1 US$1.54 = SDR 1 US$1 = SDR 0.65065195 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS ADDS Djiboutian Agency for Social Development (Agence Djiboutienne pour le Développement Social) CAMME Drug Fund (Centrale d’Achat des Médicaments et Matériels Essentiels) CAS Country Assistance Strategy CMH Regional Health Centers COGES Health Management Committees (Comités de Gestion de Santé) COSAN Health Committee (Comité de santé) CREN Centers for Recovery and Nutrition Education CSC Community Health Centers (Centres de Santé Communautaire) DEPCI Direction des Etudes, Planification et Coopération Internationale DISED National Statistics Office (Direction Statistique de Djibouti) DOTS Directly Observed Treatment Short-course DPS Heath Promotion Directorate (Direction de la Promotion de la Santé) DRHF Directorate of Human and Financial Resources (Direction des Ressources Humaines et Financières) DRS Regional Health Directorates (Direction des Régions Sanitaires) DSME Directorate of Maternal and Infant Health (Direction de Santé Maternelle et Infantile) EIA Environmental Impact Assessment EMP Environmental Management Plan FDI Foreign Direct Investment HRITF Health Results Innovation Trust Fund HSDP Health Sector Development Project IGSS Inspectorate General of Health Services (Inspection Générale des Services de Santé) IFR Interim Financial Report IMCI Integrated Management of Childhood Illnesses INDS National Initiative for Social Development (Initiative Nationale de Développement Social) MBB Marginal Budgeting for Bottlenecks MDG Millennium Development Goal MEFIP Ministry of Economy and Finance, in charge of Industry and Planning MNH Maternal and Neonatal Health MOH Ministry of Health OM Operations Manual PAPFAM Pan Arab Project for Family Health PEV Expanded Programme for Immunization (Programme Elargi de Vaccination) PFS Project Financial Statements PIU Project Implementation Unit PNDS National Health Development Plan (Plan National de Développement de la Santé) PRSP Poverty Reduction Strategy Paper RBF Results-Based Financing SIS Health Information Systems (Système d’Informations Sanitaires) SOE Statement of Expenditure STI Sexually Transmitted Infections VCT Voluntary Counseling and Testing WHO World Health Organization Regional Vice President: Inger Andersen Country Director: Hartwig Schafer Sector Director: Steen Jorgensen Sector Manager: Enis Barış Task Team Leader: Sami Ali DJIBOUTI Improving Health Sector Performance Project TABLE OF CONTENTS Page I. STRATEGIC CONTEXT .................................................................................................1 A. Country Context ............................................................................................................ 1 B. Sectoral and Institutional Context................................................................................. 1 C. Higher Level Objectives to which the Project Contributes .......................................... 3 II. PROJECT DEVELOPMENT OBJECTIVES ................................................................3 A. PDO............................................................................................................................... 3 • Project Beneficiaries ..................................................................................................... 3 • Key Results and Indicators ........................................................................................... 4 III. PROJECT DESCRIPTION ..............................................................................................4 A. Project Components ...................................................................................................... 4 B. Project Financing .......................................................................................................... 7 • Lending Instrument ....................................................................................................... 7 • Project Cost and Financing ........................................................................................... 7 • Lessons Learned and Reflected in the Project Design .................................................. 7 IV. IMPLEMENTATION .......................................................................................................9 A. Institutional and Implementation Arrangements .......................................................... 9 B. Results Monitoring and Evaluation ............................................................................ 12 C. Sustainability............................................................................................................... 12 V. KEY RISKS AND MITIGATION MEASURES ..........................................................13 A. Risk Ratings Summary Table ..................................................................................... 13 B. Overall Risk Rating Explanation ................................................................................ 13 VI. APPRAISAL SUMMARY ..............................................................................................13 A. Economic and Financial Analyses .............................................................................. 13 B. Technical ..................................................................................................................... 15 C. Financial Management ................................................................................................ 15 D. Procurement ................................................................................................................ 16 E. Social (including Safeguards) ..................................................................................... 17 F. Environment (including Safeguards) .......................................................................... 17 G. Other Safeguards Policies Triggered .......................................................................... 17 Annex 1: Results Framework and Monitoring .........................................................................18 Annex 2: Detailed Project Description .......................................................................................23 Annex 3: Implementation Arrangements ..................................................................................29 Annex 4: Operational Risk Assessment Framework (ORAF) .................................................49 Annex 5: Results-based Financing (RBF) ..................................................................................55 Annex 6. Project Cost Details ....................................................................................................61 Annex 7. Country at a Glance ....................................................................................................66 Annex 8. Country Map IBRD 33396R ......................................................................................67 . PAD DATA SHEET Djibouti DJ Improving Health Sector Performance (P131194) PROJECT APPRAISAL DOCUMENT . MIDDLE EAST AND NORTH AFRICA MNSHH Report No.: PAD279 . Basic Information Project ID Lending Instrument EA Category Team Leader P131194 Specific Investment B - Partial Assessment Sami Ali Loan Project Implementation Start Date Project Implementation End Date 02-Apr-2013 30-Jun-2018 Expected Effectiveness Date Expected Closing Date 01-Jul-2013 31-Dec-2018 Joint IFC No Sector Manager Sector Director Country Director Regional Vice President Enis Baris Steen Lau Jorgensen Hartwig Schafer Inger Andersen . Borrower: Republic of Djibouti Responsible Agency: Ministry of Health Contact: H.E.Mr. Ali Yacoub Mahamoud Title: Minister of Health Telephone 253-21356300 Email: No.: . Project Financing Data(US$M) [ ] Loan [ ] Grant [ ] Other [X] Credit [ ] Guarantee For Loans/Credits/Others Total Project Cost (US$M): 7.00 Total Bank Financing 7.00 (US$M): . Financing Source Amount(US$M) BORROWER/RECIPIENT 0.00 International Development Association (IDA) 7.00 Total 7.00 . Expected Disbursements (in USD Million) Fiscal 2013 2014 2015 2016 2017 2018 2019 0000 0000 Year Annual 0.00 1.00 1.50 2.00 1.50 0.50 0.50 0.00 0.00 Cumulati 0.00 1.00 2.50 4.50 6.00 6.50 7.00 0.00 0.00 ve . Project Development Objective(s) Proposed Development Objective(s) The project development objective is to improve the utilization of quality health care services for maternal and child health and communicable disease control programs (HIV/AIDS, tuberculosis and malaria). . Components Component Name Cost (USD Millions) Improving health services delivery performance 4.00 Strengthening health system management 1.00 Strengthening program management and monitoring and 2.00 evaluation capacity . Compliance Policy Does the project depart from the CAS in content or in other significant Yes [ ] No [ X ] respects? . Does the project require any waivers of Bank policies? Yes [ ] No [ X ] Have these been approved by Bank management? Yes [ ] No [ ] Is approval for any policy waiver sought from the Board? Yes [ ] No [ X ] Does the project meet the Regional criteria for readiness for implementation? Yes [ X ] No [ ] . Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 X Natural Habitats OP/BP 4.04 X Forests OP/BP 4.36 X Pest Management OP 4.09 X Physical Cultural Resources OP/BP 4.11 X Indigenous Peoples OP/BP 4.10 X Involuntary Resettlement OP/BP 4.12 X Safety of Dams OP/BP 4.37 X Projects on International Waterways OP/BP 7.50 X Projects in Disputed Areas OP/BP 7.60 X . Legal Covenants Name Recurrent Due Date Frequency Adoption of Project Operations Manual 01-Jul-2013 Description of Covenant The Recipient, through MoH, shall adopt the POM in a manner satisfactory to the Association not later than July 1, 2013 and shall not amend, suspend, abrogate, repeal or waive any provision of the POM without prior approval of the Association. The Recipient, through MoH, shall implement the Project in accordance with the POM. Name Recurrent Due Date Frequency Establishment of a Project Steering 01-Jul-2013 Committee (PSC) Description of Covenant The Recipient, through MoH, shall establish and maintain, under Part 1 of the Project and throughout Project implementation a Project Steering Committee not later than July 1, 2013, with a composition and terms of reference acceptable to the Association. Name Recurrent Due Date Frequency Establishment of Health Management 01-Jul-2013 Committees (COGES) Description of Covenant The Recipient, through the MoH, shall establish, under Part 1 of the Project not later than July 1, 2013, Health Management Committees (COGES) within each Participating Health Care Providers, in charge with the planning and managing community health needs and monitor their functioning throughout the Project's implementation. Name Recurrent Due Date Frequency Withdrawal Conditions 01-Jul-2013 Description of Covenant Notwithstanding the provisions of Part A of the Section IV, B1 (b), no withdrawal shall be made under Category (2) for EEPs unless: (i) the MoH has adopted the RBF Manual in a manner satisfactory to the Association; and (ii) the payments under the EEPs are made in accordance with the procedures set forth in the RBF Manual. . Conditions Name Type Description of Condition Team Composition Bank Staff Name Title Specialization Unit Hassine Hedda Finance Officer Finance Officer CTRLA Amy Champion Operations Analyst Operations Analyst MNSHH Wendy Voahangy Consultant Public Health Consultant MNSHD Ravano Wassim Turki Consultant Financial Management MNAFM Consultant Ruxandra Costache Counsel Counsel LEGAM Sami Ali Senior Operations Team Leader MNSHH Officer Maissa Ahmed Abdel- Consultant Research Consultant MNSHH Rahmane Fatou Fall Social Development Social Development MNSSO Specialist Specialist Gyorgy Bela Fritsche Senior Health Specialist Senior Health Specialist AFTHW Aissatou Dicko Senior Executive Senior Executive MNSHD Assistant Assistant Anas Abou El Mikias Consultant Senior Financial CICBR Management Specialist Walid Dhouibi Procurement Specialist Procurement Specialist MNAPC Andrew Michael Losos Environmental Specialist Environmental Specialist MNSEN Mariam William Program Assistant Program Assistant MNCEG Guirguis Amiel Blajchman Consultant Consultant MNSEN Non Bank Staff Name Title Office Phone City . Locations Country First Location Planned Actual Comments Administrative Division Djibouti Tadjourah Tadjourah X Djibouti Djibouti Djibouti Region X Djibouti Ali Sabieh Ali Sabieh Region X Djibouti Ali Sabieh Ali Sabieh Region X . Institutional Data Sector Board Health, Nutrition and Population . Sectors / Climate Change Sector (Maximum 5 and total % must equal 100) Major Sector Sector % Adaptation Mitigation Co-benefits % Co-benefits % Health and other social services Health 100 Total 100 I certify that there is no Adaptation and Mitigation Climate Change Co-benefits information applicable to this project. . Themes Theme (Maximum 5 and total % must equal 100) Major theme Theme % Human development Health system performance 40 Human development Child health 25 Human development Population and reproductive health 25 Human development HIV/AIDS 5 Human development Other communicable diseases 5 Total 100 I. STRATEGIC CONTEXT A. Country Context 1. Djibouti is a small low-income country that is resource scarce with an economy that is dependent on its port and Foreign Direct Investments (FDI). The Government of Djibouti is exploring ways to diversify the economy through the development of the private sector and industries such as tourism, fishing, transport and financial services. In order to boost growth in these sectors, the Government aims to overcome the deep structural barriers, such as the lack of basic infrastructure, the high labor cost and the lack of skilled workers, through greater investments in infrastructure, private sector development, and human capital. 2. Djibouti is endowed with a large young population which could be the engine for economic growth and social development. Almost 40 percent of the population of 850,000 is under the age of 15. Poor in natural resources, Djibouti’s development will have to depend on its human resources. According to the latest UNDP rating, Djibouti ranks 150 out of 172 countries in its human development index. 3. There has been recent economic growth, but Djibouti remains locked in a trap of high unemployment, unequal income distribution, high poverty rates, and low social development indicators. The recent increase in FDI is yet to benefit the poor as its impact on job creation has been minimal. Poverty remains high, at 42 percent absolute and 75 percent relative poverty rates. B. Sectoral and Institutional Context 4. Despite improvements in the health status in the last few years, the health indicators remain among the lowest in the world and Djibouti may not achieve the health-related Millennium Development Goals (MDGs). Despite the reduction in the under five years of age Mortality Rate (from 124 deaths per 1,000 live births in 2002 to 68 deaths per 1,000 live births in 2012), and the reduction in the Maternal Mortality Ratio (from 546 deaths per 100,000 live births in 2002 to 383 deaths per 100,000 live births in 2012), these numbers are still among the highest in the Middle East and North Africa (MNA) region. 5. In terms of service delivery, medically assisted delivery reached 87 percent in 2012 compared to 40 percent in 2002, and the proportion of children 12-23 months of age who are vaccinated with the diphtheria, pertussis and tetanus 3 vaccine before 12 months of age has increased from 45 percent in 2002 to 93 percent in 2012. Moreover, HIV/AIDS prevalence among young pregnant women (15 to 24 years old) has decreased to 1.4 percent in 2010, compared to 2.9 percent in 2002. In addition, the total number of paramedics enrolled in the High Institute of Health Sciences has increased to 1,098 students in 2012 compared to 515 students in 2008. 6. Despite the improvement in the delivery of health services, the availability of health service providers, the increase in drug availability, and the increase in management capacity, the sector is still in need of strengthening its health service delivery system and management capacity in order to achieve the MDGs. 1 7. In 2004, Djibouti developed a Poverty Reduction Strategy Paper (PRSP) that identified an ambitious four-pronged strategy. In 2007, the President launched the “National Initiative for Social Development� (Initiative Nationale de Développement Social - INDS) in order to mitigate the social risks associated with the highly inequitable economic development. The INDS defined the new broad social objectives in terms of access to basic social services, employment generation and assistance to the most vulnerable groups. 8. In March 2008, the Ministry of Health (MOH), through its own resources, completed its second National Health Development Plan (Plan National de Développement de la Santé, PNDS II) for the period 2008–2012. The plan has five strategic pillars: (i) improving the organization, management, and operation of the health system; (ii) adapting the operation and quality of health services to the needs of the population; (iii) adapting the financing and use of financial resources to the needs of the health system; (iv) developing the human resources according to the needs of the health system; and (v) improving the availability, access, and rational use of quality drugs. 9. The Bank has been supporting the Government in key economic and social development programs for the past decade. The Bank has worked in close collaboration with the Government on the analysis of the macroeconomic situation and on policy recommendations for the future of Djibouti through a combined set of analytical and operational work. In addition, the Bank has been supporting a wide range of sectors and programs, including social development and public works, flood emergency rehabilitation, urban poverty reduction, power access and diversification, and school access and improvement. 10. The Bank has been the key and largest supporter of the health sector and the HIV/AIDS, Tuberculosis (TB), and Malaria Control program since 2001. The Bank has been the leading donor in the health sector through two major projects: the Health Sector Development Project and follow-up Additional Financing (HSDP, Cr.3650, H4950) in the amount of US$22 million, which closed on June 30, 2012, and the HIV/AIDS, TB and Malaria Control Project (H0420), in the amount of US$12 million, which closed in 2008. 11. The proposed Project takes into account the activities of other partners supporting the health sector in Djibouti. The project design was discussed with members of the Health Partners Group that was established under the auspices of the MOH. It includes multilateral and bilateral institutions such as the World Health Organization (WHO), the United Nations Children’s Fund, World Food Program, Agence française de développement, and the United States Agency for International Development. There is general agreement among partners that the objectives and components of the proposed Project are in line with the development needs of the sector and complement ongoing and future donor support. 12. Bank support to the proposed Project would consolidate the gains achieved in the Bank- financed projects and would contribute to the Government’s PRSP, INDS, and PNDS II, as well as fostering coordination with development partners. The proposed Bank operation will draw on the lessons learned from the previous two Bank-financed health projects in its support to the Government’s health program. 2 C. Higher Level Objectives to which the Project Contributes 13. The Project is aligned with the Government’s Vision 2035 that will be the basis for the upcoming Bank’s Country Partnership Strategy (CPS) which includes the consolidation of human capital as one of its four pillars. As such, the activities proposed under the Project are consistent with the Vision 2035 and the upcoming CPS and will contribute specifically to the objective of improving the coverage and quality of healthcare. 14. In addition to being aligned with MNA strategic priorities, the Project is also aligned with the PRSP, INDS and PNDS II by: (i) improving the organization, management, and operation of the health system; (ii) adapting the operation and the quality of health services to the needs of the population; (iii) adapting the financing and use of financial resources to the needs of the health system; (iv) developing human resources according to the needs of the health system; and (v) improving the availability, access, and rational use of quality drugs. II. PROJECT DEVELOPMENT OBJECTIVES A. PDO 15. The project development objective is to improve the utilization of quality healthcare services for maternal and child health and communicable disease control programs (HIV/AIDS, TB and malaria). • Project Beneficiaries 16. Healthcare providers and their support staff 1 in the 29 targeted health facilities will be the main beneficiaries. They will benefit from financial incentives contingent upon their performance based on the volume and quality of services they will be providing. The various departments within the MOH 2 will also benefit from technical assistance and capacity building. The expected increased staff performance should impact the quality and quantity of the following services: a) maternal health with a potential target population (at the national level) estimated at 31,090 3 pregnant women (or expected pregnancies, of which about 18,000 4 in Djibouti- ville); 1 Estimated in 2012 at 661 people 2 Direction de Santé Maternelle et Infantile (DSME), Programme Elargi de Vaccination (PEV), Service de Formation, Programme de lutte contre le VIH/SIDA, Programme de lutte contre la Tuberculose, Programme de lutte contre le Paludisme, Unité de gestion des projets (UGP), Direction des Etudes, Planification et Coopération Internationale (DEPCI), Direction des Régions Sanitaires (DRS), Direction de la Promotion de la Santé (DPS), Système d’Informations Sanitaires (SIS), Direction des Ressources Humaines et Financières (DRHF), l’Inspection Générale des Services de Santé (IGSS), Centrale d’Achat des Médicaments et Matériels Essentiels (CAMME) 3 DISED. The percentage of pregnant women or expected pregnancies was estimated in 2009 to be 3.8 percent of the total Djiboutian population 4 Similar to the calculation in Footnote 1 using the population of Djibouti-ville (475,322 persons). 3 b) infant health with an estimated national target of 93,270 5 children aged 0 to 5 years (of which about 54,187 6 live in Djibouti-ville); c) HIV prevention and AIDS treatment with an estimated target of 35,500 7 (of which an estimated 9,000 to 10,000 people are living with HIV and about 1,500 people are currently benefiting from antiretroviral drugs); and d) other transmissible diseases such as TB with about 5,150 targeted patients, 8 and malaria. 9 • Key Results and Indicators 17. The key project results will be to: (i) improve utilization of quality child health services that contribute to a reduction in infant and child mortality rates (MDG4); (ii) improve utilization of quality maternal health services that contribute to a reduction in the maternal mortality ratio (MDG5); and (iii) improve utilization of preventive services that control the HIV/AIDS epidemic and other prevalent communicable diseases, such as TB and malaria (MDG6). 18. Selected indicators to measure the project’s final outcomes are: a) Percentage of women giving birth in a health facility assisted by qualified personnel. b) Percentage of children fully immunized before their first birthday. c) Percentage of HIV positive pregnant women receiving antiretroviral drugs according to protocol. d) Percentage of pregnant women receiving a prenatal visit before the end of the first quarter of pregnancy. e) Percentage of positive pulmonary TB cases detected (case detection rate). f) Percentage of TB patients cured (pulmonary TB cure rate). g) Percentage of suspected malaria cases that are tested and confirmed. III. PROJECT DESCRIPTION A. Project Components 19. Component 1: Improving health services delivery performance (US$4 million total, including contingencies). This component will support the delivery of improvements in: (i) child health services such as immunization, Integrated Management of Childhood Illnesses (IMCI), and treatment of malnutrition; (ii) maternal child health services such as prenatal care, family planning, skilled-attended delivery, and emergency obstetric care; and (iii) prevention and 5 DISED, General Population Census. 2009. 6 Idem, 2009 7 Estimated numbers provided by the National Program against HIV/AIDS - Programme National de Lutte contre le VIH/SIDA, le Paludisme, et la Tuberculose 8 Projection of the number of tuberculosis cases to be discovered in 2013 established by the National Program against Tuberculosis - Programme National de Lutte contre le VIH/SIDA, le Paludisme, la Tuberculose 9 Viable estimations not available 4 treatment services of HIV/AIDS and other prevalent communicable diseases such as Voluntary Counseling and Testing (VCT), Directly Observed Treatment Short-course (DOTS), and malaria. This component will finance healthcare services by disbursing the project proceeds to health providers based on specific quantifiable outputs of the health facilities that are directly linked to the achievement of the health-related MDGs, through a Results-based Financing (RBF) mechanism (see Annex 5). Through an initial two-year pre-pilot phase covering Djibouti-ville and two rural regions (Ali Sabieh and Tadjourah), the RBF initial tools will be tested and refined. All eleven public community health centers in Djibouti-ville and regional health centers in Ali Sabieh and Tadjourah will be targeted. In year three and beyond the RBF pilot scheme will be scaled up to additionally cover all regions in the rural areas. Specifically, this component will improve access to and utilization of the following services: a) Maternal and neonatal health (MNH) services. Prenatal care services, assisted deliveries by qualified staff in a healthcare facility, post-natal care services, protection against high risk and unintended pregnancies through the use of family planning, prevention of mother to child transmission of HIV/AIDS, and emergency obstetric and neonatal care. b) Integrated Management of Childhood Illnesses (IMCI). Treatment of children under 5 years of age according to the IMCI guidelines and protocols. c) Nutrition Services. The treatment of moderate and severe malnutrition among children under five years of age and pregnant women, coupled with nutrition education and practices taught in the centers for recovery and nutrition education (CREN) of peripheral and secondary health services. d) Expanded Program on Immunization (PEV). Complete immunization of children under 12 months of age with the tuberculosis vaccine (BCG), pentavalent and anti- measles, by routine services in health facilities and by mobile teams. e) HIV/AIDS prevention and treatment services. Communication for behavior change, voluntary counseling and testing (VCT), and the screening of pregnant women in antenatal care. f) Detection and treatment of TB. The detection and treatment with success of TB patients according to the protocols by level of services (DOTS), and outreach services aimed at tracing drop-out patients under treatment. g) Prevention and treatment of malaria. The diagnosis and case management through increased use of rapid diagnostic tests in the first line health facilities (with results confirmed by microscopy at hospital laboratories). 20. Component 2: Strengthening health system management (US$1.0 million total, including contingencies). This component will support activities aimed at strengthening the management capacity of the MOH and improving the performance of the different health systems in support of health services. These include: (a) MOH directorates such as: health 5 regions, health promotion, human resources, information systems, planning, health service inspections, maternal and child health, immunizations; (b) training service directorates; (c) the HIV/AIDS, TB and malaria control programs; and (d) the drug fund. 21. Specifically, this component will provide the necessary funds for limited medical equipment, office equipment, office supplies, capacity building, technical assistance and training, and would support activities to create demand for health services such as social mobilization and community outreach. This component will support the following services: a) Directorate of Epidemiology and Information Systems. The project will support strengthening of the health information systems, including standardization of the monthly service reports from the health facilities, harmonization of the reporting requirements to the different services, and provision of regular reporting, including quarterly reports and annual statistical reports. b) Directorate of Health Promotion (DPS). The support to this directorate will focus on strengthening its capacity to provide outreach and communication services to stimulate demand for maternal and child health services and preventive measures. These activities will include training of community health agents and conducting outreach campaigns. c) Drug Fund (CAMME). The project will strengthen the drug fund management capacity and ensure its financial sustainability. d) Directorate of Studies, Planning and International Cooperation (DEPCI). The project will support this critical directorate responsible for the strategic planning of the health sector and coordination of the health surveys. The project will support a number of studies, including a health utilization survey. e) Directorate of Health Regions (DRS). The project will support this directorate responsible for decentralization of the health system to the regional level. The project will support capacity building of this directorate as well as the development of its management systems. f) Directorates of Maternal and Child Health (DSME), Human Resources and Finance (DRHF), the Office of the Inspector General (IGSS), the Office of Training and Continuing Education, and the HIV/AIDS, TB and Malaria control programs. The project will also support the institutional capacity building of these directorates and services as part of the MOH effort to improve its ability to manage the reforms. 22. Component 3: Strengthening project management and monitoring and evaluation capacity (US$2.0 million total, including contingencies). This component will support the Project Implementation Unit (PIU) in managing project activities and fiduciary functions, including financial management, procurement, and environment. The component will also strengthen the monitoring and evaluation of the program, including financing independent technical audits to validate and verify the achievements of health facilities outputs on a quarterly 6 basis, and independent health surveys on a bi-annual basis, as well as health facility and client satisfaction surveys. Specifically, this component will provide the necessary funds for office equipment, office supplies, technical assistance, PIU operating costs, and PIU staff training. B. Project Financing • Lending Instrument 23. The proposed Project will be supported by a Specific Investment Loan instrument. The project financing is in the form of an IDA Credit under "Blend Terms" with a maturity of 25 years, grace period of 5 years, a 1.25 percent interest charge (plus 0.75 percent service charge), and principal repayable at 3.3 percent per annum for years 6-15 and 6.7 percent per annum for years 16-25. • Project Cost and Financing Project cost IBRD or IDA Project Components US$ m Financing % Financing 1. Improving health services delivery 4.0 IDA 100 performance 1.0 IDA 100 2. Strengthening health system management 2.0 IDA 100 3. Strengthening project management and monitoring and evaluation capacity 7.0 Total Baseline Costs 0 Physical contingencies 0 Price contingencies Total Project Costs 7.0 Interest During Implementation NA Front-End Fees NA Total Financing Required 7.0 • Lessons Learned and Reflected in the Project Design 24. The Implementation Completion and Results Report (ICR) of the IDA-financed HSDP, which was recently completed, provides the following lessons learned from previous Bank support to the health sector in Djibouti: (i) A strong commitment by the Government to support the improvement of health services is crucial to ensure the success of a health project. 7 (ii) When the health sector is being financed by the Government and by several development partners, it is important to ensure that these different interventions complement each other, without duplication of effort. (iii) Health services cannot have a favorable and sustainable impact on the population if there are no drugs and if the medical personnel are not qualified and motivated to perform their services. (iv) A functional Health Management Information System (HMIS) is important for a project that aims to reduce maternal and child mortality. (v) The establishment and operation of a drug fund must be carefully prepared with an implementation manual covering all aspects. 25. Experience in implementing RBF activities in other countries indicates that RBF approaches can be successful in rapidly increasing the use of cost-effective health interventions. Published studies on RBF in Cambodia, Haiti, and Afghanistan, as well as a randomized controlled study in Rwanda, have demonstrated the field-level effectiveness of RBF. This is not surprising as health systems in developed countries have successfully used fee-for-service payment systems for many years. Besides providing an obvious performance-based motivation for health workers, RBF has a number of other advantages, such as: (i) sending a clear signal to health workers about the priorities of the government and ensuring that facilities maintain an adequate focus on preventive and pro-poor interventions; (ii) ensuring that projects focus on producing tangible results on the ground and on strengthening monitoring and evaluation systems; and (iii) decentralizing decision-making to health managers who are much closer to the community than those at the central level. 26. However, experience suggests that RBF involves some risks that need to be addressed. While RBF is attractive and has achieved good results in other countries, it involves the following risks: (i) in order to obtain RBF resources, health facilities may focus excessively on the quantity of services they provide and not enough on quality; (ii) health facilities may exaggerate or falsify their records in order to obtain more funds, thereby compromising the integrity of the health management information system; (iii) RBF, if not properly designed, can exacerbate inequities by giving more resources to facilities to which the community already has easy physical access while underfunding those in more remote areas; and (iv) it can have other unintended consequences that are hard to predict in advance, such as over-emphasizing certain services, crowding out other services which may be of high need as well, or prompting health facilities to provide services disproportionately to people who live nearby. 27. The Project contains measures that will mitigate these risks. For example, the incentives associated with specific services can be adjusted to take into account lessons learned during project implementation. In addition, facilities will be dissuaded from focusing more on quantity than quality because the quality of services will be measured under the RBF. Strong internal verification systems will also be complemented by regular external verification of health facility records and by the fact that sanctions will be imposed on any facilities that are found to have exaggerated their records. Lastly, independent health facility and household surveys will be used to find out whether the Project has had any unintended consequences, whether equity is improving, and whether data from the health management information system is credible. 8 • Alternatives considered 28. A program-for-results (P4R) approach was considered but not undertaken for the following reasons: (a) the Government’s own systems (legal, regulatory, institutional, and policy) do not have sufficient capacity at this stage to support a P4R project; (b) this type of development support requires a majority of the project to be based on P4R and would limit the needed capacity building elements that can be included in a traditional SIL; and (c) P4R is generally based at the overall program level, whereas the interventions targeted in the proposed Project are at the individual healthcare center level. A sector-wide approach was also considered, but given that this concept is applied more broadly than to traditional sectors—to thematic, multisectoral, or multicountry programs, or to programs led by nongovernmental entities—it was agreed to focus on targeted interventions rather than general financing, given the limited resources from IDA and the need to show results. The specific interventions were chosen through a participatory process on the basis of their relevance to Djibouti’s epidemiological profile, their proven cost-effectiveness, how successfully they have been implemented either in Djibouti or in other countries, and how well they will complement activities funded by other development partners. 29. The proposed Project focuses on the PNDS II and will work closely with the Government. Consensus with development partners has been sought on the following: (a) the priority health needs and interventions; (b) a common set of indicators of success; (c) a coordinated monitoring and evaluation system; (d) a common implementation mechanism at the national level; (e) harmonized financing in order to avoid gaps in funding and duplication of efforts; and (f) how to implement RBF nationwide. As a result of experience in other countries using pooled funding from multiple development partners (in the form of co-financing), it has been agreed that pooled funding will not be sought due to the issues that may arise, such as: (a) excessive concentration on harmonizing and agreeing on processes rather than measuring and achieving actual results on the ground; (b) inhibiting bold reforms because it can be challenging to build a consensus around innovative approaches; (c) slow adaptation of lessons learned during implementation; and (d) delays in getting started due to the need to agree on the detailed arrangements for pooled funding. IV. IMPLEMENTATION A. Institutional and Implementation Arrangements 30. The implementing agency will be the MOH and its different technical departments and health facilities. A PIU, already established and experienced under the HSDP, will be responsible for procurement, monitoring and reporting, financial management, and disbursement related functions. In addition, an RBF manual will be prepared to guide implementation. 31. Specifically, the PIU will be responsible for the following: • ensuring administrative and financial management of the Project; • coordinating project activities within the different departments and health facilities responsible for carrying out project activities; 9 • managing the two special accounts, as well as all project funds and recordkeeping, in compliance with acceptable financial institution practices; • preparing and submitting project progress reports; • ensuring that procurement documents are prepared in conformity with the Credit Agreement and Bank guidelines. 32. Responsibilities of the regional health facilities are as follows: • maintaining a sub-account at the regional health facilities level to facilitate financial audits related to RBF funds. • keeping track of the necessary technical information related to the project indicators in order to follow project progress and have the information needed to carry out the Project’s final assessment of achievement of project objectives. 33. Djibouti intends to introduce RBF in the health sector in a phased way so as to eventually reach nationwide coverage at the end of the Project. Minimum inputs necessary for the sector such as personnel, drugs, supplies, and equipment will continue to be provided by MOH, but under RBF, the Government will provide complementary financing to health facilities by purchasing agreed-upon health results from health facilities based on performance. It is assumed that the improved quality of care will increase patient visits as the RBF payments will give providers the incentive to do so. 34. During the first phase of the Project, the RBF will be implemented in 11 community health centers (CSC) in Djibouti-ville and in the regional health centers (CMH) and health posts of the two regions of Ali Sabieh and Tadjourah. The CSCs were chosen to reflect the RBF experience in different contexts and to allow broad capacity building that will be fed into future expansion. Then, in the second phase of the Project, the RBF interventions would be expanded to all CMHs and health posts nationwide, in addition to the CSCs. 35. The general objective of RBF is to change the behavior of health providers at the facility level to promote delivery of more quality services. The specific objectives of the RBF are to: • provide incentives to facilities in order to increase productivity and quality of care, especially for the identified key indicators; • provide cash at the facility level to cover the local operations and maintenance costs. 36. An assessment of the RBF interventions will be carried out at the mid-term review of the Project and lessons learned will be considered in the RBF expansion during the remaining project duration. An end of project survey will be carried out by the Pan Arab Project for Family Health (PAPFAM) at the conclusion of the RBF intervention. 37. To ensure adequate supervision of the RBF component (Component 1) of the Project, a Steering Committee will be established and would comprise representatives of the Ministry of Economy and Finance, in charge of Industry and Planning (MEFIP) and the MOH, including the MOH directorates and health facilities, as well as the Djiboutian Agency for Social Development (ADDS), presidents of regional councils, and development partners. This Committee will be responsible for reviewing the technical aspects of the RBF indicators to be used in the 10 disbursement of funds for this component. Moreover, an independent Purchasing and Verification firm will be recruited using project funds to prepare the service provision contracts between the MOH and different health facilities and to conduct quarterly independent verification audits. 38. In general, RBF indicators (see Annex 6) will be collected at the level of health posts, CMH, and CSC by the health information system (SIS) on a quarterly basis. Some program indicators (HIV/AIDS, TB, malaria) will be transmitted directly to the SIS. The SIS will submit a quarterly report, including the results of health facilities, to the independent Purchasing and Verification firm. The independent firm will review the report of the SIS and verify its data through a technical audit, and will transmit a “results verification and validation report� to the Steering Committee and the World Bank. Based on the independent firm’s report, the Steering Committee will forward a request to the Bank for disbursement of funds. After reviewing the request, the Bank will transfer of the funds to the Project. The PIU will be the unit responsible for distributing the funds to health regions and programs on the basis of specific criteria, included in the Project Operations Manual. Health Management Committees (Comités de Gestion de Santé - COGESs): 39. Health management committees will be established in the CMHs and the CSCs (Djibouti- ville). The COGESs 10 adhere to the principle of efficient community participation in the planning, management and definition of community health needs. The COGES, as described by the existing decree, constitutes the executive body managing the health committee, 11 and is composed of five members 12 who oversee the management of financial and material resources, including the pharmaceutical supply to the facilities, to ensure community participation. 40. The existing decree will be revised in order to ensure a more pragmatic and functional community based structure with more adequate community representation, clearer objectives, and more clearly defined responsibilities. As the COGESs constitute an integral element of the institutional arrangements and are necessary to proceed with the reimbursement of participating health facilities, it is important that they are functional and validated in their status by project effectiveness. Previous pilot attempts to establish COGESs have failed possibly due to the lack of adequate monitoring and interest. 10 The rules of organization and functioning of the COGESs have been established by presidential decree signed in January 2010 (Decree number 2010 – 0008 PR/Ms) on the organization and functioning of management committees of health centers dependent on the MOH). 11 According to the existing decree, a health committee (Comité de santé -COSAN) would be established in each health structure and medical center, comprising representatives of the beneficiary population and staff in charge of the health center. The main stakeholders of the health committee would be: community representatives (one local elected official per neighborhood of the targeted health zone and the associations of the same health zone catered by the health center) and representatives of the MOH in the designated health center (head doctor, manager of the center, head nurse). 12 The management committee is composed of five (5) members as follows: - Two (2) members among the communal and regional elected officials of the target health zone, - Two (2) representatives of the MOH working in the health center, - One (1) representative of the associations and NGOs of the health zone of the health center. 11 41. The MOH, in particular the DRS, will be responsible for setting up the COGESs, prior to project launch. The MOH, through its DRS, will need to monitor adequately the functioning of these structures throughout the project cycle in order to guarantee its sustainability. The Project Operations Manual will include a detailed description of the functions and responsibilities of the COGESs. The preparation and adoption of the Project Operations Manual, satisfactory to the Bank, shall take place prior to July 1, 2013. B. Results Monitoring and Evaluation 42. An independent purchasing and verification firm will verify the reported activities and invoices of health facilities. This third party firm will visit health facilities every three months to inspect the registers that they maintain. Also, a random sample of patients listed in the registers will be visited in their homes to verify their existence, their receipt of the services, and their satisfaction with the care that they received. 43. Independent financial auditors will ensure the proper use of funds. Independent financial auditors will examine the bank accounts of a sample of health facilities to ensure that their expenditures are consistent with the Project Operations Manual guidelines and have been used to provide appropriate health services. 44. Independent health facility and household surveys will be carried out to ensure that there is overall progress in strengthening the quantity and quality of health services and that the RBF has had no unintended consequences and to confirm the data contained in the health information system. C. Sustainability 45. The Government has demonstrated a strong commitment to the health sector. The Government has demonstrated its commitment to improving the health of the population by: (i) including health as one of the central themes of the PRSP; (ii) progressively increasing its budget allocations to the health sector and allocating more resources to basic health services; (iii) implementing the PNDS II (2008-2012) and preparing the PNDS III (2013-2017); and (iv) harmonizing its work in the health sector with that of its development partners as demonstrated by its signing of the International Health Partnership+ global compact. 46. There is a need to be realistic about financial sustainability. Given Djibouti’s economic situation, the Government is likely to need continuous external aid in the foreseeable future in order to attain its national health goals and make progress toward the MDGs. The Project takes into consideration macroeconomic forecasts and limitations in order not to put an undue fiscal burden on the country. By spending a minimal amount per capita per year per beneficiary, the current cost is likely to be affordable in the long term. As the economy grows and the Government’s ability to mobilize domestic revenues increases, there should be an opportunity to increase public expenditure on health services and thus reduce out-of-pocket expenditures by households. 12 V. KEY RISKS AND MITIGATION MEASURES A. Risk Ratings Summary Table Stakeholder Risk Moderate Substantial Implementing Agency Risk Substantial - Capacity Moderate - Governance Substantial Project Risk Substantial - Design Low - Social and Environmental Moderate - Program and Donor Substantial - Delivery Monitoring and Sustainability Overall Implementation Risk Substantial B. Overall Risk Rating Explanation 47. The overall risk rating for the Project is substantial. The team is convinced of the Government’s strong commitment to the Project. The main risk is related to the introduction of a new instrument, the RBF, in a relatively low-capacity setting, especially at the local level. Experience from other countries shows that this can be successfully mitigated through a gradual scale-up, technical assistance and training. An Operational Risk Assessment Framework is attached in Annex 4 and details the key risks and mitigating measures. VI. APPRAISAL SUMMARY A. Economic and Financial Analyses 48. The IHSPP, in the amount of US$7 million equivalent, or approximately US$8.11 per inhabitant, corresponds to 1.8 percent of the GNP per capita and 29 percent of public expenditures on health. The Project can make a substantial contribution by attaining results and having a significant impact. 13 49. Based on RBF experience in other countries, the minimum amount to be spent per inhabitant per year is US$2.50 to attain results that significantly improve provision of health services to the population. The estimated RBF budget for the Project is US$6 million, which is above the minimum per capita amount required. 50. The Project aims to improve the quantity and quality of health services provided to mothers and children, by treating more sick mothers and children and decreasing the maternal and child mortality rates. The corollary is the number of mothers’ and children’s lives saved. The focus of the Project is also to control the incidence of HIV/AIDS, malaria and TB within the general population, thereby reducing the mortality rates from these three communicable diseases. 51. According to the MBB projections and using a total of 932 lives saved (during years 3-5 of the Project), the relative cost efficiency is US$7.40. If 999 lives are saved, the relative cost efficiency goes down to US$6.90. Given past efforts of the World Bank in health service delivery which focused on investments in equipment and technical assistance, the current Project with its focus on performance could attain significant efficiency rates. There is evidence that, in addition to positive working conditions, focusing on human resource management which would result in remuneration could be a major factor in motivating health providers and improving performance. 52. While analyzing the Project’s expected impact, it is important to note that during the past five years, there has been considerable improvement in the provision of health services. Various interventions undertaken by the projects and programs of the MOH have notably reduced the number of constraints that hindered access to health care services. • Infrastructure and equipment 53. For the majority of Djibouti-ville, there exists only a minimum accumulation of infrastructure and equipment in the facilities offering health care services. Throughout the capital, the infrastructure and equipment available is sufficient to offer acceptable health care services. The former Bank-financed project (HSDP) afforded the opportunity to renovate several health structures (nutrition and reproduction referral centers, etc.). • Pharmaceuticals, supplies and consumables 54. Pharmaceuticals, supplies and consumables that are provided by the MOH to the various health structures are normally available. In general, there are very few complaints from health service providers about the availability of drugs and there are sufficient stocks to respond promptly to demands for these items. There was, however, a problem with the supply of HIV/AIDS tests during the period 2010-2011. • Human resources, in particular healthcare providers 14 55. Efforts made in the past in human resource management have been effective, as evidenced by the availability of medical and paramedical staff in the majority of healthcare facilities. There is a deficit, however, in the number of personnel specifically trained in maternal and child healthcare (doctors and paramedical staff). This has necessitated hiring of foreign pediatricians and gynecologists. 56. Overall, with the efforts undertaken, working conditions have improved considerably and allow for the provision of acceptable healthcare services. As a result, the Project will focus less on investment needs and more on recurrent expenditures, in particular the costs of providing incentives to healthcare providers to encourage them to improve performance; this represents about half of the project costs. In addition, given the importance of reinforcing the capacity of the healthcare system, approximately 17 percent of project funds will be allocated to improving healthcare management and working conditions at several MOH departments. A special focus will be placed on reinforcing the monitoring and evaluation capacity at the various ministry departments, representing about 25 percent of the project funds. B. Technical 57. The Project has a sound technical design, reflects Djibouti’s particular circumstances, and incorporates lessons learned from the implementation of the previous IDA-financed health project in Djibouti and RBF pilots in other countries. The interventions financed under the Project are cost-effective and are expected to have a significant positive impact on child mortality, maternal mortality, and the control of communicable diseases. C. Financial Management 58. The Project is the first RBF project to be implemented in Djibouti. The RBF component will be implemented at the decentralized level through several MOH departments and health facilities. An assessment of the financial management capacities of the PIU, responsible for project implementation, as well as of the health facilities (CSCs and CMHs) responsible for delivering the RBF indicators, was conducted as part of project preparation. 59. The PIU has sound experience in implementation of IDA-financed projects and was managing the previous IDA-financed HSDP. The assessment identified the following risks: (i) project complexity: this Project is the first in Djibouti to use the RBF mechanism which will involve several MOH departments and facilities with different levels of autonomy; (ii) lack of governance and management mechanisms at heath facilities in charge of Component 1: health facilities are not autonomous and are dependent on the MEFIP (they do not have public accountants and are not able to manage government or donor funds); (iii) lack of management and financial experience and relevant tools at the health facilities: health facilities have no experience with financial management and disbursement (they have no fiduciary staff and do not have acceptable financial management tools); (iv) lack of stable fiduciary personnel at the PIU (the PIU fiduciary staff are hired under individual consultant contracts that have not been extended beyond the closing date, June 20, 2012, of the previous health project); (vi) lack of formal financial and administrative procedures and internal audit at the PIU to be able to handle the complexity and decentralization aspects of the Project; (vii) PIU Financial External Audit: The PIU is currently entrusted with several projects financed by the World Bank and other 15 development partners; the same external auditor shall be appointed for all the projects managed by the PIU for the sake of efficiency. In view of these risks, based on the weaknesses observed and the mitigation measures to be put in place, the overall financial management risk is deemed to be high. 60. The PIU should adopt the recommendations listed in the Action Plan (in Annex 3) in order to establish and maintain an acceptable financial management system. The main recommendations are to: (i) prepare a Project Operations Manual; (ii) review the health facility regulations to support greater management and financial autonomy; (iii) maintain the financial management capacity at the PIU which includes a qualified financial and administrative specialist and an experienced accountant dedicated to the Project; (iv) prepare and implement a Financial Management (FM) manual for the PIU; (v) hire an internal auditor at the PIU who will be in charge of supervising internal controls; (vi) set up a COGES for each participating health facility and provide training for its members; (vii) enter into a formal agreement with all entities involved with Component 1; (viii) appoint a public accountant, and set up an acceptable management team in each health facility, including an accountant for each health facility; (ix) prepare and implement a management manual for the COGESs; and (x) equip each health facility with relevant accounting/bookkeeping tools. D. Procurement 61. While Component 1 will involve performance-based procurement and will be supervised by a Steering Committee, the existing PIU within MOH will administer all procurement-related transactions to be financed under project components 2 and 3. The PIU is familiar with Bank procurement guidelines and procedures as it has implemented the previous IDA-financed HSDP which closed on June 30, 2012. 62. However, while the PIU is familiar with the Bank’s procurement policies and procedures, there remain some weaknesses in capacity which could cause delays in project implementation. During the last year of implementation of the HSDP, the procurement prior- and post-review revealed that the PIU experienced significant delays/difficulties in: (i) updating the procurement plan of the project; (ii) producing acceptable bidding documents and bid evaluation reports and other procurement documents; and (iii) ensuring that the procurement specialist is fully available/committed to the project to implement and oversee procurement. 63. Despite the above mentioned weaknesses, the PIU, which already has many years of experience in implementing Bank-financed projects, is capable of providing the necessary management oversight and compliance with the Bank’s procurement guidelines. The overall procurement risk is high. 64. To improve the PIU’s capacity to oversee procurement management, the following recommended actions shall be carried out: (i) deliver a training to brief and update the PIU staff involved in project implementation on the main Bank procurement policies, procedures and documents expected to be used in implementation; (iii) train the Steering Committee on Performance Based Procurement principles; and (iii) hire a procurement specialist to ensure that 16 the PIU has the required support for the preparation of procurement documents and the bid evaluation process. E. Social (including Safeguards) 65. In terms of social safeguards policies, none of the project financed activities would result in involuntary land acquisition leading potentially to involuntary displacement of people and/or loss of (or loss of access to) resources, habitat or income. There are no construction, rehabilitation and/or works planned in the context of the proposed Project. The Operational Policy 4.12 is not triggered. 66. The number of beneficiaries is expected to be approximately 300,000, of which 70 percent are expected to be female. 67. Moreover, financial retributions provided to the health structures will not finance any activity which could cause involuntary land acquisition or involuntary displacement of people. The Project Operations Manual (and any other relevant project documents) will include these conditions. F. Environment (including Safeguards) 68. Most project activities will have no direct environmental impacts, as they consist of technical assistance, improving management systems, improving health systems, and monitoring. However, as the health sector grows, it is likely to produce more medical waste (e.g., needle sharps and biomedical waste). Therefore, a comprehensive medical waste system will be put in place for the Project. 69. The Project is categorized “B� according to the Bank’s Environmental Assessment Policy (OP 4.01). To mitigate the impact of medical waste, the Project: (i) has undertaken an Environmental Impact Assessment (EIA) to evaluate the environmental impact of the Project; (ii) has assessed the existing medical waste management plan in Djibouti; (iii) has proposed mitigation measures in the form of an Environmental Management Plan (EMP); and (iv) will monitor the implementation of those measures. The EIA includes training and capacity building in environmental aspects. G. Other Safeguards Policies Triggered 70. No safeguard policy other than OP 4.01 is triggered. The Integrated Safeguards Data Sheet was published in InfoShop on December 11, 2012. 17 Annex 1: Results Framework and Monitoring . Country: Djibouti Project Name: DJ Improving Health Sector Performance (P131194) . Results Framework . Project Development Objectives . PDO Statement The project development objective is to improve the utilization of quality health care services for maternal and child health and communicable disease control programs (HIV/AIDS, tuberculosis and malaria). . Project Development Objective Indicators Data Responsibility Cumulative Target Values Source/ for Unit of End Methodolog Data Collection Indicator Name Core Baseline YR1 YR2 YR3 YR4 Frequency Measure Target y Percentage of women giving MOH/HIS birth in a facility Percentage 53.00 55 60 65 70 75.00 Yearly PAPFAM MOH assisted by 2017 qualified personnel Percentage of MOH/HIS children fully DSME PEV immunized Percentage 83.00 85 87 89 90 90.00 Yearly MOH PAPFAM before their first 2017 birthday 18 Percentage of HIV positive 20 pregnant women receiving MOH/HIS Percentage 12.00 28 37 45 55.00 Yearly MOH antiretroviral DSME PEV therapy according to protocol Percentage of pregnant women receiving a MOH/HIS/ prenatal visit DSME before the end Percentage 22.00 25 30 42 52 55.00 Yearly MOH PAPFAM of the first 2017 trimester of pregnancy (CPN1<4) Percentage of positive MOH/HIS/ pulmonary TB Percentage 35.00 60.00 Yearly PNLT MOH cases detected 40 43 48 55 WHO (case detection rate) Percentage of pulmonary TB MOH/HIS/ patients cured Percentage 80.00 82 83 84 84 85.00 Yearly PNLT MOH (Pulmonary TB WHO cure rate) . Intermediate Results Indicators Data Responsibility Cumulative Target Values Source/ for Unit of End Methodolog Data Collection Indicator Name Core Baseline YR1 YR2 YR3 YR4 Frequency Measure Target y 19 Percentage of child nutritional growth RBF Percentage 5.00 10 15 23 30 40.00 Yearly MOH monitoring database visits (well-baby clinic visits) Percentage of HIV test results MOH/HISP received by all Percentage 70.00 75 78 83 85 87.00 Yearly MOH LSS persons tested for HIV Percentage of suspected malaria cases Percentage 11.00 10 8 7 5 5.00 Yearly MOH that are tested and confirmed Percentage of established and functioning 90 95 100 100 Percentage 15.00 100.00 Yearly MOH COGESs in CSCs and CMHs Percentage of pregnant women receiving at MOH/HIS/ Percentage 29.00 60.00 Yearly MOH least two doses 33 40 47 54 DSME of tetanus toxoid (TT2) Percentage of women receiving two MOH/HIS, Percentage 9.00 15 25 35 40 45.00 Yearly MOH postnatal care DSME visits (PoNC1 and PoNC2) 20 between 8th and 42nd day after delivery Percentage of WCBA visiting the public MOH/HIS system to obtain 17 19 21 23 DSME modern family Percentage 13.00 25.00 Yearly MOH PAPFAM planning (oral 2017 contraceptives and injections; IUDs; implants) Number of curative care MOH/HIS visits per person Number 0.20 0.25 0.33 0.4 0.45 0.52 Yearly PAPFAM MOH per year in the 2017 public system Average score MOH/HIS on the quality Percentage 45.00 45 50 58 70 75.00 Yearly RBF MOH checklist database Pregnant/lactati ng women, adolescent girls and/or children under age five- Number 50000.00 65000 70000 78000 85000 90000 Yearly MOH reached by basic nutrition services (number) Children between the age Number of 6 and 59 Sub-Type 50000.00 60000 70000 78000 85000 90000 Yearly MOH months Breakdown receiving 21 Vitamin A supplementation (number) People with access to a basic package of health, nutrition, Number 155000.00 165000 175000 185000 195000 200500 Yearly MOH or reproductive health services (number) People receiving tuberculosis treatment in accordance with the WHO- recommended Number 300.00 325 375 425 475 500.00 Yearly MOH “Directly Observed Treatment Strategy� (DOTS) (number) Direct project Health Number 0.00 50000 100000 160000 215000 300000 Monthly MOH beneficiaries facilities Percentage Female Sub-Type 0.00 20000 45000 100000 160000 210000 beneficiaries Supplemental . 22 Annex 2: Detailed Project Description Djibouti Improving Health Sector Performance (P131194) Introduction 1. While the HSDP was mostly focused on inputs, including strengthening the capabilities and capacities of MOH staff at all levels, this Project will continue to support the development of the health sector by focusing on outcomes, outputs and results, with increased emphasis on delivery of services and continuing support to some of the crucial level services and directorates. Performance of services is achieved by an increased utilization of health services by targeted beneficiaries and is expressed by gradually increasing observable and quantified quality results. It is recognized that service utilization also depends on demand factors, however, due to the necessity to capitalize on the gains from previous health sector development, the novelty of the RBF mechanism to be applied in the Project, and available resources, it was agreed by all concerned parties that the supply of services will be prioritized. Further, experience has shown that demand should not be vigorously stimulated until the supply of services is fully functional and readily available to satisfy it. 2. The Project comprises three components: (a) improving health services delivery performance; (b) strengthening health system management; and (c) strengthening program management and monitoring and evaluation capacity. Nationwide in scope and using an RBF mechanism, the Project aims over a five-year period to improve the performance of the first two levels of the health system and related third level referral services and facilities. The expected results are projected quarterly or yearly based on previous trends and the amount and cost of services are determined for each facility, taking into consideration the relative number of the targeted beneficiaries and the relative weight of each result/indicator (i.e., how much the result is contributing to the achievement of the health-related MDGs and the degree of complexity to achieve the expected result). The novelty of the financing process consists in the quarterly remuneration of results achieved by distinct facilities within selected Djibouti health regions. Payments are conditional on the validation of achieved quantified results by both the RBF steering committee and an international independent purchasing and verification agency. Project description Component 1: Improving health services delivery performance (US$4 million equivalent, including contingencies) 3. This component will support improvements of coverage and quality in: (i) child health services such as immunization, IMCI and growth monitoring and promotion for children aged 1 month to 59 months, particularly during the first 1,000 days of life; (ii) maternal child health services such as prenatal care during the first trimester of pregnancy, family planning, skilled attended delivery in health facilities, and emergency obstetric and neonatal care; (iii) prevention and treatment services of HIV/AIDS and other prevalent communicable diseases such as TB and malaria; and (iv) ambulatory curative care for beneficiaries 5 years old and older (anyone not 23 targeted under IMCI). This component will finance healthcare services by disbursing the project proceeds to health providers based on specific quantifiable outputs of the health facilities that are directly linked to the achievement of the health-related MDGs, through an RBF mechanism (see Annex 5). 4. Specifically, this component will improve the utilization of the following services: a) Maternal health services – prenatal services: prenatal services are provided to: (i) detect risks and pathologies linked with pregnancy that affect the health of the pregnant woman and the fetus and to reduce or treat whenever possible; (ii) prevent the transmission of HIV from mother to newborn; and (iii) immunize against tetanus. The prenatal services are offered in health posts, in community health centers of Djibouti-Ville, in health facilities, and for pathological cases they are also referred to levels two and three maternity wards. In general, pregnant Djiboutian women use prenatal services for the first time to confirm a pregnancy,--to ascertain its duration and a second time to find out whether the pregnancy is on a normal course. Such practice often excludes the crucial first prenatal visit before the end of the first trimester, as well as the important third trimester visits, particularly the visits during the last weeks preceding the delivery that would give the birthing prognosis needed for delivery preparation. The expected performance improvement by service providers will be to conduct physical examinations of all pregnant women during the end of the first trimester for initial screening and later during three prenatal visits or more in order to detect and treat the last quarter pathologies, to emit a prognosis for an eventual “birthing plan� by family decision makers. b) Prevention of mother-to-child transmission of HIV: considering the consequences of HIV/AIDS infection, this is an important part of prenatal services. It begins early with voluntary counseling and confidential testing for HIV among pregnant women. The testing itself is followed by post-test counseling and collection of HIV test results and if needed the initiation of the antiretroviral therapy around the delivery date, thereby preventing further HIV transmission to the newborn. While the acceptability of voluntary confidential HIV testing is quasi universal among pregnant women, significant improvements are needed to occur for post-test counseling and collection of the results of HIV tests by the pregnant women. In Djibouti, about a third to half of HIV positive pregnant women are not aware of their HIV status. The expected performance improvement by service providers will be to have all tested pregnant women return for post-test counseling and collection of results and know their HIV status prior to giving birth. This performance will be facilitated by the current use of rapid HIV tests in a prenatal care setting where HIV test results can be obtained within 35 – 45 minutes. c) Assisted delivery by qualified personnel in health facilities Even when pregnant women are well monitored during the course of pregnancy, unpredictable complications can still occur during labor and delivery and within the 24 – 72 hours after delivery, in the form of eclampsia during labor, hemorrhage of various causes and puerperal infection, which are all complications that can end with the death of a 24 patient. The goal is to increase the chance of survival of pregnant women during labor, delivery and during the 24 – 72 hours after delivery. The expected performance improvement by service providers will be to have every pregnant woman give birth in a health facility with assistance from qualified personnel, primarily by a midwife or a trained matron. For instance, the midwife or a trained matron can use the partogram to determine if an evacuation or a cesarean section is needed and inform the obstetrician and accompanying relatives. d) Basic and complete emergency obstetrical and neonatal care (BEmONC and CEmONC): Deliveries assisted by qualified personnel in health facilities prevent or allow timely treatment of complications occurring during delivery and in the hours that follow. All midwives assigned within the Djibouti health system are trained to provide BEmONC (soins obstétricaux et néonataux d’urgence de base, SONUB) and CEmONC (soins obstétricaux et néonataux d’urgence complets, SONUC), particularly those trained in SONUB practice in all maternities attached to health posts and maternities attached to some of the community health centers of Djibouti-ville. As for the SONUC, they are available in level 3 referral maternities (i.e., Balbala, Dar El Hanan) and in maternity wards attached to the regional health centers (CMH). The expected performance improvement by service providers will pertain to timely evacuation of obstetrical and neonatal emergencies from level 1 (CSCs, mobile teams and health posts) to referral maternities and pediatric services at the secondary and tertiary levels. e) Postnatal services (consultation post natales 1 et 2, CPoN1 et CPoN2): Similar to the prenatal services, they are offered in health posts in regions, in CSCs of Djibouti- ville and health facilities, and for the pathological cases, also offered in referral maternities of level 2 and 3. Postnatal visits are crucial to detect eventual complications by the 8th day of post partum (CPoN1) and to detect those occurring from 8th to 42nd day of post partum (CPoN2). The first postnatal visit is necessary for women who give birth in health facilities where they are staying for at least 24 hours during which they are trained in and begin with the exclusive breastfeeding, during which the BCG and polio zero vaccines are given to newborns. The first postnatal visits are also necessary for those who give birth outside health facilities in order to diagnose and treat any complications, to give the first vaccines to newborns and also to establish the birth certificates that are mandatory to later start school. The second postnatal visits (CPoN2) between the 8th and 42nd – 45th day of post partum are equally important, still to diagnose and treat any complication and above all to assess the overall health status of the women, provide personalized appropriate advice, particularly advice on the healthy spacing of pregnancies and the correct use of modern family planning contraceptive methods that should be started before the end of the mandatory 40 days of sexual abstinence after giving birth. The expected performance improvement by service providers will be to: (i) conduct postnatal care in the form of thorough physical examinations and provision of proper advice to all women who gave birth before the 42nd – 45th day of post partum; and (ii) conduct a follow-up of overall health status of both mothers and newborns. 25 f) Child health services – curative care visits for children under 5 years old or IMCI: In particular, the treatment of children under five years old according to the IMCI guidelines and protocols will be provided. IMCI that is implemented at both the community (C-IMCI) and facility levels consists of a rationalization and standardization of the case management of sick children so as to ensure the quality of care dispensed by paramedics, namely the nurses who monitor patients without continuing or close supervision by medical doctors. IMCI aims to prevent and treat the most common pathologies (diarrhea, fever, pneumonia and diagnosis of underweight, malnutrition and update of immunization calendar). Thanks to the integrated mother–child patient flow established in the regional health posts and community health centers, IMCI becomes an opportunity to refer the patient and also check the health status of mothers. Symptoms and signs among under five-year old patients are diagnosed and treated as per the IMCI protocol that is mostly intended and practiced by nurses assigned in 29 health posts and in 13 community health centers of Djibouti-Ville, in the 6 health facilities and by nurses assigned in pediatric services of first and second level of the health system. The expected performance improvement by service providers will be to maintain the use of IMCI protocol by all nurses and to maintain the percentage of new cases of sick children under 60 percent, so as to avoid skill erosion among IMCI practitioners while maintaining the health status of the targeted under-five year old beneficiaries. It should be mentioned that the IMCI protocol includes systematic child feeding advice and the screening of underweight and malnourished children and, if needed, the immediate referral to nutrition services. Further, it should be noted that the IMCI protocol is currently being revised to include HIV/AIDS related care. g) Nutrition services: The most updated evidence and science have shown that the first 1000 days of life are the time when most human organs develop. It is proven that any nutritional deficiency during that period impairs psychological and motor skill development and may cause irreversible damages. This can be avoided through an efficient well-baby care service for growth monitoring and promotion. Such service (known as PMI or protection maternelle et infantile) was offered before the 1990s at which time it was replaced by curative ambulatory nutritional treatment and rehabilitation to thwart the increasing cases of malnutrition. Growth monitoring and promotion service will be re-introduced so as to develop and increase preventative nutritional services. The expected performance improvement from provider is to ensure the operations of growth monitoring and promotion for children under five years old. Additionally, this project will establish linkages with the community-based nutritional component implemented under the Bank Social Safety Net Project. h) Expanded immunization program (PEV): The goal of the PEV is to prevent the occurrence of epidemics of transmissible diseases and of tetanus in the general population and mostly among children under five years old and mothers as they are the most vulnerable population groups. Any epidemic is prevented when the immunization rate by antigen and per group of population is maintained above 85 percent. PEV activities to curtail epidemics are being implemented by routine 26 services and by mobile teams that cover nomadic populations and localities beyond the 5 kilometer radius from any health center. The expected performance improvement by service providers will be to achieve 90 percent coverage of children less than 12 months of age with the following vaccines: BCG, polio zero, hepatitis B0, pentavalent and measles. Further, the immunization of pregnant women against tetanus is important to both protect the woman and to prevent neonatal tetanus. The performance improvement expected from providers is to ensure that at least half of all pregnant women receive two doses of anti-tetanus vaccine. i) Services for the screening and/or treatment of HIV/AIDS, TB and malaria. HIV/AIDS in the general population: The impact of the awareness activities of previous years has faded and translated into a decrease of the voluntary and confidential HIV screening and collection of results by beneficiaries. The expected performance improvement by service providers will be to ensure that all HIV counseled and tested persons will return for the post-test counseling and collection of results so they will know their HIV status and act accordingly. As mentioned above, this performance will be facilitated by the current use of rapid HIV test during VCT within CSCs and CMHs where HIV test results can be obtained within 35 – 45 minutes. j) TB: The expected performance improvement by service providers will be increased detection of pulmonary tuberculosis and subsequent successful treatment of TB patients within each cohort, according to protocols and for each level of service (ambulatory DOTS and within hospitals), and the improvement of services to track down patients under treatment that have missed appointments. k) Malaria: The diagnosis and case management are based on the increased utilization of rapid diagnostic tests by service providers for any case of fever, with confirmation by microscopy at laboratories of secondary level hospitals, whenever possible. It is worth mentioning that in Djibouti, the program to fight malaria has entered its elimination phase so the expected performance improvement from providers is to have suspected malaria cases tested and confirmed by the laboratory. Component 2: Strengthening health system management (US$1 million equivalent, including contingencies) 5. This component will support activities aimed at strengthening the MOH management capacity and improving the performance of the different health systems in support of health services. These include different MOH directorates such as the health regions, health promotion, human resources, information systems, planning, health services inspections, maternal and child health, immunizations and training services directorates, as well as the HIV/AIDS, TB and malaria control programs and the drug fund. 6. Specifically, this component would provide the necessary funds for limited medical equipment, office equipment, office supplies, capacity building, and technical assistance, and 27 will support demand creation activities such as social mobilization and community outreach. This component will support the following services: a) Directorate of Epidemiology and Information Systems. The project would support strengthening of the health information systems, including standardization of the monthly service reports from the health facilities, harmonization of the reporting requirements to the different services, and provision of regular reporting including quarterly reports and annual statistical reports. b) Directorate of Health Promotion (DPS). The support to this directorate will focus on strengthening its capacity to provide outreach and communication services to stimulate demand for maternal and child health services and preventive measures. These activities will include training of community health agents and conducting outreach campaigns. c) Drug Fund (CAMME). The project will strengthen the drug fund management capacity and ensure its financial sustainability. d) Directorate of Studies, Planning and International Cooperation (DEPCI). The project will support this critical directorate responsible for the strategic planning of the health sector and coordination of the health surveys. The project will support a number of studies, including a health utilization survey. e) Directorate of Health Regions (DRS). The project will support this directorate responsible for decentralization of the health system to the regional level. The project will support capacity building of this directorate as well as the development of its management systems. f) Directorates of Maternal and Child Health (DSME), Human Resources and Finance (DRHF), the Office of the Inspector General (IGSS), the Office of Training and Continuing Education, and the HIV/AIDS, TB and Malaria control programs. The project will also support the institutional capacity building of these directorates and services as part of the MOH effort to improve its ability to manage the reforms. Component 3: Strengthening project management and monitoring and evaluation capacity (US$2 million equivalent, including contingencies) 7. This component will support the PIU in managing project activities and fiduciary functions, including financial management, procurement, and environment. The component will also strengthen the monitoring and evaluation of the program, as well as finance the independent technical audits to validate and verify the achievements of health facilities on a quarterly basis, and independent health surveys on a bi-annual basis, as well as health facility and client satisfaction surveys. 8. Specifically, this component would provide the necessary funds for operating costs, including office equipment, office supplies, technical assistance, and training. 28 Annex 3: Implementation Arrangements Djibouti Improving Health Sector Performance (P131194) Project Institutional and Implementation Arrangements 1. The implementing agency will be the MOH and its different technical departments and health facilities. A PIU, already established and experienced under the HSDP, will be responsible for procurement, monitoring and reporting, and financial management. 2. Specifically, the PIU will be responsible for the following: • ensuring administrative and financial management of the project; • coordinating project activities within the different departments and health facilities responsible for carrying out project activities; • managing the two special accounts, as well as all project funds and recordkeeping, in compliance with acceptable financial institution practices; • preparing and submitting project progress reports; • ensuring that procurement documents are prepared in conformity with the Financing Agreement and Bank guidelines; 3. Responsibilities of the regional health facilities are as follows: • maintaining a sub-account at the regional health facility level to facilitate financial audits related to RBF funds. • keeping track of necessary technical information related to the project indicators in order to follow project progress and have the information needed to carry out the project’s final assessment of achievement of project objectives. 4. Djibouti intends to introduce RBF in the health sector in a phased way so as to eventually reach a nationwide coverage at the end of the project. Minimum inputs necessary for the sector such as personnel, drugs, supplies, and equipment will continue to be provided by MOH, but under RBF the government will provide complementary financing to health facilities, purchasing agreed-upon health results from health facilities. It is assumed that the improved quality of care will increase patient visits as the RBF payments will give providers the incentive to do so. 5. During the first phase of the project, the RBF will be implemented in 11 CSCs in Djibouti- ville and in the CMHs and health posts of the two regions of Ali Sabieh and Tadjourah. The CSCs were chosen to reflect the RBF experience in different contexts and to allow broad capacity building that will be feed into future expansion. Then, in the second phase of the project, the RBF interventions would be expanded to all CMHs and health posts nationwide, in addition to the CSCs. 6. The general objective of RBF is to change the behavior of health providers at facility level for them to deliver more quality services. The specific objectives of the RBF are to: 29 • provide incentives to facilities in order to increase productivity and quality of care, especially for the identified key indicators; and • provide cash at facility level to cover the local operations and maintenance costs. 7. The RBF interventions will be prospective, given that a baseline survey has been carried out by PAPFAM (2011). An assessment will be carried out at the Project mid-term review and lessons learned will be considered in the RBF expansion during the remaining Project duration. An end of Project survey will be carried out by the PAPFAM at the end of the RBF intervention. 8. To ensure adequate supervision of the RBF component (Component 1) of the project, a Steering Committee will be established and would include representatives of MEFIP and MOH, including the directorates of the MOH and health facilities, as well as ADDS, presidents of regional councils, and development partners. This committee will be responsible for reviewing the technical aspects of the RBF indicators to be used in the disbursement of funds for this component. Moreover, an independent Purchasing and Verification firm will be recruited using Project funds to establish the service provision contracts between the MOH and different health facilities and to conduct quarterly independent verification audits. 9. In general, RBF indicators (see Annex 6) will be collected at the level of health posts, CMHs, and CSCs by the health information system (SIS) on quarterly basis. Some program indicators (HIV/AIDS, TB, malaria) will be transmitted directly to the SIS. The SIS will submit a quarterly report including the results of health facilities to the independent Purchasing and Verification firm. The independent firm will review the report of the SIS and verify its data through a technical audit, and shall transmit a “results verification and validation report� to the Steering Committee and the World Bank. Based on the independent firm’s report, the Steering Committee will forward a request for disbursement of funds to the Bank which, after reviewing the request, will transfer of the funds to the project. The PIU will be the unit responsible for distributing the funds to health regions and programs on the basis of specific criteria, included in the Project Operations Manual. Health Management Committees (Comités de Gestion de Santé - COGESs) : 10. Local community management committees will be established in the CMHs and the CSCs (Djibouti-ville). The COGESs 13 adhere to the principle of efficient community participation to the planning, management and definition of community health needs. The COGES, as described by the existing decree, constitutes the executive body managing the health committee, 14 and is composed of five members 15 who oversee the management of financial and 13 The rules of organization and functioning of the COGESs have been established by presidential decree signed in January 2010 (Decree number 2010 – 0008 PR/Ms on the organization and functioning of management committees of health centers depending from the Health Ministry) 14 According to the existing decree, a health committee (COSAN) would be established in each health structure and medical center, constituted of representatives of the beneficiary population and of staff in charge of the health center. The main stakeholders of the health committee would be: community representatives (one local elected official per neighborhood of the targeted health zone and the associations of the same health zone catered by the health center) and representatives of the Health Ministry in the designated health center (head doctor, manager of the center, head nurse). 30 material resources, and of pharmaceutical products of the facilities to guarantee the sustainability of community participation. 11. The existing decree will be revised in order to ensure a more pragmatic and functional community-based structure with more adequate community representation, clearer objectives and responsibilities. As the COGESs constitute an integral element of the institutional arrangements and are necessary to proceed with retribution of participating health structures, it is important that they are functional, capacitated and validated in their status, prior to project launch. Previous pilot attempts to establish COGESs had failed possibly due to the lack of adequate monitoring and interest. 12. The MOH, in particular its DRS, will be responsible for setting up the COGESs, prior to project launch. The MOH, through its DRS, will need to monitor adequately the functioning of these structures throughout the project cycle in order to guarantee its sustainability. The Operations Manual will include at least a description of the tasks of the COGESs. Financial Management, Disbursements and Procurement Financial Management 13. The Republic of Djibouti has a body of complete and sufficient texts for sound management of its public finances. Notably, the legal framework of Djibouti includes: (i) the Constitution of September 4, 1992; and (ii) the law n°107/AN/00 which outlines how government funds are used, how the annual budget is prepared and voted upon, and how the overall budget is managed. 14. The institutional framework contains the systems necessary for public financial management. The institutional framework meets the needs regarding preparation as well as execution and control of the budget. However, there are some practices being used that affect the applicability of the texts. 15. The Project will be implemented according to World Bank guidelines through the PIU that has already been established within the MOH. Project funds will be disbursed from a credit account established by IDA using advances to a designed account, direct payments, reimbursement and Special Commitments accompanied by supporting documents or statements of expenditure for sums less than the predefined thresholds for each expenditure category, following the applicable procedures and the World Bank's Disbursement Handbook. Interim Unaudited Financial Reports and Annual Financial Statements will be used as a financial reporting mechanism and not for disbursement purposes. 15 The management committee is composed of five (5) members as follows: - Two (2) members among the communal and regional elected officials of the target health zone, - Two (2) representatives of the MOH working in the health center, - One (1) representative of the associations and NGOs of the health zone of the health center, 31 16. Transparency and governance: The 2011 corruption perception index compiled by Transparency International ranks Djibouti 100th out of 182 countries. Overall, procurement laws, rules and regulations are fairly adequate. There are a number of weaknesses in the procurement management process (such as thresholds for open bidding procedures not being systematically applied). However, the government is actively strengthening capacities and transparency. Corruption is actively prosecuted and has led to several arrests in the past few years. The activation of the Court of Accounts as an independent court, and the strengthening of the capacity of l’Inspection Générale de l’Etat and l’Inspection Générale des Finances are important steps for uncovering and prosecuting corruption cases. Implementation and administrative arrangements 17. This project is the first RBF project to be implemented in Djibouti. The RBF component will be technically carried out at a decentralized level through several MOH departments and health facilities. Assessment of the implementing framework identified some financial management risks that need to be mitigated in order to establish and maintain acceptable administrative arrangements. The main recommendations are:  update the FM manual to include: (i) the different entities involved and their duties, procedures, materials and tools to be used; (ii) the technical aspects of the RBF indicators to be used in the disbursement of funds; (iii) the flow of information, tools, collection procedures and technical audit; and (iv) the project flow of funds between the entities. The revised FM manual will be subject to approval by the Bank.  enter into formal agreements with all health entities involved that describes the duties and relationship with the steering committee and the PIU; to stipulate the possibility of auditing the RBF indicators, financial reports, books and bank account of beneficiary entities;  Change the regulations of the health facilities (CSCs, CMHs and health posts) to provide them with more management and financial autonomy and to clarify the institutional relationship between health facilities at the regional level (CMHs and health posts). 18. Project Implementing Unit: The Project will be implemented by the PIU already established and experienced under the HSDP. This PIU was established as the “Department of projects management� directly linked to the MOH’s General Secretary. This Department was established by Law n°173 of April 2007 regarding reorganization of the MOH. 19. The PIU will be responsible for day to day management of the project namely:  administrative and financial management;  coordination of activities between the various departments and the other health structures in charge of implementation to ensure that the technical aspects of the Project are in accordance with established strategies;  management of designated accounts and other Project funds under its authority, maintaining bookkeeping and supporting documents according to accounting standards required and appropriate for development partners;  preparation and submission of periodic management and progress reports of activities being implemented;  commitment and follow-up of procurement activities of; 32  participation in evaluation committees;  contribution to follow-up and to evaluation of the Project, in conjunction with the Department of Studies, Planning and International Cooperation of the MOH. 20. The PIU will be responsible for all fiduciary management and accounting in compliance with generally accepted accounting standards. It will be responsible for preparing periodic reports on implementation progress, including both physical and financial achievements (by component and expenditure category). 21. The PIU will maintain project accounting and will produce annual Project Financial Statements (PFS) for each fiscal year and quarterly Interim Financial Reports (IFR) within 45 days of the end of each calendar quarter. 22. Overall, the PIU will be responsible for maintaining a financial management system that is acceptable to the World Bank. It will be responsible for managing the Designed Accounts, as well as all project funds and recordkeeping, in compliance with acceptable practices. 23. Health Facilities: The achievement of Component 1, based on specific quantifiable outputs through the RBF mechanism, will be carried out by health facilities which include 5 CMHs, and 11 CSCs. The CMHs will involve the health posts and the mobile teams of each concerned region. For the first two-year phase of the project, a limited number of pilot health facilities will be involved. 24. The health facilities will be responsible for:  keeping track of the necessary technical information related to RBF project indicators in order to follow project progress and have the necessary information required for the final assessment of achievement of project objectives;  conducting fiduciary and account management in compliance with the RBF agreement with the PIU;  maintaining a subaccount at health facility level to facilitate financial audits related to the use of RBF funds;  preparing quarterly reports on the use of the sub account funds. 25. Health facilities are governed by presidential decree n°2010-0008 that established health facility management committees (COGESs). This decree is being reviewed to give the health facilities more management and financial autonomy. The review is expected to be completed by July 1, 2013. 26. Local community management committees will be established at the health facility level based on the principle of community participation. The goal of these committees is to effectively involve the targeted communities in planning, managing and defining their health needs, including the cost of the proposed interventions. 33 27. The MOH is in charge of setting up each COGES through the DRS and the DPS. A COGES should be set up in each health facility given its crucial co-management role in the institutional arrangements of each health facility. The operational and functional capacity of the COGESs will be one of the conditions of RBF procurement and disbursement of funds for each respective health facility. These conditions will be included in the Project’s Operations Manual. 28. Steering Committee: To ensure adequate supervision of Component 1, a steering committee will be established and would include representatives of the MEFIP and MOH, including the departments of the MOH health facilities, ADDS, presidents of regional councils, and development partners. This steering committee will be responsible for reviewing the technical aspects of the RBF indicators to be used in the disbursement of funds for this component. 29. In general, RBF indicators will be collected at the level of the CMH and CSC by the SIS on a quarterly basis. Some program indicators (HIV/AIDS, TB, malaria) will be transmitted directly to the SIS. 30. The SIS will submit a quarterly report to include the RBF indicator results of each health facility to an independent purchasing and verification firm to be hired under the Project. This independent firm will be in charge of the RBF agreement conditions control including financial quarterly report and designated account audit and SIS technical data report verification and shall transmit a quarterly “results verification and validation report� to the steering committee and the World Bank. Financial Management Risk Assessment and Mitigation measures 31. Assessment of financial management capacities identified the following risks: (i) project complexity: this Project is the first in Djibouti to use the RBF mechanism which will involve several MOH departments and facilities with different levels of autonomy; (ii) lack of governance and management mechanisms at heath facilities in charge of Component 1: health facilities are not autonomous and are dependent on the MEFIP. They do not have public accountants and are not able to manage government or donor funds; (iii) lack of management and financial experience and relevant tools at the health facilities: health facilities have no experience with financial management and disbursement. They have no fiduciary staff and do not have acceptable financial management tools; (iv) lack of stable fiduciary personnel at the PIU. The PIU fiduciary staff are hired under individual consultant contracts that have not been extended beyond the closing date of the previous health project; (vi) lack of formal financial and administrative procedures and internal audit at the PIU able to handle the complexity of the Project and the decentralization aspects. In view of these risks, of the weaknesses observed and of the mitigation measures to be put in place, the overall financial management risk is deemed to be HIGH. 32. An action plan has been prepared for the PIU, MOH, and health facilities to carry out in order to establish and maintain acceptable financial management arrangements. The main recommendations are: (i) prepare a Project Operational Manual; (ii) review the regulations of health facilities to provide them more management and financial autonomy; (iii) maintain the 34 financial management capacity at the PIU which includes a qualified financial and administrative specialist and an experienced accountant dedicated to the project; (iv) prepare and implement an FM manual for the PIU; (v) hire an internal auditor at the PIU who will be in charge of supervising internal controls; (vi) set up a COGES for each participating health facility and provide training for its members; (vii) enter into a formal agreement with all entities involved with Component 1; (viii) appoint a public accountant, setup an acceptable management team in each health facility including an accountant for each health facility; (ix) prepare and implement a management manual for the COGESs; and (x) equip each health facility with accounting bookkeeping tools sufficient to its activity level. 33. Budgeting: The PIU will prepare an annual budget for each component. The PIU capacity assessment reveals that the process of planning and budgeting should be improved based on the following recommendations: (i) the procurement unit should keep all project commitments up to date on the “Success� management information system; 16 (ii) “Success� software should be configured to automatically manage the procurement plan; (iii) an annual budget and payment plan should be prepared at the end of each fiscal year; and (iv) cost tables should be updated periodically and reconciled with the project procurement plan. 34. Project accounting system: Financial transactions will be registered in the accounting system by the project accountant under the supervision of a financial specialist. The project financial specialist is responsible for preparing the Interim Financial Reports (IFRs) before their transmission to the PIU Chief for approval. Periodic reconciliation between accounting statements and IFRs will also be carried out by the financial specialist. 35. The general accounting principles for the Project are as follows: (i) project accounting will cover all sources and uses of Project funds, including payments made and expenses incurred. All transactions related to the Project will be entered into the accrual accounting system and the appropriate reports. Disbursements made from the project designated accounts will also be entered into the project accounting system; (ii) Project transactions and activities will be distinguished from other activities undertaken by the PIU. IFRs summarizing the commitments, receipts, and expenditures made under the Project should be produced every quarter using the templates established for this purpose and sent to the PIU; and (iii) the Project chart of accounts will be compliant with the classification of expenditures and sources of funds indicated in the Project documents (Project appraisal document, COSTAB) and the general budget breakdown. The chart of accounts should allow for data entry to facilitate the financial monitoring of Project expenditures by component and sub-component, expenditure classification, disbursement category and source of funds. 36. Human Resources Capacity: According to Law n°173 of April 2007 regarding reorganization of the MOH, the PIU human resources include: a project manager; an administrative and financial person; an architect responsible for procurement; an engineer 16 The PIU has a management information system (Success) which covers procurement, accounting, financial reporting and fixed asset management. 35 responsible for the follow-up of technical aspects (civil engineering); an accountant and accounting assistants; and a management assistant. 37. PIU staff have been recruited under individual consultant contracts and include those who are civil servants under leave of absence (project manager, procurement specialist). 38. To ensure acceptable financial and accounting management of the project, the PIU needs to maintain its financial staffing capacity, including qualified financial and administrative specialists and an experienced accountant dedicated to the project. 39. Moreover, with regard to the project complexity and decentralization aspects and in order to strengthen weaknesses in the roles and responsibilities of current staff and match skills with the needs of the work program, the PIU should hire an internal auditor to provide oversight of the project’s internal controls. 40. To be able to proceed with Component 1, the MOH will be in charge of setting up the COGESs through the DRS and the DPS. The COGESs should be set up in each health facility before the RBF contracting process begins, given their crucial co-management role in the institutional arrangement of the health facilities, and their members need to be trained on management and financial issues. The effective existence of COGESs will be one of the conditions of disbursement of funds to each respective health facility. 41. Moreover, to be able to manage the Governmental allocation, health facilities revenues and the project’s RBF funds, to maintain a financial and accounting acceptable system and to report on financial and on the specific quantifiable outputs of the health facilities for the RBF mechanism, the COGESs need to ensure that a management team, including at least a public accountant, appointed by the MEFIP, and an accountant are in each health facility. 42. The development of the operational and functional capacity of the COGESs, through the appointment of the public accountant and the recruitment of an accountant for the health facility, will be one of the conditions of disbursement of funds to each respective health facility. Internal Control: 43. Project commitments will be subject to the local procurement procedures through the National Procurement Committee, for any amount exceeding the threshold fixed by the local regulations. This Committee will then be involved in monitoring all procurements steps. 44. Payment of eligible expenses will be done based on instructions signed by both the MOH and of the MEFIP (External Finance Department-EFD). The EFD will then be responsible for monitoring the eligibility of all expenses. 45. The existing administrative and financial procedures manual at the level of the PIU will be updated by July 1, 2013. This Manual should cover: (i) the organization chart and clearly define the role, the function and responsibilities of every position in the PIU; (ii) the staff policy and management procedures; (iii) the flows of fund, disbursement procedures and financial 36 management system; (iv) information system and financial reporting; and (v) the chart of accounts, bookkeeping standards and procedures. This manual of procedures will be subject to the approval of the Bank. 46. The management of health facilities will be assured by each COGES according to the regulations to be prepared and the procedures manual of COGES to be adopted. The COGES management manual should cover all the administrative, financial and accountant aspects of the health facility management, including: (i) procurement procedures according to national procurement guidelines; (ii) flow of funds and disbursement procedures of the Government allotment, donor funds and health facility revenues; (iii) chart of accounts, bookkeeping standards and procedures; (iv) financial reporting procedures, templates and frequency; (v) staff management procedures; and (vi) inventory procedures. 47. For disbursement purposes, on Government allocation heath facility revenues and sub- designated account, public accountants need to be appointed for the health facilities. 48. To be able to maintain acceptable financial management, bookkeeping and financial reporting system, each health facility needs to be equipped with accounting tools sufficient to its activity level. 49. The Government will maintain the right to oversee the functioning of the health facilities. This may include the institutional, administrative and financial functioning. 50. Project reporting: The project financial reporting will include IFRs and yearly Project Financial Statements (PFS). IFRs should include data on the financial situation of the project. These reports should include: (a) a statement of funding sources and uses for the period covered and cumulative figures, including a statement of the bank project account balances; (b) a statement of use of funds by component and by expenditure category; (c) a reconciliation statement for the designated account; and (d) a budget analysis statement indicating forecasts and discrepancies relative to the actual budget. The PIU should produce IFRs every quarter and send them to the World Bank within 45 days from the end of each quarter. PFSs should be produced annually. The PFS shall cover the period of one fiscal year of the Recipient, commencing with the fiscal year in which the first withdrawal was made under the Project, and should include: (a) a cash flow statement; (b) a closing statement of financial position; (c) a statement of ongoing commitments; and (d) an analysis of payments and withdrawals from the grant account. IFRs and PFSs should be produced based on the accounting system and should be subject to an external financial audit. 51. Audit of the project financial statements: An annual external audit of the project accounts will cover all aspects of the project and all uses of funds and all the committed expenditures of 37 the Project. It will also cover the financial operations, internal control and financial management systems and would also include a comprehensive review of statements of expenses (SOEs). 52. An external auditor will be appointed according to terms of reference acceptable to the Bank and should conduct the audit in accordance with international auditing standards. The auditor should produce: (i) an annual audit report including his opinion on the project's annual financial statements; (ii) a management letter on the project internal controls; and (iii) a limited review opinion on the IFRs. The annual reports should be submitted to the World Bank within six months of the end of each fiscal year and the limited review opinion should be submitted to the World Bank with the IFRs. 53. The audit of the use of funds disbursed to the sub-designated accounts opened for the Project in each regional health facility will be conducted by the independent “purchasing and verification firm�. 54. The PIU is entrusted with different projects financed by World Bank and other development partners; it is recommended that the same external auditor be appointed for all projects managed by the PIU for more efficiency and in order to mitigate the existing risk of financing the same activity for several projects or financiers. The auditor and its terms of reference should be acceptable to the Bank. 55. Flow of funds: At the level of the PIU, payment will be instructed by the double signature of the MOH and the MEFIP and in order to facilitate the management of funds and disbursement procedures for eligible expenses. Two separate Designated Accounts (DA) in US Dollars will be opened at a commercial bank in Djibouti acceptable for the World Bank, one for Component 1 and one for the remainder of the components. Advances from the Project account will be disbursed to the designated accounts to be used for the project expenditures. 56. Both the MOH and MEFIP will appoint a person authorized to sign jointly the payment requests. MOH-authorized payment requests will be sent to the MEFIP, which should verify the supporting documents and the eligibility of the expenses in line with procedures and official agreements with the Bank and will then proceed with the joint signature of the payment instruction. The PIU will file the original supporting documents. 57. For Component 1 of the Project, based on the independent purchasing and verification firm’s review of the SIS quarterly report and after receiving funds from the World Bank, the PIU will proceed with disbursement of the funds to sub-designated accounts opened by the health facilities, regions and programs on the basis of specific criteria to be included in the Operations Manual and fixed by the Steering Committee. 58. At the level of the health facilities, the new regulation would define the persons responsible for authorizing payments based on the double signature of the health facility and the public accountant (MEFIP). In order to facilitate the management of funds and disbursement procedures for eligible expenses, a sub-designated account in DJF for each regional health facility will be opened at a commercial bank in Djibouti acceptable to the World Bank. The regional health facility will file the original supporting documents. 38 59. Flow of information: The PIU will be responsible for preparing periodic reports on project implementation progress and on both physical and financial achievements based on technical and physical information on the progress of project activities (by component and by expenditure category). 60. RBF indicators will be collected by the health information system (SIS) at the level of health facilities on a quarterly basis. Some program (HIV/AIDS, TB, malaria) indicators will be transmitted directly to the SIS. The SIS will submit a quarterly report, including the results of health facilities performance to an independent purchasing and verification firm, recruited using project funds. The independent purchasing and verification firm will review the report of the SIS and verify its data through a technical audit, to be performed by an international external technical auditor, and shall transmit a “results verification and validation report� to the Steering Committee and the World Bank. 61. Health facilities will be responsible for preparing quarterly reports on the RBF funds use and sub-designated account situation. 62. The PIU will maintain the project bookkeeping, report periodically to the MOH and the Steering Committee and produce annual PFSs and quarterly IFRs. 63. Summary of actions to be implemented: Project implementation support actions are summarized below: Actions Deadline Prepare an OM that lists: (i) the different entities involved within the Project, July 1, 2013 their duties, procedures, materials and tools to be used; (ii) the technical aspects of the RBF indicators to be used in the disbursement of funds for Component 1; (iii) the flow of information, tools, collection procedures and technical audit; and (iv) the project flow of funds between the different entities. Review the health facility regulations (CSCs, CMHs, health posts and MT) to July 1, 2013 provide them more management and financial autonomy and to clarify the institutional relationship between health facilities at regional level (CMHs, health posts and MT). Maintain the financial staffing capacity at the PIU including qualified financial July 1, 2013 and administrative specialists and an experienced accountant dedicated to the project. Prepare an FM manual for the PIU. This Manual should cover: (i) the July 1, 2013 organization chart and clearly define the roles, functions and responsibilities of each person at the PIU; (ii) the staff policy and management procedures; (iii) the flow of funds, disbursement procedures and financial management system; (iv) information system and financial reporting; and (v) the chart of accounts, bookkeeping standards and procedures. 39 Actions Deadline Hire an internal auditor for the PIU in charge of the project’s internal control July 1, 2013 supervision. Set up the COGESs for the health facilities and train their members on health Disbursement for office management procedures. each concerned CSC – CMH Enter into formal agreements with all entities involved in Component 1 in order to Disbursement for outline their duties and the relationship with the Steering Committee and the PIU; each concerned CSC to stipulate the possibility of auditing the RBF indicators, financial reports, books - CMH and bank accounts of beneficiary entities. Appoint a public accountant and setup an acceptable management team including Disbursement for an accountant for each health facility. each concerned CSC - CMH Prepare an RBF manual which will be validated by the Department of Public Disbursement for Accounting and Audit within the MEFIP. This Manual should cover all the each concerned CSC administrative, financial and accountant aspects of health facility management, - CMH including: (i) procurement procedures according to national procurement guidelines; (ii) flow of funds and disbursement procedures regarding the Government allotment, donor funds and health facility revenues; (iii) chart of accounts, bookkeeping standards and procedures; (iv) financial reporting procedures, templates and frequency; (v) staff management procedures; and (vi) inventory procedures. Equip each health facility with accounting tools and software in line with its Disbursement for activity level. each concerned CSC - CMH 64. Supervision Schedule: The frequency and scope of World Bank supervision missions will be adapted to the needs of this Project and will involve review of project activities both at the central and regional levels. Supervision frequency will be semi-annually, to be adjusted as needed. b. Disbursement 65. The IDA funds will be disbursed according to World Bank guidelines to finance project activities. 66. Project funds will be disbursed from an account established by IDA using advances to a designated account, direct payments, and withdrawals for eligible expenditures accompanied by supporting documents or, for statements of expenditure for sums less than the predefined thresholds for each expenditure category, following the applicable procedures and the Bank's Disbursement Handbook. 40 67. The Bank will honor eligible expenditures for services rendered and goods delivered by the project closing date. A four-month grace period will be granted to allow for the payment of any eligible expenditures incurred before the project closing date. 68. Designated Accounts (DA). To facilitate fund and disbursement management for eligible expenditures, two separate designated accounts (DA) in US Dollars will be opened at a commercial bank in Djibouti acceptable to the World Bank: one designated account for Component 1and one designated account for the remaining components of the Project. Advances from the project account will be transferred to the designated accounts to be used for the specific project expenditures. 69. Payments of eligible expenses will be made through the designated accounts based on the instructions signed by both the MOH and the MEFIP. 70. The ceiling of the second designated account would be 10 percent of the Credit amount. The PIU will be responsible for submitting monthly replenishment applications with appropriate supporting documentation. Statements of expenditures (SOEs) 71. Necessary supporting documents will be sent to the World Bank in connection with contracts that are above the prior review threshold, except for expenditures under contracts with an estimated value of (a) US$0.1 million or less for goods; (b) US$0.1 million or less for consulting firms; and (c) US$0.05 million or less for individual consultants. In addition, all operating costs, training, workshops, study tours and audit fees, will be claimed on the basis of SOEs. The documentation supporting expenditures will be retained at the PIU and will be readily accessible for review by the external auditors and periodic Bank supervision missions. All disbursements will be subject to the conditions of the Financing Agreement and disbursement procedures as defined in the Disbursement Letter. 72. Allocation of the Credit Proceeds: Percent of Amount of the Credit Expenditures to be Category Proceeds Allocated Financed Inclusive of (US$) Taxes (1) Goods, non-consulting services, consultants’ services, audit, Training and 3,000,000 100 Incremental Operating Costs for the Project (2) Eligible Expenditure Payments to the Participating Health Care Providers (health 4,000,000 100 care facilities) under Component (1) of the Project Total 7,000,000 41 e-Disbursement. The Bank has introduced e-Disbursement for all projects in Djibouti. Under e- Disbursement, all transactions will be conducted and associated supporting documents and SOEs scanned and transmitted online through the World Bank’s Client connection system. The use of e-Disbursement functionality will streamline online payment processing to: (a) avoid common mistakes in filling out WAs; (b) reduce the time and cost of sending WAs to the Bank; and (c) expedite the Bank processing of disbursement requests. Retroactive financing. Withdrawals up to an aggregate amount not to exceed US$250,000 equivalent may be made for payments made prior to the date of signature of the Financing Agreement, but not prior to January 1, 2013 for expenditures under Category 1. Procurement General 73. Procurement for the proposed Project will be carried out in accordance with the World Bank "Guidelines: Procurement of goods, works, and non-consulting services under IBRD loans and IDA credits & grants by World Bank borrowers� dated January 2011 (“Procurement Guidelines�), and "Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits and Grants by World Bank Borrowers� dated January 2011(“Consultant Guidelines�), and the provisions stipulated in the Credit Agreement. National Competitive Bidding (NCB) will be carried out with procedures acceptable to IBRD. 74. For the purposes of using National Competitive Bidding Procedures, the following shall apply: In the Standard Bidding Documents, as enacted by the by Government Decision n°2010- 349/PRE, dated May 8, 2010, the “Fraud and Corruption� clause shall be revised to read as follows for all contracts financed by the present Financing Agreement: “It is the World Bank’s policy to require that Borrowers (including beneficiaries of World Bank administered Financing Agreements), bidders, suppliers, contractors and their agents (whether declared or not), sub-contractors, sub-consultants, service providers or suppliers, and any personnel thereof, observe the highest standard of ethics during the procurement and execution of World Bank-financed contracts. In pursuance of this policy, the World Bank: (a) defines, for the purposes of this provision, the terms set forth below as follows: (i) “corrupt practice� is the offering, giving, receiving, or soliciting, directly or indirectly, of anything of value to influence improperly the actions of another party (ii) “fraudulent practice� is any act or omission, including a misrepresentation, that knowingly or recklessly misleads, or attempts to mislead, a party to obtain a financial or other benefit or to avoid an obligation; 42 (iii) “collusive practice� is an arrangement between two or more parties designed to achieve an improper purpose, including to influence improperly the actions of another party; (iv) “coercive practice� is impairing or harming, or threatening to impair or harm, directly or indirectly, any party or the property of the party to influence improperly the actions of a party; (v) “obstructive practice� is: (aa) deliberately destroying, falsifying, altering, or concealing of evidence material to the investigation or making false statements to investigators in order to materially impede a World Bank investigation into allegations of a corrupt, fraudulent, coercive or collusive practice; and/or threatening, harassing or intimidating any party to prevent it from disclosing its knowledge of matters relevant to the investigation or from pursuing the investigation, or (bb) acts intended to materially impede the exercise of the World Bank’s inspection and audit rights provided for under paragraph (e) below. (b) will reject a proposal for award if it determines that the bidder recommended for award, or any of its personnel, or its agents, or its sub-consultants, sub-contractors, service providers, suppliers and/or their employees, has, directly or indirectly, engaged in corrupt, fraudulent, collusive, coercive, or obstructive practices in competing for the contract in question; (c) will declare misprocurement and cancel the portion of the loan/agreement allocated to a contract if it determines at any time that representatives of the Borrower or of a recipient of any part of the proceeds of the loan/agreement engaged in corrupt, fraudulent, collusive, coercive, or obstructive practices during the procurement or the implementation of the contract in question, without the Borrower having taken timely and appropriate action satisfactory to the World Bank to address such practices when they occur, including by failing to inform the World Bank in a timely manner at the time they knew of the practices; (d) will sanction a firm or individual, at any time, in accordance with the prevailing Bank’s sanctions procedures, including by publicly declaring such firm or individual ineligible, either indefinitely or for a stated period of time: (i) to be awarded a World Bank-financed contract; and (ii) to be a nominated sub-contractor, consultant, supplier, or service provider of an otherwise eligible firm being awarded a World Bank-financed contract; (e) hereby requires that a clause be included in bidding documents and in contracts financed by a World Bank loan/agreement, requiring bidders, suppliers and contractors, and their sub- contractors, agents, personnel, consultants, service providers, or suppliers, to permit the World Bank to inspect all accounts, records, and other documents relating to the submission of bids and contract performance, and to have them audited by auditors appointed by the World Bank; and (f) will require that, when a Borrower procures goods, works or non-consulting services directly from a United Nations (UN) agency under an agreement signed between the Borrower and the 43 UN agency, the above provisions regarding sanctions on fraud or corruption shall apply in their entirety to all suppliers, contractors, service providers, consultants, sub-contractors or sub- consultants, and their employees that signed contracts with the UN agency. As an exception to the foregoing, (d) and (e) will not apply to the UN agency and its employees, and paragraph (e) will not apply to the contracts between the UN agency and its suppliers and service providers. In such cases, the UN agencies will apply their own rules and regulations for investigating allegations of fraud or corruption subject to such terms and conditions as the World Bank and the UN agency may agree, including an obligation to periodically inform the World Bank of the decisions and actions taken. The World Bank retains the right to require the Borrower to invoke remedies such as suspension or termination. UN agencies shall consult the World Bank’s list of firms and individuals suspended or debarred. In the event a UN agency signs a contract or purchase order with a firm or an individual suspended or debarred by the Bank, the World Bank will not finance the related expenditures and will apply other remedies as appropriate.� • Bidders shall sign, as part of their bids, the ethical charter Form enacted as Annex 3 by the Decree # 2010-0085PRE dated May 8, 2010; and • No preference shall be granted for domestic bids. Project Management and Procurement Capacity assessment 75. While Component 1 will involve performance-based procurement to be supervised by a multi-stakeholder Steering Committee, the existing PIU within MOH will administer all procurement-related transactions to be financed under Components 2 and 3 of the Project. The MOH and the PIU are familiar with Bank procurement guidelines and procedures as they implemented the HSDP. 76. Despite the above mentioned weaknesses, the PIU, which already has many years of experience in implementing Bank-financed projects, would be able to provide the necessary management oversight of compliance with the Bank’s procurement and consultant guidelines. The overall assessment of Procurement Risk is high. 77. To improve the PIU’s capacity to oversee the procurement management, the recommended actions below shall be taken: 1-Train the PIU and the Steering Committee on performance-based procurement principles; 2-Carry out training to brief and update the PIU staff involved in the project on carrying out the Bank’s procurement procedures; and 3-Make sure that a procurement specialist is assigned or hired in order to provide the PIU, during the project implementation, with the required support for the preparation of the procurement documents and carrying out of the bid evaluation process. 44 Procurement of Works 78. No works are currently foreseen under this project. Procurement of health services (non-consulting services) under Component 1: 79. Procurement of health services under Component 1 will involve performance based procurement. The MOH will directly contract with specific pilot health service centers, and will make payments based on measured outputs. The outputs will be verified by an independent auditor. Payment will be made in accordance with the quantity of outputs delivered, subject to their delivery at the level of quality required. Reductions from payments (or retentions) may be made for lower-quality level of outputs and, in certain cases, premiums (bonuses). The use of Performance Based Procurement in the proposed project shall be agreed by the Bank as the result of a satisfactory technical analysis of the different options available and incorporated in the procurement plan. Procurement of Goods (under Components 2 and 3) 80. Goods procured under the proposed Project would mainly include: (i) office equipment (computers and furniture); (ii) field equipment (vehicles); (iii) medicine; (iv) laboratory tests; and (v) software. The procurement methods will involve International Competitive Bidding (ICB), National Competitive Bidding (NCB) and Shopping. 81. The procurement will be carried out using the Bank’s Standard Bidding Documents (SBD) for all ICB, National SBD agreed with and satisfactory to the Bank and National Shopping Standard Document as enacted by the by Government Decision n°2010-349/PRE, dated May 8, 2010. Consultancy services 82. Consultancy services financed under this Project will mainly include the selection of: (i) PIU members (six consultants); (ii) individual consultants and trainers for the strengthening of the MOH management capacity and improvement of the performance of the different health systems in support of health services; (iii) independent auditor for the verification of service outputs/indicators; (iv) financial auditor; and (v) independent survey firms, such as the PAPFAM. 83. The selection methods will involve: (i) Quality-and Cost-based Selection (QCBS), (ii) Selection based on Consultants’ Qualifications, (iii) Single-Source Selection (SSS) and (iv) Selection of Individual Consultants. The QCBS will be carried out using the Bank’s Standard Request for Proposals (RFP). The methods to be used for the procurement under this project, and the estimated amounts for each method, as well as the prior review thresholds are set forth in Table A below. Procurement Methods and Prior review Thresholds 45 Table A. Prior review and Procurement Method Thresholds Prior Review Thresholds (in USD) Procurement Type High Risk Implementing Agency Prior Review Thresholds Works, Turnkey and S&I of Plant and Equipment 0.3 million Goods 0.1 million IT Systems and Non-consulting Services 0.1 million Consulting Firms 0.1 million Individual Consultants 0.05 million Procurement Method Thresholds (in USD) Djibouti Goods/Non-consulting Services Works ICB NCB Shopping ICB NCB Shopping > 150,000 ≤ 150,000 ≤ 25,000 > 1 million ≤ 1 million ≤ 200,000 Procurement Planning 84. A Project Operations Manual will be prepared and will include the description of applicable procurement procedures, as well as the detailed procurement plan for the first 18 months of activity, to be approved during project negotiations. 85. Works/Goods/Non-consulting services. It is foreseen that the procurement of vehicles for field teams will be carried out through International Competitive Bidding. 86. Consultancy services. The consulting services are detailed in the procurement plan. Consultancy assignments with short-list of international firms are set in Table B below. Table B: List of consultancy assignments with short-list of international firms Bank Cost Est. Date Date Ref. Description of the Selection review (‘000 Submission of Contract No. Assignment Method (prior/ US$) Proposals Signing post) 1 Technical Assistance to 100 QCBS Prior 11/22/13 12/30/13 DEPCI 2 Auditor for the verification 400 QCBS Prior 11/4/13 12/12/13 of RBF outputs/indicators 3 Financial Auditor 200 LCS Prior 2/21/14 3/31/14 Advance Contracting and Retroactive Financing 87. The Government of Djibouti may wish to proceed with the initial steps of procurement before signing the related Bank loan. In such cases, the procurement procedures, including 46 advertising, shall be in accordance with the Guidelines in order for the eventual contracts to be eligible for Bank financing, and the Bank shall review the process used by the Borrower. The Djiboutian Ministry of Health undertakes such advance contracting at its own risk, and any concurrence by the Bank with the procedures, documentation, or proposal for award does not commit the Bank to make a loan for the project in question. If the contract is signed, reimbursement by the Bank of any payments made by the Borrower under the contract prior to loan signing is referred to as retroactive financing and is only permitted within the limits specified in the Section IV B (1) of the Financing Agreement. Environmental and Social (including safeguards) Social Safeguards: 88. OP 4.12 is not triggered. In addition, financial retributions provided to the health structures cannot finance any activity which could cause involuntary land acquisition or involuntary displacement of people. The operations manual (and any other relevant project documents) should include these conditions. 89. Environmental Safeguards: 90. The Project is a broad initiative to improve and build the capacity of health systems in Djibouti. Most project activities would have no direct environmental impacts, as they consist of TA, improving management systems, improving health systems, and monitoring. However, as a health sector grows, it is likely to produce more medical waste (for example sharps and biomedical waste). Therefore, a comprehensive medical waste system (separation, incineration, landfilling) needs to be in place for the Project. 91. The project is categorized “B� (moderate impacts) according to the Bank’s Environmental Assessment policy (OP 4.01). The measure that the Project is undertaking to mitigate the impacts of medical waste is to finance an Environmental Impact Assessment (EIA) to evaluate the environmental impacts of the Project, evaluate the existing medical waste management plan in place, propose mitigation measures in the form of an EMP, and monitor those measures. The EIA includes training and capacity building in environmental aspects. Monitoring & Evaluation 92. The project will strengthen the monitoring and evaluation of the program, including financing independent technical audits to validate and verify the achievements of health facilities outputs on a quarterly basis, and independent health surveys on a bi-annual basis, as well as health facility and client satisfaction surveys. 93. To ensure adequate supervision of component (1) of the project, a Steering Committee will be established and would include representatives of the MEFIP and the MOH, including the directorates of the MOH and health facilities, as well as ADDS, presidents of regional councils, and development partners. This Committee will be responsible for reviewing the technical 47 aspects of the RBF indicators to be used in the disbursement of funds for this component. In general, RBF indicators will be collected at the level of the health posts, CMH, and CSC by the SIS on quarterly basis. Some program indicators (HIV/AIDS, TB, malaria) will be transmitted directly to the SIS. The SIS will submit a quarterly report including the results of health facilities to an independent purchasing and verification firm, recruited using project funds. The firm will review the report of the SIS and verify its data through a technical audit, and shall transmit a “results verification and validation report� to the Steering Committee and the World Bank. Based on the firm’s report, the Steering Committee will forward a request for disbursement of funds to the Bank which, after reviewing the request, will be the transfer of the funds to the project. The PIU will be the unit responsible for distributing the funds to health regions and programs on the basis of specific criteria, included in the Operations Manual. 94. The project’s results framework is included in Annex 1. 48 Annex 4: Operational Risk Assessment Framework (ORAF) DJIBOUTI: IMPROVING HEALTH SECTOR PERFORMANCE Project Stakeholder Risks Stakeholder Risk Rating Moderate Description: Risk Management: 1. The issue of delays in response from the Ministry of Finance was raised with the 1. Delays in response for key project documents from the Director of External Finance who agreed to resolve the matter. Ministry of Finance. Resp: Status: Stage: Recurrent: Due Date: Frequency: 2. Given Djibouti's persistent fiscal constraints, the MOH Client In Progress Both Quarterly may not be able to mobilize adequate resources for operational expenses required to sustain the project Risk Management: investments. 2. The Bank will have to engage with the Government through PER and PRSP discussions to ensure adequate allocation for the social sectors, including health. Resp: Status: Stage: Recurrent: Due Date: Frequency: Bank Not Yet Due Implementation 31-Dec-2013 Implementing Agency (IA) Risks (including Fiduciary Risks) Capacity Rating Substantial Description: Risk Management: 1. The project implementation arrangements will ensure coherent support for 1. High and frequent turnover of key personnel in the coordination of project activities through a steering committee composed of MOH: After the general election in April 2011, the representatives of different departments of the MOH, under the leadership of the Minister of Health was replaced. The new Minister in turn Secretary General of the MOH . In addition, the PIU is well established and functioned conducted a reshuffling of Directors and key personnel in well during the implementation of the HSDP. the Ministry, including the Director of Projects and the Director of Planning, among others. More recently, Resp: Status: Stage: Recurrent: Due Date: Frequency: another reshuffling of directors took place within the Client Not Yet Due Implementation 01-Jul-2013 49 ministry. Given these changes, it will take some time for Risk Management: the new staff to learn about the functioning of their 2. An RBF manual will be prepared and training will be offered to all health facility departments. managers. The RBF manual will include all necessary forms for keeping track of services provided, incentives received, quality checklists, etc. 2. There is limited capacity of the Government at all levels to implement the RBF component. Resp: Status: Stage: Recurrent: Due Date: Frequency: Client Not Yet Due Implementation 01-Jul-2013 3. Procurement: Many of the systemic governance and anti-corruption (GAC) risk and control issues at the Risk Management: country level may affect the procurement management 3. The PIU, which already has many years of experience in implementing Bank- under the Project. While the PIU is familiar with the financed projects, would be able to provide the necessary management oversight of Bank’s procurement procedures, there remain some compliance with the Bank’s procurement and consultants guidelines. However, to weaknesses in capacity which could cause delays in improve the PIU’s capacity to oversee the procurement management, the following project implementation. In fact, during the last year of recommended actions shall be taken before project’s effectiveness: (i) carry out training implementation of the HSDP, the procurement prior and to brief and update the PIU staff in the Bank’s procurement procedures; ii) make sure post-review revealed that the PIU is experiencing that a procurement specialist is hired in order to provide the PIU with the required difficulties in: (i) updating the procurement plan of the support to prepare procurement documents and bid evaluations. project, (ii) producing acceptable Bidding documents and bid evaluation reports and other procurement documents Resp: Status: Stage: Recurrent: Due Date: Frequency: and (iii) making the procurement specialist (consultant) Client Not Yet Due Implementation Monthly fully available/committed to the project to implement and oversee procurement. Risk Management: 4. An action plan has been prepared with the following recommendations: (i) prepare a 4. Financial management: The following FM risks have Project Operational Manual; (ii) review the regulations of health facilities to provide been identified regarding implementation of the RBF them more management and financial autonomy; (iii) maintain the financial component: (i) project complexity; (ii) lack of governance management capacity at the PIU which includes a qualified financial and administrative and management mechanisms at heath facilities as these specialist and an experienced accountant dedicated to the project; (iv) prepare and are not autonomous and are dependent on the MOF; and implement an FM manual for the PIU; (v) hire an internal auditor at the PIU who will be (iii) lack of management and financial experience and in charge of supervising internal controls; (vi) set up a COGES for each participating relevant tools at the health facilities, which have no health facility and provide training for its members; (vii) enter into a formal agreement experience with financial management and disbursement. with all entities involved in RBF; (viii) appoint a public accountant, set up an acceptable Additional FM risks are the lack of formal management team in each health facility including an accountant for each health facility; financial/administrative procedures and internal audit at (ix) prepare and implement a management manual for the COGESs; and (x) equip each the PIU able to handle the complexity of the Project and health facility with accounting tools sufficient to its activity level. the decentralization aspects. Resp: Status: Stage: Recurrent: Due Date: Frequency: 50 Client Not Yet Due Implementation 01-Jul-2013 Governance Rating Moderate Description: Risk Management: 1. The Bank is providing technical assistance under the governance and Anti-Corruption 1. Transparency and governance. The 2008 transparency (GAC) program. Technical assistance has been provided in the areas of procurement, index compiled by Transparency International ranks budgeting, and auditing. Djibouti 102nd out of 180. There is no strong indication for corruption in Djibouti. Overall, procurement laws, Resp: Status: Stage: Recurrent: Due Date: Frequency: rules and regulations are fairly adequate. There are a Bank In Progress Both 01-Jul-2013 number of weaknesses in the procurement management process (such as thresholds for open bidding procedures Risk Management: not being systematically applied). However, the 2. The core staff of the PMU including the PS is experienced in IDA- financed government is actively strengthening capacities and procurement and will continue to be responsible for procurement under the project. transparency. Corruption is actively prosecuted and has There will be no major issues if the PS continues under the project. led to several arrests in the past few years. The creation of the Court of Accounts as an independent Court, the Resp: Status: Stage: Recurrent: Due Date: Frequency: strengthening of the capacity of l’Inspection Générale de Client Not Yet Due Implementation Monthly l’Etat and l’Inspection Générale des Finances are important steps for uncovering and prosecuting corruption Risk Management: cases. The business environment is mixed, with a highly 3. The project team would require the revision of the Decrees governing the Drug favorable regime in the free zone, and a more restrictive Fund and engage in policy dialog using the GAC report and recommendations. set of regulations in the rest of the country (although in view of the size of Djibouti, most enterprises can establish Resp: Status: Stage: Recurrent: Due Date: Frequency: themselves in the free zone). With regards to property Both Not Yet Due Implementation 31-Dec-2013 rights, the the right of private property is secured by Djibouti’s constitution, and there are legal provisions for corporate matters such as information access, equity and profit sharing, stakeholder participation and transparency. In 2009, a new investment code was issued. It includes provisions to guarantee commercial freedom and to regulate contractual rights as well as bankruptcy. However, capacity weaknesses in institutions assigned to protect these rights as well as a lack of awareness of new legal development often hinder an effective implementation of these laws. 51 2. Many of the systemic Governance and Anti- Corruption (GAC) risk and control issues at the country level may affect the procurement management under the project. 3. Poor governance of the Drug Fund may affect its sustainability. Risk Management: The independent verification firm will be hired to ensure the reliability of the data provided by the healthcare providers. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both Not Yet Due Implementation 01-Jul-2013 Project Risks Design Rating Substantial Description: Risk Management: 1. The RBF process allows for adjustment over time (as frequently as monthly) of the 1. Healthcare providers may be inclined to offer services services provided for which incentives are received so as to that some services are not that receive RBF funding instead of offering all services, overemphasized and others underutilized. thereby skewing production of services. Incentives may be too low (therefore not leading to any Resp: Status: Stage: Recurrent: Due Date: Frequency: increased service provision or motivation of staff) or too Both Not Yet Due Implementation Quarterly high (thereby leading to only offering services with high purchase prices and therefore putting some patients at a Risk Management: disadvantage). 2. The project team would require the MOF to make the full payment of arrears to the Drug Fund through direct payment of the drugs procured by the Drug Fund and then 2. Delayed payments of the MOF to the Drug Fund may earmark stable revenue to ensure regular payments thereafter. In addition, health centers affect the availability of drugs in MOH facilities. will have the ability to purchase drugs with incentive funds to ensure a steady supply of needed medications without having to rely only on the Drug Fund. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both Not Yet Due Implementation 30-Sep-2013 52 Social and Environmental Rating Low Description: Risk Management: Weak management of medical waste. The project will implement an existing medical waste management plan. Resp: Status: Stage: Recurrent: Due Date: Frequency: Client In Progress Both Quarterly Program and Donor Rating Moderate Description: Risk Management: Other donors may be reluctant to contribute with financing The Bank team holds regular meetings with other donors in Djibouti to keep them to the Program due to the lack of knowledge about the apprised of the Project and how it is progressing. There is also the possibility of scaling RBF mechanism. up with additional funding from the HRITF. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Both Quarterly Delivery Monitoring and Sustainability Rating Substantial Description: Risk Management: 1. The project will support the Operations and Maintenance Unit of the MOH and 1. Lack of Operations and Maintenance systems. strengthen its capacity. 2. Sustainability: Given Djibouti’s economic situation, the Resp: Status: Stage: Recurrent: Due Date: Frequency: GoD is likely to need continuous external aid in the Both Not Yet Due Implementation 01-Jul-2013 foreseeable future in order to attain its national health goals and make progress toward the MDGs Risk Management: 2. The Project takes into consideration macroeconomic forecasts and limitations in order not to put an undue fiscal burden on the country. By spending a minimal amount per capita per year per beneficiary, the current cost is likely to be affordable in the long term. As the economy grows and the Government’s ability to mobilize domestic revenues increases, there should be an opportunity to increase public expenditure on health services and thus reduce out-of-pocket expenditures by households. Resp: Status: Stage: Recurrent: Due Date: Frequency: Client Not Yet Due Implementation Yearly 53 Resp: Status: Stage: Recurrent: Due Date: Frequency: Overall Risk Implementation Risk Rating: Substantial Comments: Given the mitigation measures proposed, the Bank team assesses implementation risk as Substantial. 54 Annex 5: Results-based Financing (RBF) DJIBOUTI: IMPROVING HEALTH SECTOR PERFORMANCE What is RBF? 1. RBF pays for outputs or results and this is different from classical programs which focus on procuring inputs. In the health sector, outputs or results are predominantly produced by health facilities whereas some results are produced by the health administration. Such outputs or results include quality services carried out by health facilities and certain actions by the health administration. Income from RBF is used by health facilities and the health administration to procure necessary inputs and to pay performance bonuses. 2. RBF is based on operational and tacit knowledge developed over the past 15 years for World Bank lending operations in Southeast Asia and Africa, and is in continuous development incorporating lessons learned. The effectiveness of RBF was proven through a rigorous impact evaluation in Rwanda. 17 A RBF toolkit is being developed by the World Bank and will be available in the second quarter of 2013. 3. RBF is applicable in a wide variety of lower and middle income country contexts. The diversity and the applicability of RBF are evident when looking at the contexts where such programs are carried out: Burundi, DRC South-Kivu, Nigeria, Indonesia, Kyrgyzstan and Vietnam. Currently, over 30 countries in Africa, and Central and South-East Asia are planning, designing, and implementing such programs. 4. Certain aspects of RBF and how they relate to Djibouti will be discussed in the following sections. These aspects are: (a) purchasing quality services; (b) separation of functions; (c) health facility autonomy; (d) verification and counter-verification; (d) data management and invoicing; and (e) adapting the RBF approach to Djibouti. Purchasing Quality Services 5. RBF purchases quality health services. Important notions are leveraging existing resources; changing incentive structures; purchasing balanced packages; purchasing conditional on quality; and RBF pricing versus the real cost of services. 6. RBF purchases quality health services through leveraging existing means of production. The purchase is through a fee-for-service provider payment mechanism, conditional on the 17 Basinga, P., Gertler, P., Binagwaho, A., Soucat, A., Sturdy, J. & Vermeersch, C. (2011) Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. The Lancet, 377, 1421-28. Gertler, P., Vermeersch, C. (2012) Using Performance Incentives to Improve Health Outcomes. Policy Research Working Paper WPS6100, Washington DC, the World Bank. Dewalque, D., Gertler, P., et al (2012) The Effect on HIV Testing and Counseling Services in Rwanda of Paying Health Care Providers for Performance: an Impact Evaluation (submitted). 55 quality of services. Key to understanding RBF is the notion of leveraging. Existing building, equipment, medical consumables, cash income from other sources and staffing are leveraged through RBF. 7. RBF changes incentive structures at various levels in the health system. The incentives need to be strong enough to influence health worker coping strategies while they provide additional income to enable health facilities to procure missing equipment, to maintain and repair equipment and premises and to stock essential life-saving drugs. 8. RBF purchases a balanced package of services at the community and health center level and at the first referral hospital level. A lack of coverage for essential health services guides purchasing at the community and health center level. At the hospital level, additional services complementing the primary levels are purchased; for instance complicated deliveries or more sophisticated reproductive health services. In general, there are 15-25 services in each package. Ideally, incentives are targeted at preventive services used by everybody whilst facilitating access to curative services for the poorest. 9. RBF budget allocation is about 2/3 at the community and health center level, and 1/3 for the first referral hospital level. 10. Quality is measured and rewarded through the use of a quantified quality checklist. This checklist is custom-made to reflect the particularities of each context. It is measured once per quarter, typically by an incentivized district health administration (for the health centers) or by a peer-evaluation mechanism (for the hospitals). The impact of the quality measure depends on the type of RBF system. It can be a quality bonus with a maximum of 25 percent of earnings (in the ‘carrot’ system) or a deduction of 100 percent of earnings if the quality is 0 (in the ‘stick’ system). 11. RBF fees have little to do with the actual cost of services. First, the actual cost of a service (which includes apportioned annuity of building and equipment; staff cost; drugs and medical consumables) is much higher than a RBF fee for that service. Second, RBF is a pricing system; the fee is proportional to the relative public health importance and the level of coverage of that service. Third, a RBF fee includes a rural hardship element, and therefore the fee is higher in harder to reach areas. Finally, certain services can be targeted to the poorest of the poor and attract a higher fee than the same service for the better off. Also, RBF fees can be changed depending on budget availability; upward if more money becomes available, and downward if the disbursement is higher than expected. 12. A simplified example of RBF is provided in Table 1 below: individual health facilities are provided funds based on the quantity and quality of services they produce as independently verified. For example, if a health facility fully immunizes 60 children in a quarter, they could earn US$120 (60 x US$2 per child fully vaccinated (1) and (2)). The total amount would be adjusted for the remoteness or difficulty of the facility (equity bonus), since urban or peri-urban facilities could earn a disproportionate amount. In the example below, this particular facility would earn 20 percent more because of the difficulties it faces (5). The total would also be adjusted by a quality score based on a checklist administered at the facility every quarter. This 56 facility would earn 60 percent of what it would be entitled to due to the quality correction. The quality correction is a maximum of 25 percent of earnings from the past quarter (3). This facility thus earns 60 percent of the 25 percent for its quality (3). The funds earned (US$3,030 in this example (6)) are transferred to the bank account of the facility and can be used for (7): (i) health facility operational costs, such as drugs and consumables, outreach expenses, health facility maintenance and repair, etc.; (ii) performance bonus for health workers (up to 50 percent) according to defined criteria; this facility decided to spend 26 percent of its total income on performance bonuses (34 percent of its RBF earnings, however, due to other sources of cash income, such funds are managed integrally); and (iii) savings – this health facility is saving up to buy a motorcycle to facilitate community outreach but also to have a cash buffer. Table 1: Simplified Example of Performance Based Financing in a Health Facility Health Facility Revenues Number Provided Unit Price Total Last quarter Earned Child fully vaccinated 60 $2 $120 1 2 Skilled birth attendance 60 4 $18 $1,080 Curative care 1,480 $0.5 $740 Curative care for the 320 $0.80 $256 vulnerable patient (up to a maximum of 20% of curative consultations) Sub-Total $2,196 Remoteness (Equity) Bonus +20% $439 5 Quality bonus 60% of 25% 3 $395 Total RBF subsidies 6 $3,030 Other Revenues (direct – insurance etc.) $970 Total revenues $4,000 Health Facility Expenses Fixed salaries staff 7 $800 Operational costs $350 Drugs and consumables $1,000 Outreach expenditures $250 Repairs to the health facility $300 Savings into health facility bank account $250 Sub-total $2,950 Bonuses to staff in the facility = total expenses minus sub-total $1,050 Total expenses $4,000 Separation of Functions 13. A precondition for obtaining credible performance results is a separation of functions. In RBF it is best practice to strive for a full separation of functions between the chief players in the health care arena: the fund-holder, the purchaser, the provider, the community, community health committees, local RBF steering committees and the national RBF coordination mechanisms. 57 14. In a separation of functions different functions are allocated to different health system stakeholders. In RBF, the following functions are distinguished: Provision; Regulation; Purchasing; Fund holding and Community voice. In figure 1 below, the separation of functions is illustrated: Figure 1: The Separation of Functions and its Governance Issues 18 Health Facility Autonomy 15. Health facility autonomy is an important pre-requisite for RBF. Health facility autonomy is important in (i) holistic management of cash resources; (ii) managing a bank account; (iii) procurement of goods; (iv) repairs to facility and equipment; and (v) managing human resources. 16. Community oversight is important when decentralizing public funding. To enhance governance, community oversight mechanisms are strengthened when available, or introduced when absent. Verification and Counter-Verification 17. Credible verification is at the heart of RBF systems and two types can be discerned. a. The first type is the so-called ‘ex-ante verification’; the verification before payment for performance is made. The ex-ante quantity verification is typically carried out by a third party contracted to do the purchasing on behalf of the fund holder(s) and regulator. The ex-ante quality verification is frequently carried out by the district health administration through a performance contract. b. The second type is the ‘ex-post verification’; the verification which is done after payment for performance has been carried out. Whereas the ex-ante verification is routinely (monthly and quarterly) carried out for all contracted health facilities, the ex-post verification is done on a random sample of health facilities and health administrations. Different systems exist, but the ex-post quantity verification is typically carried out by the purchasing agent, through grassroots organizations. Such mechanisms are also called ‘community client satisfaction surveys’. On the one hand, 18 Remme, M., Peerenboom, P.-B., Douzima, P.-M., Batubenga, D. M., Inoussa, M. I. & Weerd, J. V. D. (2012) Le Financement base sur la Performance et al Bonne Gouvernance: Leçons apprises in République Centrafricaine. PBF Cop Working Paper Series WP8 ed. Adapted from Peter-Bob Peerenboom and used with permission 58 such systems discourage the ‘phantom patient phenomenon’ (a service claimed that did not take place), and on the other they collect valuable feedback from the community on their perception of the quality of these services. Data management and invoicing 18. RBF needs good data-management and invoicing systems to pay regularly for performance. Such RBF data-management and invoicing systems are characterized by (i) limited data-sets; (ii) good data accuracy; (iii) a high degree of data completeness; (iv) good data accessibility, and (v) transparency. In an increasing number of RBF projects, a web-enabled application is used. A public frontend makes accessible information on performance and payments to the general public. Accessibility to these web-enabled applications down to the district level is reasonable in Lower Middle-income Countries, and this accessibility is improving with growing connectivity. 19. RBF data management and invoicing systems are purposefully linked to decentralized governance mechanisms. In well-designed RBF systems, a district level steering committee acts as a district-level governing board for RBF. Such decentralized decision making is important as knowledge on how health facilities function is best at the district level. Purposefully linking civil society and government systems in this steering committee enhances governance significantly. Timely access to good quality data and invoices through the web-enabled application effectively enable such governance mechanisms. Adapting the RBF approach to Djibouti 20. For Djibouti: c. A separation of functions is introduced through contracting of a technical assistance agency. This technical assistance agency will carry out the purchasing, verification, counter-verification on behalf of the government. In addition, the agency will have an important role in coaching health facilities to perform better, and in increasing the technical capabilities of the district and central MOH. d. Autonomy for health facilities will be enhanced. Each health facility will have a bank account, and a new health facility committee will have oversight over the public funds. e. Through an initial two-year pre-pilot phase covering Djibouti-ville and two rural regions (Ali Sabieh and Tadjourah), the RBF initial tools will be tested and refined. All eleven public community health centers in Djibouti-ville and regional health centers in Ali Sabieh and Tadjourah will be targeted. In year three and beyond the RBF pilot scheme will be scaled up to additionally cover all regions in the rural areas. f. The RBF system will be a ‘carrot’ system: up to 25 percent additional earnings can be had if the quality is 100 percent. This is an additional bonus for good quality services. If the quality is less than 50 percent, then there will be no quality bonus. g. The Djibouti RBF system will introduce and test an important and innovative risk- protection for the poorest. Up to 40 percent of all curative care consultations will be free of charge for the poorest and the financing will be through RBF. This is similar to how some Health Equity Funds have financed care for the poorest in Cambodia. 59 An appropriate post-identification mechanism for the poorest will be piloted in the initial phase of the project. Lessons from other contexts will be incorporated in its design. 19 h. The MOH will be under a performance framework for carrying out the quantified quality checklist, and a series of other activities related to supervision, health management information system, coordination, capacity building, and secretarial functions for the RBF steering committee, vaccine supply facility and district pharmacy. i. The minimum package of health services consists of 14 services (see Annex 6). The hospital sector will not be supported through this project. However, inpatient care for malnourished children – through special nutritional centers - is considered for RBF. Also, referral of a complicated delivery to a first level referral hospital will be financed. Weighting of the services and a financial risk forecasting have resulted in a pricing, which will be tested and refined during the pre-pilot phase. j. The RBF output budgets have been set as US$2.5 per capita per year for the community/health centers in Djibouti-ville, and at US$3.50 per capita per year for the regions. The allocation of available budget is relatively high for the community/health center and this is due to the perceived higher need for budget at these levels (community health workers; destituteness; staffing problems). k. An impact evaluation financed by the Health Results Innovations Trust fund will rigorously study the effects of RBF and compare this with a counter factual. The impact evaluation will inform future policy direction for RBF in Djibouti. 19 ANNEAR, P. (2010) A comprehensive review of the literature on health equity funds in Cambodia 2001-2010 and annotated bibliography. Health Policy and Health Finance Knowledge Hub working paper series. Melbourne, The Nossal Institute for Global Health. SOETERS, R., HABINEZA, C. & PEERENBOOM, P. B. (2006) Performance- based financing and changing the district health system: experience from Rwanda. Bulletin of the World Health Organization, 84. SOETERS, R., PEERENBOOM, P.-B., MUSHAGALUSA, P. & KIMANUKA, C. (2011) Performance Based Health Financing Experiment Improves Care in a Failed State. Health Affairs, 30, 1518-1527. 60 Annex 6. Project Cost Details DJIBOUTI: IMPROVING HEALTH SECTOR PERFORMANCE DJIBOUTI Improving Health Sector Performance Table 103. Financement basé sur les résultats Detailed Costs Totals Including Contingencies (US$) 2013 2014 2015 2016 2017 Total I. Investm ent Costs A. Djibouti-ville 500,000.0 500,000.0 500,000.0 500,000.0 700,000.0 2,700,000.0 B. Ali-Sabieh et Tadjourah 250,000.0 250,000.0 250,000.0 250,000.0 300,000.0 1,300,000.0 Total 750,000.0 750,000.0 750,000.0 750,000.0 1,000,000.0 4,000,000.0 61 DJIBOUTI Improving Health Sector Performance Table 201. Composante 2 RENFORCEMENT DU SYSTÈME DE SA Detailed Costs Totals Including Contingencies (US$) 2013 2014 2015 2016 2017 Total I. Investm ent Costs A. SNIS 1. Renouveler l'équipement informatique des CMH, CSC, SNIS et niveau hospitalier (5CMH,11 CSC,3Hop,4SIS) 34,500.0 - - - - 34,500.0 2. Assurer la maintenance des équipements informatiques (antivirus, petit matériel) 700.0 700.0 700.0 700.0 700.0 3,500.0 3. Concevoir les supports RFB et Reproduire tous les outils (support RBF,fiches de visite et régistres) 7,000.0 7,000.0 7,000.0 - - 21,000.0 4. Contrôle de la qualité des données dans les régions et à Djibouti-ville 2,000.0 2,000.0 2,000.0 2,000.0 2,000.0 10,000.0 5. Recruter 1 statisticien pour SNIS 25,500.0 25,500.0 25,500.0 25,500.0 - 102,000.0 6. Appuyer la parution du bulletin de rétro information sur le SNIS et le FBR 2,000.0 2,000.0 2,000.0 2,000.0 2,000.0 10,000.0 Subtotal 71,700.0 37,200.0 37,200.0 30,200.0 4,700.0 181,000.0 B. DPS 1. Recruter un assistant technique pour une durée de 3 mois pour former l'équipe sur la conception des outils 24,000.0 - - - - 24,000.0 2. Etendre l'approche d'unités de soins dans les établissement scolaire des régions (achat immobilier, médicam 5,000.0 - - - - 5,000.0 3. Rendre opérationnel des espaces de santé au sein des centres de developpement communautaire pour jeu 5,000.0 - - - - 5,000.0 4. Constituer une équipe multidisciplinaire pour assurer une prise en charge globale pour la population des rég 5,000.0 - - - - 5,000.0 5. Redynamiser les cellules d'écoute dans les lycées et universités pour repondre aux besoins des jeunes et a 5,000.0 - - - - 5,000.0 6. Former les enseignants sur les themes santé des jeunes 5,000.0 - - - - 5,000.0 7. Supervision des activités de routine 3,000.0 3,000.0 3,000.0 3,000.0 3,000.0 15,000.0 8. Réaliser les Visites médicales au sein des établissements scolaires 2,000.0 2,000.0 2,000.0 2,000.0 2,000.0 10,000.0 Subtotal 54,000.0 5,000.0 5,000.0 5,000.0 5,000.0 74,000.0 C. DEPCI 1. Appuyer la DEPCI en complément a IHP+ 75,000.0 - - - - 75,000.0 D. IGSS 1. surveiller la circulation des stupéfiants et des substances psychotropes, d'en identifier notamment les entré 2,000.0 2,000.0 - - - 4,000.0 2. Achat d’outil d’inspection et contrôle de qualité des médicaments importés (minilab) 2,000.0 - - - - 2,000.0 3. Organiser au moins deux fois par an une réunion avec les responsables des cliniques + officines privées e 2,000.0 - - - - 2,000.0 4. Atelier de Formation de cours sur la bonne pratique de fabrication (GMP), contrôle qualité et l’assurance qua - 5,000.0 - - - 5,000.0 5. Former les inspecteurs nommés au contrôle des services de santé 25,000.0 - - 25,000.0 - 50,000.0 Subtotal 31,000.0 7,000.0 - 25,000.0 - 63,000.0 E. DRS 1. Recruter un consultant international pour l’élaboration de la politique SSP 8,400.0 - - - - 8,400.0 2. Former les cadres des 5 régions sur le processus de planification opérationnelle, ainsi que les cadres des c 3,000.0 3,000.0 - - - 6,000.0 3. Elaborer/Actualiser les normes relatifs au fonctionnement des structures notamment les dispositifs organisa 6,000.0 - - - - 6,000.0 4. Développement et mise en oeuvre d’une approche communautaire pour une meilleure participation à l’amélior 16,500.0 - - 16,500.0 - 33,000.0 5. Appui à la supervision périodique des activités des régions sanitaires (Direction centrale et sous directions 4,000.0 4,000.0 4,000.0 4,000.0 4,000.0 20,000.0 6. Appui à la gestion et à la tenue des dossiers du patients dans les structures sanitaires 2,000.0 2,000.0 2,000.0 2,000.0 2,000.0 10,000.0 7. Dotation des carburants pour les activités des equipes mobiles 7,000.0 7,000.0 7,000.0 7,000.0 7,000.0 35,000.0 8. Acquisition de petits équipements, matériels bureautiques et informatiques pour les CMH et CSC 6,000.0 - - - - 6,000.0 Subtotal 52,900.0 16,000.0 13,000.0 29,500.0 13,000.0 124,400.0 F. DSME 1. Former le personnel de santé des régions en SONU 5,000.0 5,000.0 5,000.0 5,000.0 5,000.0 25,000.0 2. Organiser mensuellement les activités avancées de SR dans les localités éloignées par les équipes mobiles 5,000.0 5,000.0 5,000.0 5,000.0 5,000.0 25,000.0 3. Organiser périodiquement des sensibilitsation/éducation des jeunes sur les grossesses non désirées, VIH/IS 4,000.0 4,000.0 4,000.0 4,000.0 4,000.0 20,000.0 4. Former les Sages femmes sur l'intégration de la CPN, CPoN et PTPE dans les CS 5,000.0 5,000.0 - - - 10,000.0 5. Néonatologue (2 ans plus voyage) Contrat 60,000.0 60,000.0 - - - 120,000.0 Billets d'avion 2,500.0 2,500.0 - - - 5,000.0 Subtotal 62,500.0 62,500.0 - - - 125,000.0 Subtotal 81,500.0 81,500.0 14,000.0 14,000.0 14,000.0 205,000.0 G. PEV 1. Ameliorer les services de vaccination dans toutes les structures de base 3,000.0 3,000.0 3,000.0 3,000.0 3,000.0 15,000.0 2. Renforcer les competences des agents de santé 5,000.0 5,000.0 5,000.0 - - 15,000.0 3. Information, éducation et mobilisation sociale de la population sur l'interêt de la prevention par la vaccinatio 4,800.0 4,800.0 - - - 9,600.0 4. Assurer le suivi, la surveillance et la supervision des activites du PEV 4,000.0 4,000.0 4,000.0 4,000.0 4,000.0 20,000.0 Subtotal 16,800.0 16,800.0 12,000.0 7,000.0 7,000.0 59,600.0 H. Activités Program m e VIH/sida (PL SIDA/SANTE) 1. Renforcer les compétences des TS dans les zones de prostitution pour la réduction des risques 2,500.0 2,500.0 - - - 5,000.0 2. Renforcer les compétences des HSH pour la réduction des risques chez des hommes à haut risques (HSH 5,000.0 5,000.0 - - - 10,000.0 3. Appuyer l'acquisition de tests de dépistage du VIH 2,000.0 2,000.0 2,000.0 2,000.0 2,000.0 10,000.0 4. Former les professionnels de la santé (médecins, infirmiers et sages femmes) des secteurs privés et public 6,500.0 - 6,500.0 - - 13,000.0 5. Organiser des campagnes de promotion et de réalisation de dépistage dans les 5 districts en partenariat av 5,000.0 5,000.0 5,000.0 5,000.0 5,000.0 25,000.0 Subtotal 21,000.0 14,500.0 13,500.0 7,000.0 7,000.0 63,000.0 I. Activités Program m e TUBERCULOSE 1. Formation sur la gestion des médicaments 5,000.0 - - - - 5,000.0 2. Former à l'étranger sur les différents aspects du contrôle de la tuberculose 15,000.0 - - - - 15,000.0 3. Appuyer la recherche de perdus de vue par les structures et les associations 5,000.0 5,000.0 5,000.0 5,000.0 5,000.0 25,000.0 4. Mettre en place une stratégie d'implication de la communauté dans la PEC des patients TB 15,000.0 - - - - 15,000.0 5. Appuyer la fourniture de petits matériels de laboration BSL3 pour la multirésistance 8,000.0 8,000.0 - - - 16,000.0 Subtotal 48,000.0 13,000.0 5,000.0 5,000.0 5,000.0 76,000.0 J. Activités Program m e PALUDISME 1. Appuyer l'achat des tests rapides de dépistage du paludisme 5,000.0 5,000.0 5,000.0 5,000.0 5,000.0 25,000.0 2. Contractualiser avec les associations pour renforcer la mobilisation communautaire 8,000.0 - 8,000.0 - - 16,000.0 Subtotal 13,000.0 5,000.0 13,000.0 5,000.0 5,000.0 41,000.0 K. DRHF 1. Mettre en place un logiciel de gestion des Ressources Humaines 10,000.0 - - - - 10,000.0 2. Constituer une banque de données sur les Ressources Humaines 8,000.0 - - - - 8,000.0 3. L'élaboration du plan de développement des RH 20,000.0 - - - - 20,000.0 Subtotal 38,000.0 - - - - 38,000.0 Total 502,900.0 196,000.0 112,700.0 127,700.0 60,700.0 1,000,000.0 62 DJIBOUTI Improving Health Sector Performance Table 301. Composante 3 Unité de gestion Detailed Costs Totals Including Contingencies (US$) 2013 2014 2015 2016 2017 Total I. Investm ent Costs A. Unité de gestion de projet 1. Réaliser les audits financiers niveau central et suivi des régions par UGP 30,000.0 30,000.0 30,000.0 30,000.0 30,000.0 150,000.0 2. Former et mettre en place les organes de gestion et de rétribution du RBF (avec 1 mois d'appui d'un consultant) 55,000.0 - - - - 55,000.0 3. Mettre en œuvre le plan de déchets sanitaire 50,000.0 - - - - 50,000.0 4. Financer les charges liées au fonctionnement du comité technique y compris les supervisions 11,000.0 11,000.0 11,000.0 11,000.0 11,000.0 55,000.0 5. Participation au financement des prochaines enquêtes indépendantes biennales (PAPFAM) - - - - 230,000.0 230,000.0 6. Financement des audits techniques indépendants à base trimestrielle 60,000.0 60,000.0 60,000.0 60,000.0 60,000.0 300,000.0 7. Organisation de la revue à mi parcours du projet - - 60,000.0 - - 60,000.0 8. Evaluation finale et d'impact du projet - - - - 70,000.0 70,000.0 9. Appuyer le fonctionnement de l'UGP (fourniture bureaux, entretiens divers) 15,000.0 15,000.0 15,000.0 15,000.0 15,000.0 75,000.0 10. Appuyer le paiement des salaires UGP 145,000.0 145,000.0 145,000.0 145,000.0 145,000.0 725,000.0 11. Payer les factures de Djibouti Télécom et Internet 10,000.0 10,000.0 10,000.0 10,000.0 10,000.0 50,000.0 12. Fournir le carburant pour le fonctionnement (15000l/an) 24,000.0 24,000.0 24,000.0 24,000.0 24,000.0 120,000.0 13. Formation équipe UGP 12,000.0 12,000.0 12,000.0 12,000.0 12,000.0 60,000.0 412,000.0 307,000.0 367,000.0 307,000.0 607,000.0 2,000,000.0 63 RBF – Djibouti-ville No Service PMA Index Fee DF Monthly_Target Qty_2013 Qty_2014 Qty_2015 Qty_2016 Qty_2017 Total_Budget 1 Nouvelle Consultation Curative 1 $0.32 57 pop/12 42,540 43,306 44,085 44,879 45,687 $730,468 Nouvelle Consultation Curative par un patient pauvre 2 (max 25%) 1.5 $0.48 85 pop/12*25% 10,635 10,826 11,021 11,220 11,422 $273,926 Enfants complètement vaccinés par les services de 3 vaccination de routine 8 $2.56 453 pop/12 *3.3% 1,404 1,429 1,455 1,481 1,508 $326,535 Consultation nutritionelle - surveillance et promotion 4 de la croissance 1.5 $0.48 85 pop/12*11.4%*4 19,398 19,747 20,103 20,465 20,833 $234,993 Nombre de femmes enceintes recevant le deuxième 5 dose de VAT 2 par les services de routine 3 $0.96 170 pop/12*3.8%*80% 1,293 1,316 1,340 1,364 1,389 $72,424 Visite Postnatale: CPoN1 et CPoN2 (entre 8 et 42 6 jours) 5 $1.60 283 pop/12*3.8%*80% 1,293 1,316 1,340 1,364 1,389 $107,216 Visite prénatale (CPN1) avant fin du première 7 trimestre de grossesse 5 $1.60 283 pop/12*3.8%*80% 1,293 1,316 1,340 1,364 1,389 $90,167 Accouchement eutocique dans une structure sanitaire 8 par du personnel qualifié 15 $4.80 850 pop/12*3.8%*80% 1,293 1,316 1,340 1,705 1,389 $398,468 Nouvelles acceptrices et utilisatrices continues de méthodes modernes de longue durée de planning familiale (injectables, DIU, implants) préscrites dans 9 le système publique 2 $0.64 113 pop*26%/12*22%*4*90% 8,760 8,918 8,927 9,241 9,408 $152,724 Nombre de résultats de tests de VIH/SIDA récupérés par toutes personnes testées pour le 10 VIH/SIDA 0.6 $0.19 34 pop/12*40% 17,016 17,322 17,634 17,952 18,275 $208,343 Femme enceinte séropostivie (VIH+) mise sous 11 prophylaxie ARV 35 $11.20 1,982 pop/12*3.8%*3.1%*50% 25 26 26 26 27 $2,186 12 Dépistage des cas TBC positifs 15 $4.80 850 pop/100.000*309*80%/12 105 107 109 111 113 $35,349 Cas TBC positifs traités et guéris dans le même 13 cohort 30 $9.60 1,699 pop/100.000*309*80%/12 105 107 109 111 113 $85,111 177 pop 2012 TOTAL $2,717,911 64 RBF – Ali-Sabieh and Tadjourah No Service PMA Index Fee DF Monthly_Target Qty_2013 Qty_2014 Qty_2015 Qty_2016 Qty_2017 Total_Budget 1 Nouvelle Consultation Curative 1 $0.40 71 pop/12 15,541 15,821 16,106 16,396 16,691 $327,686 Nouvelle Consultation Curative par un patient pauvre 2 (max 45%) 2 $0.80 142 pop/12*45% 6,994 7,120 7,248 7,378 7,511 $294,917 Enfants complètement vaccinés par les services de 3 vaccination de routine 10 $4.00 708 pop/12 *3.3% 513 522 531 541 551 $183,103 Consultation nutritionelle - surveillance et promotion de la 4 croissance 1.5 $0.60 106 pop/12*11.4%*4 7,087 7,214 7,344 7,477 7,611 $105,417 Nombre de femmes enceintes recevant le deuxième dose 5 de VAT 2 par les services de routine 3 $1.20 212 pop/12*3.8%*80% 472 481 490 498 507 $32,489 6 Visite Postnatale: CPoN1 et CPoN2 (entre 8 et 42 jours) 5 $2.00 354 pop/12*3.8%*80% 472 481 490 498 507 $48,097 Visite prénatale (CPN1) avant fin du première trimestre 7 de grossesse 5 $2.00 354 pop/12*3.8%*80% 472 481 490 498 507 $40,449 Accouchement eutocique dans une structure sanitaire par 8 du personnel qualifié 10 $4.00 708 pop/12*3.8%*80% 472 481 490 498 507 $48,740 Reference pour accouchement complique a l 'hopital 9 (preuve de contre-reference) 10 $4.00 708 pop/12*3.8%*20% 118 120 122 125 127 $29,151 Nouvelles acceptrices et utilisatrices continues de méthodes modernes de longue durée de planning familiale (injectables, DIU, implants) préscrites dans le 10 système publique 2 $0.80 142 pop*26%/12*22%*4*90% 3,200 3,258 3,261 3,376 3,437 $68,512 Nombre de résultats de tests de VIH/SIDA récupérés 11 par toutes personnes testées pour le VIH/SIDA 2 $0.80 142 pop/12*3.8%*80% 472 481 490 498 507 $23,677 12 Femme enceinte VIH+ mise sous prophylaxie ARV 30 $12.00 2,124 pop/12*3.8%*3.1%*50% 9 9 9 10 10 $840 13 Dépistage des cas TBC positifs 15 $6.00 1,062 pop/100.000*309*80%/12 38 39 40 41 41 $15,858 14 Cas TBC positifs traités et guéris dans le même cohort 50 $20.00 3,540 pop/100.000*309*80%/12 38 39 40 41 41 $63,635 177 pop 2012 TOTAL $1,282,571 65 Annex 7. Country at a Glance DJIBOUTI: IMPROVING HEALTH SECTOR PERFORMANCE Djibouti Balance of Payments and Trade 2000 2011 Governance indicators, 2000 and 2010 (US$ millions) Total merchandise exports (fob) 32 53 Voice and accountability Total merchandise imports (cif) 207 511 Net trade in goods and services -84 -226 Polit ical stability and absence of violence Current account balance -19 -156 Regulat ory quality as a % of GDP -3.4 -12.6 Rule of law Workers' remittances and compensation of employees (receipts) 12 33 Control of corruption Reserves, including gold 68 228 0 25 50 75 100 2010 Country's percentile rank (0-100) Central Government Finance higher values imply better ratings 2000 (% of GDP) Source: Worldw ide Governance Indicators (w w w .govindicators.org) Current revenue (including grants) 31.1 32.2 Tax revenue 21.5 21.6 Current expenditure 30.2 23.3 Technology and Infrastructure 2000 2010 Overall surplus/deficit -1.8 -0.7 Paved roads (% of total) 45.0 .. Highest marginal tax rate (%) Fixed line and mobile phone Individual .. .. subscribers (per 100 people) 1 21 Corporate .. .. High technology exports (% of manufactured exports) .. 0.1 External Debt and Resource Flows Environment (US$ millions) Total debt outstanding and disbursed 258 648 Agricultural land (% of land area) 69 73 Total debt service 13 41 Forest area (% of land area) 0.3 0.3 Debt relief (HIPC, MDRI) – – Terrestrial protected areas (% of land area) 0.0 0.0 Total debt (% of GDP) 46.8 52.3 Freshwater resources per capita (cu. meters) 392 344 Total debt service (% of exports) 6.1 8.6 Freshwater withdrawal (% of internal resources) 6.3 6.3 Foreign direct investment (net inflows) 3 14 CO2 emissions per capita (mt) 0.55 0.61 Portfolio equity (net inflows) 0 0 GDP per unit of energy use (2005 PPP $ per kg of oil equivalent) .. 11.5 Composition of total external debt, 2010 Energy use per capita (kg of oil equivalent) .. 170 Short-term, 1 IBRD, 0 Private, 20 IDA, 155 World Bank Group portfolio 2000 2010 IMF, 12 (US$ millions) Bilateral, 309 IBRD Total debt outstanding and disbursed 0 0 Disbursements 0 0 Principal repayments 0 0 Other multi- lateral, 254 Interest payments 0 0 US$ millions IDA Total debt outstanding and disbursed 50 155 Disbursements 4 1 Private Sector Development 2000 2011 Total debt service 1 3 Time required to start a business (days) – 37 IFC (fiscal year) Cost to start a business (% of GNI per capita) – 169.8 Total disbursed and outstanding portfolio – 0 Time required to register property (days) – 40 of which IFC own account – 0 Disbursements for IFC own account – 0 Ranked as a major constraint to business 2000 2010 Portfolio sales, prepayments and (% of managers surveyed who agreed) repayments for IFC own account – 0 n.a. .. .. n.a. .. .. MIGA Gross exposure – 234 Stock market capitalization (% of GDP) .. .. New guarantees – 427 Bank capital to asset ratio (%) .. .. Note: Figures in italics are for years other than those specified. 4/4/12 .. indicates data are not available. – indicates observation is not applicable. Development Economics, Development Data Group (DECDG). 66 IBRD 33396R D JI B O U TI SELECTED CITIES AND TOWNS MAIN ROADS REGION CAPITALS RAILROADS NATIONAL CAPITAL REGION BOUNDARIES RIVERS INTERNATIONAL BOUNDARIES 42°E 43°E To REP. OF Assab ERIT REA YEMEN DJIBOUTI Khôr ‘Angar Daddato O B O C K Dorra Sarta i E T H IOP IA Balli Malah 12°N 12°N TA D J O U R AH Obock D Randa ou bie To Bati Tadjourah Gulf of Aden Day 1783 m Lake Galafi Assal urah Sagallou of Tadjo Pl ain o f Plain Gulf Ga ga Gag de ade Ambado DJIBOUTI DJIBOUTI Arta Ambouli lai n o f P lain Yoboki Chebelley ChEbelley H an le Han Damerjog Loyada Goubetto Ch A RTA eik BAR P E TI T B AR A eti Ho D I K H I L Hol Hol lH ol e Beyad GR A N D ARA B AR 'ALI Lake Plateau Mouloua SABIEH To Berbera Abbé of Dakka 'Ali Sabieh Ali Adda Dikhil P lain lai n o f To SO MA LIA b aad Go baad As Ela Dira Dawa 11°N Modahtou Gobaad 11°N 0 4 8 12 16 20 Kilometers This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank 0 4 8 12 16 20 Miles Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. 42°E 43°E JUNE 2007