PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: PIDA253 Public Disclosure Copy Project Name Punjab Health Sector Reform Project (P123394) Region SOUTH ASIA Country Pakistan Sector(s) Health (100%) Lending Instrument Specific Investment Loan Project ID P123394 Borrower(s) Economics Affairs Division, Government of Pakistan Implementing Agency Health Sector Reform Program, Department of Health, Health Sector Reform Unit, Department of Health Environmental Category B-Partial Assessment Date PID Prepared/Updated 06-Mar-2013 Date PID Approved/Disclosed 14-Mar-2013 Estimated Date of Appraisal 22-Mar-2013 Completion Estimated Date of Board 28-May-2013 Approval Decision Public Disclosure Copy I. Project Context Country Context Pakistan is the world’s sixth most populous country with a population of 180 million and with a per capita income of US$1,120 in 2011. Pakistan faces a growing burden to meet the basic needs of its exploding population and a seemingly endless string of challenges including an economic downturn with high inflation, insecurity and a changing political climate. Pakistan's progress in human development has been slow and uneven and unlikely to achieve the Millennium Development Goals (MDGs) by 2015. There has been some improvements in primary school enrollments and gender parity in primary and secondary education. However, despite improvements, efforts remain inadequate to address the large burden caused by the increasing population. Significant inequity in health service access and utilization exists, with little change for the poorest and rural population since the 1990s. Addressing the above challenges requires strong leadership, good governance, and effective management, particularly at the provincial and district levels in the context of the 18th Amendment to the Constitution. II. Sectoral and Institutional Context Home to about 60% of the total population, Punjab holds the key to Pakistan's progress towards attaining the MDGs. Punjab's overall health outcomes are comparable to the national average or slightly better than other provinces, but the pace of change remains slow and uneven with significant Page 1 of 4 disparities among regions, rural and urban areas, and by economic status. The quality of care in public facilities is sub-optimal, resulting in low utilization of public sector provided health services. Punjab has gradually reduced child mortality. Recent data indicates stagnation and even a slight Public Disclosure Copy increase in infant mortality rates (IMR) in 2011. A high level of disparity in child mortality exists in Punjab, especially regarding mothers’ educational attainment. Child nutrition has not improved in the past decade. Stunting is 39% among children under five, a slight increase from the last survey in 2001. Immunization coverage remains low; only one in three children aged 12-23 months are fully immunized (34.6%). Punjab’s maternal and reproductive health outcome and service indicators too have shown a steady but far too slow progress. Punjab’s maternal mortality ratio of 227 per 100,000 live births is somewhat lower than the national average of 276; however, only 43% of deliveries are assisted by skilled health personnel - 37% of deliveries in Punjab occur at health facilities with only 10% of deliveries in public facilities. In addition, still one in three pregnant women in Punjab receives no prenatal consultation. Punjab's total fertility rate is 3.9 (2006), the lowest among Pakistan's four provinces and it also has lowest unmet need for family planning at 23%. Furthermore, Punjab faces a concentrated epidemic of HIV/AIDS among high risk groups e.g. injecting drug users and a significant burden of endemic tuberculosis. The major cities in Punjab are known to have sizeable numbers of vulnerable or at risk populations for HIV/AIDS. Punjab's slow progress in improving HNP outcomes is due to external and internal factors. Factors external to the health sector include persisting high levels of poverty mainly in the southern part of the province, low levels of education, inadequate availability of safe water and poor sanitation. Factors internal to the health sector are many. The sector is struggling in delivering expected results to their people as performance remains less than desired due to weak management particularly at district level, lack of accountability mechanisms, low motivation of staff to perform and work in rural and remote southern districts and low public expenditure on health, even as compared to most developing countries. Provincial health expenditures increased from 0.3% of provincial GDP in 2000/01 to 0.5% in 2006/07, but have remained unchanged ever since. Public Disclosure Copy The Government of Punjab is demonstrating strong leadership in implementing reforms in health and education as it has realized that it must make progress on human development to build a productive workforce with its large and increasing share of youth. In health it has developed a holistic sectoral strategy based on health system six building blocks framework. The Punjab Health Sector Strategy (HSS) 2012-2020 outlines a clear strategic direction with a results focus and envisages implementing management governance and accountability reforms; and strengthening health systems to undertake stewardship functions to provide the foundation for improving sectoral performance thereby improving health outcomes in the province. III. Project Development Objectives The development objective of the proposed project is to (a) enhance coverage, quality and access to essential health care especially for the poor and the vulnerable in under developed districts; and b) improve DoH capacity and systems for enhanced accountability and stewardship functions. IV. Project Description Component Name Component 1: Improving Health Service Delivery Component 2: Enhancing Efficiency and Effectiveness of the Health System Component 3: Strengthening Provincial Department of Health Management Capacity Page 2 of 4 Component 4: Improving the Capacities in Technical Areas for Equitable Health Services V. Financing (in USD Million) Public Disclosure Copy For Loans/Credits/Others Amount BORROWER/RECIPIENT 830.00 International Development Association (IDA) 100.00 UK British Department for International Development (D 165.00 Health Results-based Financing 21.50 Total 1116.50 VI. Implementation The project will be implemented through the existing institutional arrangements of the Government of Punjab and the Department of Health as it intends to support Government's reform program which will be implemented across all districts of Punjab. The Planning and Development Board will be responsible for overall coordination of the reform program. The proposed project will be implemented through the provincial Department of Health responsible for overseeing planning, implementation and monitoring of the sector. Within the Department, the Punjab Health Sector Reform Unit will be responsible for overall coordination monitoring and evaluation and implementation of reform program. In technical areas, the Directorate General of Health Services office will take lead. The Department will rely heavily on the district level Department of Health for program implementation and regular monitoring. The project will support measures to improve the capacity of both provincial and district managers for effective implementation. The proposed project of IDA US$100 million is expected to be financed through a Sector Investment Loan (SIL), which will use a programmatic approach to support the implementation of GOPb’s strategic sectoral plan. The project will be also supported by US$21.5 million from the Public Disclosure Copy Health Results Innovation Trust Fund (HRITF) with an in-built impact evaluation to implement the results-based financing (RBF) and health care financing (HCF) pilots. The project will use three disbursement modalities: (1) reimbursement against the selected Eligible Expenditure Programs (EEPs) of the DoH annual budget, subject to the achievement of Disbursement Linked Indicators (DLIs); (2) performance based financing for districts and health facilities, partly funded by HRITF under the RBF pilots and impact evaluation for the pilots; and (3) traditional Statement of Expenditure (SoE) based payments for technical assistance and pilots. The project will employ DLIs as an incentive to achieve project results by disbursing a portion of the total project financing upon achievement of key results related to the implementation of the project components. DLIs include key intermediate results, implementation performance targets, or milestones for institutional change The DLI targets are critical to advancing the reform process and achieving the Project Development Objective (PDO). VII. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 ✖ Natural Habitats OP/BP 4.04 ✖ Forests OP/BP 4.36 ✖ Pest Management OP 4.09 ✖ Page 3 of 4 Physical Cultural Resources OP/BP 4.11 ✖ Indigenous Peoples OP/BP 4.10 ✖ Public Disclosure Copy Involuntary Resettlement OP/BP 4.12 ✖ Safety of Dams OP/BP 4.37 ✖ Projects on International Waterways OP/BP 7.50 ✖ Projects in Disputed Areas OP/BP 7.60 ✖ VIII.Contact point World Bank Contact: Inaam Ul Haq Title: Senior Health Specialist Tel: 5722+155 Email: ihaq@worldbank.org Borrower/Client/Recipient Name: Economics Affairs Division, Government of Pakistan Contact: Mr. Javed Iqbal Title: Secretary Tel: 92519210629 Email: secretary@ead.gov.pk Implementing Agencies Name: Health Sector Reform Program, Department of Health Contact: Capt (Retd.) Arif Nadeem Title: Secretary Tel: 00924299210749 Email: secyhealth@punjab.pk Name: Health Sector Reform Unit, Department of Health Public Disclosure Copy Contact: Farasat Iqbal Title: Director Tel: 923003568379 Email: farasat_iqbal@yahoo.com IX. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop Page 4 of 4