Page 1 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 1 YEMEN GPOBA COMMITMENT DOCUMENT Project Name : Queen of Sheba Safe Motherhood Program (P104946) - Overview: The Queen of Sheba Safe Motherhood Program is a four year community based program that comprises the provision of a defined ‘Mother-Baby package’ of essential quality services as defined by WHO, such as antenatal care, birth attendance by skilled birth attendants, postnatal care, complicated care services and family planning, to eligible women of reproductive age (15-49) in Sana’a, Yemen. The package price will be US$150. The costs of treatment and medication are included in the package price including an assumed estimated 15% of patients requiring caesarian sections/emergency care. While the package price is at a discount to current quoted prices, it is deemed fair given that the bulk of services will be delivered at community level and not at hospital level. A minimal user fee of US$15 will be required from targeted women, which will be paid in month 8 or 9 of the pregnancy, prior to delivery. The US$15 was determined based on the current practice of Yemeni families giving US$10-US$20 on the day of delivery to whoever helped the pregnant woman deliver. The project does not use a voucher scheme as initially designed – instead eye scanning/finger prints will be used as the identification and tracking mechanism for eligible women in the program. Description: All services will be provided by the private sector: (1) Two private Yemeni hospitals, the Saudi German Hospital (SGH) and University of Science and Technology (USTH) Hospitals have been identified as appropriate clinical service providers for the first phase. Primary care services will be provided to targeted women by midwives at satellite clinics to be established in the districts and owned and managed by the hospitals. Patients requiring emergency or complicated care will be referred to the two private hospitals; (2) SOUL, a reputable local Yemeni NGO, will serve as project implementation and promotion unit responsible for program promotion, awareness campaigns and targeting of eligible pregnant women; and (3) A fiduciary agent will be the recipient of the GPOBA grant and manage the fund flow in the project. The private providers will bear the operational risks of the program as they will be reimbursed retroactively post service delivery and performance target verification by an independent verification expert (IVE). Please see diagram below: 49297 Page 2 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 2 Once a woman is identified as eligible to the program, her digital eye/finger print will be recorded in a database managed by SOUL and shared with service providers at the satellite clinics and main hospitals. For each visit/service sought by the registered women, her eye/finger print will be taken each time and will need to match with recorded data in order for the service to be provided. At the end of each quarter, service providers will invoice the fiduciary agent for the services provided. The fiduciary agent will first check invoices against the defined package of services and agreed prices and then disburse the money to the service providers. Every other quarter, an independent verification expert contracted by the fiduciary agent will conduct a quality performance review for the previous 6 month period. Depending on achievement of certain performance indicators (as outlined in Section B.2), payment will be triggered on a sliding scale basis. Program Sustainability : The program will be launched as an initial model to have a demonstration effect in year 1 and appropriately modified and expanded over years 2-4. It is anticipated that successful implementation of the first phase may attract local private large corporate companies e.g. oil and industrial groupings to participate in the program. Specifically, it could provide a good demonstration of how private businesses in Yemen could make investments that are socially responsible and contribute to the health of poorer communities. A successful first phase will also provide lessons for scale-up and replication. GPOBA Fiduciary agent Service Providers SGH & USTH SOUL Targeted Women (beneficiaries) External Audit Independent Verification E Outreach and Marketing Service delivery Page 3 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 3 At a later stage, the program may also serve as a model that may be adopted by the Government of Yemen as well as attract other bilateral/multilateral donors and healthcare providers to ensure sustainability. Further, as currently designed, the satellite clinics will be operated as profit centers. The providers have agreed to deposit any profits (if any) in excess of 5% margin into an escrow account/fund to be used to fund any legitimate unexpected cost-overruns in the short-run e.g. larger than estimated percentage of women requiring more expensive complicated and tertiary care. In the long run, the main purpose of these funds would be to serve as a ‘sustainability fund’ that could attract co-financing. While the program was designed in a way that the satellite clinics will be providing services at cost, these clinics may generate additional revenues for paying patients outside the scheme and not eligible to benefit from GOPBA subsidy. Sponsor: The Saudi German Yemen Hospital initiated this program based on its interest in providing antenatal and maternal care services to women from poorer and underserved communities in Sana’a. The Saudi German Hospitals Group, an IFC client, began its operations in 1998 and is one of the largest private for profit healthcare providers in the Middle East. It currently operates five hospitals in the MENA region and is about to establish a new hospital in Cairo, Egypt. Most recently, in June 2006, the Group opened a 300-bed multi-specialty hospital in Sana’a, Yemen at a total project cost of US$100 million, US$ 20 million of which is being funded by IFC in the form of a loan. Total project costs : US$7,574,100 Total GPOBA funding requested : US$6,682,100 a) Subsidy funding (W3) = US$6,193,600 as follows: o Funding of services: US$5,508,000 o Funding of capital costs 1 : US$ 140,000 o Program administrative costs: US$ 351,600 o Educational and awareness campaigns’ costs: US$ 194,000 b) Funding for program preparation start-up cost (W3): US$ 38,500 c) Independent Verification Expert: US$ 90,000 d) Fiduciary Agent Fee: US$ 80,000 e) Auditing: US$ 60,000 f) GPOBA Supervision: US$ 220,000 GPOBA subsidy as % of Total Costs: 88% GPOBA Window 3 Funding: 100% IFC Additional funding sources : · Patient user fees: US$15 per package of services amounting to US$612,000 1 For the first two years representing 50% GPOBA share for the establishment of the satellite clinics. Page 4 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 4 · Private Financing Leveraged: 50% of capital cost of establishing satellite clinics to be funded by private providers for year 1 and year 2. In year 3 & 4, service providers will fund 100% of capital costs needed. Service providers’ contribution is estimated at US$280,000. Outputs : The expected estimated output will be to achieve approximately 40,800 safe child birth deliveries attended by skilled birth attendants amongst the target population over the project period. Defined package of services delivered to patients at district satellite clinics and referred to private hospitals (as necessary for complicated care), measured through specific performance indicators and volume targets and monitored by an independent verification expert. IRR and ERR: A preliminary analysis was conducted based on secondary research and the Program’s cost assumptions - it was deemed that a quantitative economic and financial analysis of the Program would not provide useful insights into the program, primarily as there are minimal revenue streams (minimal user fees of US$15 per patient) as compared to the per patient investment of US$150 made by GPOBA. Further, in the absence of detailed pricing and household spending data, quantifying the expected economic benefits and conducting a robust economic analysis was deemed not feasible and inappropriate. However, an IRR was calculated for the satellite clinics and estimated to be 11%. Targeting the poor and expected beneficiaries : The program will target women (first time mothers and those with up to two children) of reproductive age (15-49) in two underserved districts in Sana’a in first year (household income less than US$2/day), based on certain defined eligibility criteria. GPOBA subsidy “efficiency” / Value for money: subsidy per capita: GPOBA provides a US$135 subsidy per safe motherhood package, or US$158.38 (including implementation costs) per safe motherhood package. Grant recipient : Fiduciary agent, to be procured through competitive bidding post commitment Financial Management : Financial Management Annex to be finalized the week of June 4 th , 2007. GPOBA subsidies will be disbursed to the fiduciary agent; Final financial management clearance will be obtained once fiduciary agent has been selected through the competitive bidding process. Disbursement : Three types of disbursements will take place during the life of the program (please refer to Annex 3): 1. Program preparation/design and start up costs: US$38,500 will be disbursed to SOUL upon GPOBA grant agreement being signed. GPOBA (W3) will be funding these design / start up costs. 2. Capital costs of satellite clinics: The total capital cost of establishing 4 satellite clinics in year 1 is estimated at US$140,000. This cost will be split on 50:50 basis between GPOBA and the service providers. US$35,000, which represents 50% of Page 5 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 5 GPOBA share of the capital costs, will be paid to service providers after commissioning of the said clinics. The remaining 50% of GPOBA share i.e. US$35,000 will be paid after the first 3 months of operations and subject to a satisfactory quality performance report by the Independent Verification Expert. The same will apply in Year 2. 3. Invoiced Services: Starting from the first quarter of operations, GPOBA, through fiduciary agent, will make performance payments to (1) service providers based on invoices of service provided; and to (2) SOUL based on cost recovery of fixed costs and agreed costs for the promotional/education & awareness campaign activities. Every other quarter, an independent verification expert contracted by the fiduciary agent will conduct a quality performance review for the previous 6 month period which will serve as the basis for the payment based on a sliding scale (as indicated in Section B.2). The performance indicators will be appropriately modified to reflect the expected clinical services to be provided in the preceding 6 month period. Procurement : Procurement clearance received. The selection of the two service providers (SGH and USTH) and the NGO (SOUL) as implementation partners has been approved. Competitive tendering for fiduciary agent, independent verification expert and auditor post commitment approval. Environmental clearance : The draft environment and social assessment is under discussion with the relevant specialists and pending additional information from the local partners. Clearance is expected in the week commencing June 4, 2007. The project does not trigger any social safeguards and will be classified as Category B. Government endorsement : Pending from Republic of Yemen, Ministry of Public Health and Population expected the week of June 4, 2007. Exchange rate : ~ 200 Yemeni Riyal per USD Summary Response to comments of Panel of Experts at Eligibility/Concept Stage : 1. Voucher scheme: The merits of a voucher scheme were considered and rejected as adding an unnecessary level of complexity and costs to the overall project. 2. Package pricing : A package price of US$150 was negotiated and agreed with the service providers. The costs of treatment and medication are included in the package price including an assumed estimated 15% of patients requiring caesarian sections/emergency care. This price was also compared to local and international peer pricing. While the package price agreed by the two providers is within range of pricing of other private Yemeni providers, the quality (services, staff, facilities, equipment) and capacity of the two providers’ current private hospitals far exceed that of the other local Yemeni private providers (see Table 1). Internationally, the package pricing was also comparable e.g. costs of similar quality services by similar quality providers in India range from US$ 350-1500. 3. Economic and Financial Analysis : Cost-effectiveness of maternal interventions : Page 6 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 6 Improvements in the quality of prenatal and delivery care are well documented as being cost-effective interventions. Expanding coverage of these services is also of comparable cost-effectiveness (See section B4). Economic and Financial Analysis of Program: A preliminary analysis was conducted based on secondary research and the Program’s cost assumptions - it was deemed that a quantitative economic and financial analysis of the Program would not provide useful insights into the program, primarily as there are minimal revenue streams (minimal user fees of US$15 per patient) as compared to the per patient investment of US$150 made by GPOBA. Further, in the absence of detailed pricing and household spending data, quantifying the expected economic benefits and conducting a robust economic analysis was deemed not feasible and inappropriate. However, it is noted that the package price agreed upon with the service providers is reasonable based on the comprehensiveness of the services to be provided in the Program and the high quality as compared to existing services and pricing thereof (see Table 1). 4. Scaling Up : A successful first phase will provide lessons for scale-up and replication of the program. It is expected that the program will first be scaled up within districts in Sana’a during early years and depending on progress, outcomes achieved and lessons learned, consideration given to scaling up to other surrounding governorates in Yemen. Page 7 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 7 Abbreviations: DALY Disability-Adjusted Life Year FA Fiduciary Agent GNI Gross National Income GPOBA Global Partnership on Output Based Aid IVE Independent Verification Expert NGO Non-Governmental organization SGH Saudi German Yemen Hospital UNDP United Nations Development Program USTH University of Science and Technology Hospital Page 8 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 8 Table of Contents Abbreviations:.....................................................................................................................7 Table of Contents................................................................................................................8 A. STRATEGIC CONTEXT AND RATIONALE.............................................................9 A.1. Country and Sector Issues.......................................................................................9 A.2. Rationale for GPOBA involvement ......................................................................10 A.3. Higher level objectives to which the project contributes......................................10 B. PROJECT DESCRIPTION..........................................................................................11 B.1. Project and Services Overview..............................................................................11 B.2. Project development objectives and key performance indicators .........................13 B.3. Project Cost and Financing Plan............................................................................15 B.4. Economic and financial analysis ...........................................................................16 B.5. Lessons Learned....................................................................................................17 B.6. Alternatives considered and rejected.....................................................................18 C. IMPLEMENTATION ..................................................................................................18 C.1. Milestones for project implementation..................................................................18 C.2. Local Partners and implementation arrangements.................................................18 C.3. Reporting and Monitoring and Evaluation of outcomes .......................................20 C.4. Sustainability.........................................................................................................21 C.5. Critical risks...........................................................................................................21 ANNEX 1. PROJECT COSTS & SCHEDULE ...........................................................23 ANNEX 2. FINANCIAL MANAGEMENT ...............................................................24 ANNEX 3. DISBURSEMENT PLAN..........................................................................25 ANNEX 4. PROCUREMENT......................................................................................26 ANNEX 5. ENVIRONMENT AND SOCIAL SAFEGUARDS.................................31 ANNEX 6. RESULTS FRAMEWORK AND MONITORING MECHANISM..........32 ANNEX 7. PROJECT PREPARATION & SUPERVISION.......................................33 Page 9 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 9 A. STRATEGIC CONTEXT AND RATIONALE A.1. Country and Sector Issues Yemen’s population of 20.9 million is predominantly rural (73 per cent), with GNI estimated at US$600 per capita (July 2005) and about 42% of people living in poverty (per 1998 Household Survey estimates) with limited access to basic health services. Yemen ranked 151st out of 177 countries on the 2005 UNDP Human Development Index 2. Yemen also has one of the highest maternal mortality ratio at 570/100,000 live births (2000 estimates) with only 27% of births attended by skilled birth attendants (2003) as well as a high fertility rate (average of 7 children/woman). Yemen has a pluralistic fragmented healthcare system with several different public and private providers and financing agents. The number of quality health service providers (either public or private) in Yemen is very limited. The facilities are generally substandard and characterized by lack of capacity, equipment and supplies. This problem is compounded by a scarcity in the number of physicians and other medical professionals and the poor quality and standards of medical training in the country. Amongst those Yemenis that can afford to, many travel abroad for private treatment. In the poorest communities in Yemen, poor access to quality services, lack of confidence in the healthcare providers and lack of affordability of care are contributory factors to the high maternal mortality ratio and key barriers to safe maternal care and services. There are also certain cultural specificities in health seeking behavior – these include the state of pregnancy not being viewed as requiring any medical attention, the choice to seek medical care is often made by the husband or mother-in-law, the lack of female doctors and a distrust of the providers that are exacerbating factors. As a result, amongst poorer communities it is not uncommon to find women not seeking any medical care during pregnancy and delivering at home. The safe motherhood program will seek to address some of these barriers by providing defined quality maternal services including working with the targeted communities to increase utilization of these services and ensuring birth attendance by skilled birth attendants amongst the targeted communities. 2 World Bank, WHO sources Page 10 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 10 A.2. Rationale for GPOBA involvement This project meets GPOBA operational criteria, as well as the core OBA principals of: ¾ Payment linked to performance; ¾ Explicit/targeting of subsidies; ¾ Encouraging accountability of service providers; ¾ Increased private participation in service provision and financing; ¾ Performance risk borne by the providers; ¾ Providing incentives for innovation and efficiency; ¾ Encouraging sustainability; and, ¾ Monitoring of results. GPOBA has a mandate to fund pro-poor output-based subsidies in the health sector, with special emphasis on the poorest countries. This program would be the first GPOBA Window 3 project in the health sector in Yemen. It will also be the first performance/output based contracting program with local private health providers in Yemen targeted at underserved communities. If successful, the program would provide a useful model for replication and lessons on the role and participation of the private health sector in health provision in Yemen including linkages with Government and public policy. A.3. Higher level objectives to which the project contributes ¾ Improve access and quality of services available in Sana’a, Yemen (including relieving some of the strain experienced by the overburdened public sector) ¾ Republic of Yemen, Ministry of Health and Population’s Health Sector Review and national focus on improving mother and child care, emergency obstetric care, reproductive health and family planning ¾ Millennium Development Goals (improvement of maternal health and reduction in child mortality) ¾ Opportunity to assess private sector health provision and opportunities/lessons for public private partnership in health service delivery ¾ Sustainability of provision of good maternal services amongst poorer communities - if successful, the program could attract additional funds e.g. local private corporations, additional donors etc. ¾ Aligned to the World Bank’s May 2006 Country Assistance Strategy for Yemen for FY2006 - FY2009 and current Health Reform Support Project Page 11 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 11 B. PROJECT DESCRIPTION B.1. Project and Services Overview The safe motherhood program is a four year community based program that comprises the provision of a defined ‘Mother-Baby package’ to eligible women of reproductive age (15-49) in Sana’a, Yemen. A fiduciary agent will be the recipient of GPOBA grant and manage payment flow to service providers. Selection criteria: Women from two districts in Sana’a will be identified and eligible to receive the defined mother-baby package of quality services based on the following selection criteria: ¾ 15-49 years in age ¾ First time mothers or mothers with up to two children ¾ Women from households with less than US$2/day in identified districts ¾ First trimester of pregnancy ¾ Payment of user fees ¾ Interested, willing and able to commit to attending and complying with antenatal visits and seeking care at satellite clinics SOUL will be responsible for program promotion, awareness campaigns and targeting of eligible pregnant women. Once a woman is identified as eligible to the program, her digital eye/finger print will be recorded in a database managed by SOUL and shared with service providers at the satellite clinics and main hospitals. For each visit/service sought by the registered women, her eye/finger print will be required to match with recorded data for the service to be provided. Mother-Baby Package of Services: The services to be provided are based on WHO defined mother-baby package of 12 interventions, and may be modified to align with Yemeni national health guidelines and local needs as appropriate. These services comprise: ¾ Antenatal care – at least four antenatal visits providing basic antenatal care ¾ Management of syphilis, gonorrhoea, chlamydia, severe anaemia and treatment of malaria ¾ Normal delivery care – clean and safe delivery, basic newborn care, post-partum care ¾ Essential obstetric care – management of eclampsia, sepsis, haemorrhage and abortion complications and emergency caesarian sections as required ¾ Family Planning – information and education ¾ Nutritional package Page 12 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 12 Service model: Primary care services will be provided to targeted women at the level of the community by midwives at satellite clinics within the districts. In year 1, two satellite clinics will be established, owned, and managed by service providers in each of the two districts. Patients with complications will be referred to in-house specialists based at the satellite clinics. Those patients requiring more tertiary or emergency care would be referred to two private hospitals for management using the emergency transportation systems of these private hospitals. Services Package cost: A detailed appraisal and costing analysis was conducted jointly by the service providers and an IFC appraisal team . The appraisals were conducted in Sana’a in September 2006 (SGH appraisal) and May 2007 (Safe Motherhood program appraisal). A package price of US$150 was negotiated and agreed with the service providers. The costs of treatment and medication are included in the package price including an assumed estimated 15% of patients requiring caesarian sections/emergency care. While this price is at a discount to their quoted prices, it is deemed fair given that the bulk of services will be delivered at community level in the satellite clinics and not at hospital level. This price was also compared to local and international peer pricing. While the package price agreed by the two providers is within range of pricing of other private Yemeni providers, the quality (services, staff, facilities, equipment) and capacity of the two providers’ current private hospitals far exceed that of the other local Yemeni private providers (based on a recent market survey and analytical work by IFC and a local NGO in Sana’a - see table 1). The market survey, based on the Mother-Baby package of services per client at the hospital level, estimated that average treatment costs per patient ranged from US$34 to US$65 for antenatal care, from US$68 to US$180 for normal delivery, and from US$298 to US$750 for emergency caesarian sections. Average costs per patient for treatment of anaemia, syphilis and gonnorrhoea were US$13 each. Internationally, the package pricing was also comparable e.g. costs of similar quality services by similar quality providers in India range from USUS$ 350-1,500. Table 1: Summary of costs from five Yemeni hospitals (US$) Azal Hospital Saudi German Hospital UST Hospital German Yemen Hospital Mother Hospital Antenatal Care 54 57 64 64 34 Delivery 155 180 149 180 68 Family Planning 18 29 20 20 12 Basic Package 227 266 233 264 114 C-Section 300 750 390 450 298 Weighted Average Cost 242 363 264 301 151 Quality and capacity assessment Poor quality of current facilities Good Good Lack of capacity Low quality care Page 13 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 13 It was also noted that in the public system in Yemen, only the initial consultation is free, thereafter patients are required to pay out of pocket for all additional services, diagnostic tests and medication. Even, when patients from the poorest communities deliver at home and with the aid of local birth attendants/midwives (varying levels of training – mostly inadequate), these patients make payments to these attendants. B.2. Project development objectives and key performance indicators The project has two main development objectives: ¾ To provide quality maternal care to eligible women in targeted districts in Sana’a ¾ To design and implement a model of care that provides key lessons and serves as a demonstration effect of use of innovative models of care that integrate Yemeni public policy on maternal and child care and private health provision in Yemen Key Program indicators which will be monitored and evaluated include: ¾ % utilization of services amongst identified eligible targeted women ¾ % of births attended by skilled birth attendants amongst identified eligible target population The following table provides the Performance Indicators required from the private service providers which will determine level of GPOBA subsidy received: Table 2: Performance Indicators (private providers) # Performance Indicator Description Quarterly Threshold Target Clinical 1 % of births attended by skilled attendants Amongst registered patients, % of births attended by skilled attendants at clinics or homes 85% 2 Neonatal Mortality rate Neonatal mortality rate amongst registered patients 20/1000 live births 3 Maintenance of Patient Medical Records Percentage measure of the accessibility, accuracy and completeness of random samples of medical records examined 95% Patient Volume and Utilization 4 % of patients that complete basic antenatal care visits (4 visits) % of targeted patients that complete at least four antenatal visits during pregnancy 85% 5 Annual Patients Minimum annual patient base of 4800 in year 1 Minimum average of 100 per month Client satisfaction 6 Patient & family satisfaction Rate of satisfaction measured by periodic patient and family surveys 80 % Page 14 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 14 Equipment 7 Clinic and Hospital Equipment Rate of compliance with quality and service standards 95% Facilities Management 8 General condition and cleanliness Rate of compliance with service and quality standards 90% Final description of each Performance Indicator and threshold target are being reviewed and may be modified based on revised Government indicators. Patient volume and utilization targets will be modified after year 1. It is intended that the number of satellite clinics will be increased from year 2 to 4 in each of the districts and may be extended to other districts as well. The following table provides the Performance Bands that the Service Providers are required to meet in order to receive varying percentages of the GPOBA subsidy. The Performance Indicators will be assessed semi-annually by an Independent Verification Expert. As indicated below, failure to meet these targets will result in (i) the automatic reduction or elimination of the GPOBA payment for the relevant quarter (ii) adjustment (if any) of the GPOBA payment for the preceding quarter. Payments for the subsequent quarters will be based on the next semi-annual assessment by the IVE (refer to Annex 3). It will not be possible to recuperate subsidy payments not paid in the previous quarter due to inability to meet performance indicators. Table 3: Performance Bands (Service Providers) Number of Quarterly Targets Met Amount of Subsidy Received Comment At least six of eight targets 100% Five of eight targets 75% Three or four targets 50% Two or fewer targets No subsidy Clinical Indicators 1,2 and 3 are mandatory Actual payment of subsidies is based on quarterly invoices. Service providers will get reimbursed for actual delivery of services based on agreed prices for each intervention i.e. antennal care, delivery, post natal care, will all be priced separately and capped within the package price. Therefore, if a pregnant woman receives the whole package of services, service providers would have received US$150 (US$135 from GPOBA and US$15 from beneficiaries), assuming that at least six out of eight performance indicators have been met. SOUL will be required to meet targets 4 and 5 in Table 2 above. A portion (i.e., US$38,500) of SOUL’s project start up and fixed costs will be paid upfront by the GPOBA (W3). The balance of reimbursement will be paid after delivery of services and verification i.e. number of educational/promotional activities, areas of coverage, and number of new pregnant women added to the program during the quarter. Payments to SOUL will be based on cost recovery of fixed costs and agreed costs for the promotional/education & awareness campaign activities. SOUL will be reimbursed for 100% of these costs if it meets targets 4 and 5. SOUL will be subject to a sliding scale payment if it fails to meet the performance indictors (to be defined in the operations manual). Page 15 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 15 B.3. Project Cost and Financing Plan The estimated total project size is US$7.5 million and will be split into two phases (see Table 4): ¾ Phase one (year 1): design and implementation of pilot program ¾ Phase two (years 2-4): revision and expansion of the program by establishing additional satellite clinics in the two districts and possibly in other eligible districts Table 4: Project Cost and proposed GPOBA schedule of payments (US$) Year 1 Year 2 Year 3 Year 4 Total Program preparation start-up costs 38,500 - - - 38,500 Number of Satellite Clinics 4 8 10 12 Satellite clinics capital costs ($35,000 per clinic) 140,000 140,000 70,000 70,000 420,000 Number of beneficiaries 4,800 9,600 12,000 14,400 40,800 Funding of service provider costs for mother-baby package 720,000 1,440,000 1,800,000 2,160,000 6,120,000 Implementation Unit admin costs 87,900 87,900 87,900 87,900 351,600 Educational and awareness campaigns 48,500 48,500 48,500 48,500 194,000 Fiduciary agent 20,000 20,000 20,000 20,000 80,000 Auditing fees 15,000 15,000 15,000 15,000 60,000 Independent Verification Body fees 25,000 25,000 20,000 20,000 90,000 Annual Supervision and External Monitoring and Evaluation (GPOBA) 55,000 55,000 55,000 55,000 220,000 Total Use of Funds 1,149,900 1,831,400 2,116,400 2,476,400 7,574,100 GPOBA 1,007,900 1,617,400 1,866,400 2,190,400 6,682,100 Service Providers (SGH & USTH) 70,000 70,000 70,000 70,000 280,000 User fees 72,000 144,000 180,000 216,000 612,000 Total Source of Funds 1,149,900 1,831,400 2,116,400 2,476,400 7,574,100 Package Unit Cost 150.00 150.00 150.00 150.00 Implementation Unit admin costs per Unit 18.31 9.16 7.33 6.10 Educational and awareness campaigns per Unit 10.10 5.05 4.04 3.37 Other costs per Unit 23.96 11.98 9.17 7.64 Grand Total 202.38 176.19 170.53 167.11 Program preparation start-up costs US$ Baseline study (consultant+staff training+field work expenses) 13,400 Eye print/finger print equipment + installation 8,247 Furniture & equipment 8,990 Staff salaries for 2 months (4 people) 7,800 Total start up costs 38,437 Use of Funds Source of Funds Page 16 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 16 Satellite Clinic Capital Cost US$ Renovation 500 Furniture 2,052 Share in Ambulance Cost 8,333 Medical Equipment 9,660 Eye/Finger Equipment 8,500 Instruments 435 Linen Items 123 Office Equipments 2,484 Contingency 3,000 Total capital cost per satellite clinic 35,087 Financial Model Assumptions · During the first year two districts in Sana’a will be selected in consultation with service providers and Ministry of Health. · Four satellite clinics in year 1 increasing to 12 by year 4. In Year 1 and 2, GPOBA to share satellite clinics establishment costs 50:50 with service providers. Services providers will be reimbursed for the 50% capital cost once certain defined performance indicators (to be specified in the Operations Manual) have been met. · Each month, each satellite clinic will add 100 new pregnant women (in their first trimester) to its outpatient database. · Each pregnant women will receive the antenatal care package for a price capped at US$60 to be charged over a period of 6 months (1/6 each month). · Starting month 6, the clinic will oversee 100 new deliveries per month assuming 15% C-section to be referred to the relevant hospital, 60% to be delivered at the clinic and 25% to be delivered at home. · Post delivery, each mother will receive the postnatal care package for a price capped at US$20 to be charge over a period of 1 month. · Price for deliveries was assumed to be as follows: US$400 for C-section, US$30 for normal delivery at the clinic, US$20 for normal delivery at home. Cost of C-section at the level of the hospital was assumed to be 85% of the price i.e. US$340. · Satellite clinics to be run as profit centers, operating costs to be borne by the satellite clinics and a maximum profit margin (if any) of 5% is allowed. · SOUL administrative costs include administrative staff costs (US$4,200 per month for 5 people), field work staff costs for women identification (US$1,700 for 8 people per month), US$9,000 per year for follow up and evaluation activities, documentation, and capacity building, and 10% contingency. · Education and awareness campaign costs include material cost of US$12,750 per year and field work staff costs (average US$2,600 per month for 25 people), and 10% contingency. B.4. Economic and financial analysis IRR Page 17 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 17 Based on the financial model assumptions above and projected cash flow statement for satellite clinics, the estimated IRR amounts to 11%. Economic cost effectiveness of maternal interventions: Improvements in the quality of prenatal and delivery care are well documented as being cost-effective interventions (US$2,729 to US$5,107 per death averted and US$82 to US$142 per DALY averted). Improving the quality of care and expanding coverage of services are also of comparable cost-effectiveness (The Disease Control Priorities in Developing Countries, 2 nd Edition, 2006 - based on extensive primary research and systematic reviews of available research). Economic and Financial Analysis of the Program A preliminary analysis was conducted based on secondary research and the Program’s cost assumptions. Based on these findings, it was deemed that a quantitative economic and financial analysis of the Program would not provide useful insights into the program, primarily as there are minimal revenue streams (minimal user fees of US$15 per patient) as compared to the per patient investment of US$150 made by GPOBA. However, it is noted from a cost perspective, the package price agreed upon with the service providers is deemed reasonable based on the comprehensiveness of the services to be provided in the Program and the high quality as compared to existing services and pricing thereof. (see Table 1). From an economic analysis standpoint, the primary benefits can be named qualitatively, but would require far more comprehensive data (including data from household surveys) in order to estimate quantitatively. These economic benefits include expenditure benefits or possible costs savings to patients to the extent that the targeted women are currently incurring formal and informal out of pocket expenditures depending on whether deliveries and pre-and ante-natal care take place at home or at current facilities. In the absence of detailed pricing and household spending data, quantifying these expenditure benefits and conducting a robust analysis is not feasible. Other potential benefits identified include productivity gains (less productive time lost) due to better health during pregnancy and better post-partum care, welfare gains from the targeted women who are effectively provided emergency obstetric care insurance through this program and the welfare benefits of education and dissemination of information regarding safe motherhood. B.5. Lessons Learned ¾ Importance of good local committed partners ¾ Encouraging ownership of the program by local partners – IFC and GPOBA play role of facilitator ¾ Importance of understanding local sector context (public and private) ¾ Importance of understanding local culture and how this influences local health needs, demand and health seeking behavior Page 18 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 18 ¾ Ensure design of program is based on realities on the ground ¾ Importance of transparency and open dialogue B.6. Alternatives considered and rejected The project has two key differences from the project as described in the original concept note: Voucher scheme: The merits of a voucher scheme were considered and then rejected as adding an unnecessary level of complexity and costs to the overall project. Provision of package of services at level of private hospitals: This model was rejected as being not feasible nor best suited to the needs of target population. A community based approach was instead adopted which has greater potential of increasing access and utilization at community level and will be more cost- effective. C. IMPLEMENTATION C.1. Milestones for project implementation Milestone Expected completion GPOBA provides panel endorsement June 2007 GPOBA provides subsidy commitment July/August 2007 Final tender documents (as relevant) July/August 2007 Bids received, evaluated and fiduciary agent appointed August/September 2007 GPOBA Grant Agreement signed End September 2007 Implementation agreement signed End September 2007 GPOBA (W3) disbursement begins October 2007 Services start at satellite clinics January 2008 Services start at hospital January 2008 GPOBA disbursement ends September 2011 C.2. Local Partners and implementation arrangements C.2.1. Project Implementation Unit: SOUL, a local Yemeni NGO, will be the project implementation unit. Its key responsibilities include: (i) community outreach, education (including family planning and good nutrition practices) and targeted program promotion activities in the identified communities. This will include definition of clear eligibility criteria and active targeting and recording of eligible women using eye-scanning/finger printing technology (ii) Page 19 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 19 ongoing monitoring and evaluation that will include creating a database of basic data of eligible women for the program, conducting regular visits to the service providers and communities, conducting patient and family satisfaction surveys The Yemeni NGO SOUL was selected based on short listing of four Yemeni NGOs working in maternal care and having sufficient capacity for this program, and were identified as eligible and assessed using the criteria specified in the procurement annex 4. Contractual arrangements of SOUL to deliver on the above mentioned services would be with Fiduciary Agent, based on definition of responsibilities in Operations Manual as defined by GPOBA. C.2.2. Service Providers: The selected private providers will establish, manage and operate satellite clinics in the targeted districts providing clearly defined primary and secondary level maternal care services to recipients of the program. Those women who require complicated or tertiary care services would be referred to private hospitals for complicated care. During an IFC appraisal conducted last year, an assessment of the private health sector and private hospitals in Sana’a was conducted. Based on the criteria specified in the procurement annex 4, only two private Yemeni hospitals, the Saudi German Yemen Hospital (SGH) and University of Science and Technology Hospital (USTH) were identified as meeting all the criteria and hence appropriate service providers for the first phase of this program. Further, currently and in general, the private health sector in Sana’a is mostly characterized by sub-standard quality services and facilities, have limited capacity and there is a paucity of qualified staff, equipment and supplies. Also, and importantly, the local communities were noted to have low confidence in these facilities and staff. It is envisioned that at a later stage, should the program be scaled up, other providers may become eligible and could participate in the program through a competitive process. This would apply for example to certain providers that were interested in the program but currently lack capacity or do not meet the quality standards. In the future, should these providers’ facilities be expanded and standards be upgraded, such providers could become eligible. Contractual arrangements of private service providers would be with the Fiduciary Agent, based on definition of responsibilities in Operations Manual as defined by GPOBA . The hospitals will be required to keep standardized medical records and provide them upon request. The private providers will bear the operational risks of the program as they will be reimbursed retrospectively post service delivery. C.2.3. Fiduciary Agent/External Auditor/Independent Verification: Page 20 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 20 An independent credible organization will be contracted by GPOBA to verify hospital records and invoices and manage the flow of funds. The Fiduciary Agent will be responsible for procuring the External Auditor and the Independent Verification Expert. Annex 4 provides the procurement requirements for the selection of these roles. C.2.4 Joint Technical Committee: A small Joint Technical Committee comprising the main representative (and one alternative) of each of SGH, USTH and SOUL was established as an interim structure to co-ordinate and manage the early set-up and implementation of the project. C.3. Reporting and Monitoring and Evaluation of outcomes Reporting: All providers will be contractually required to provide regular progress reports including exception reporting/implementation difficulties and achievement of performance indicators. GPOBA is in the process of finalizing the FM and reporting requirements and is awaiting clearance from the FM specialist. Once financial management, fund flows and reporting agreements are finalized they will be included. Monitoring and Evaluation: There will be five elements of monitoring and evaluation: ¾ monitoring and evaluation by an independent assessor after one year (this function may be outsourced to an independent consultant and be guided by availability of appropriate expertise); ¾ self-monitoring and evaluation by the service providers and maintenance of records linked to performance indicators; ¾ ongoing monitoring, evaluation and revisions by the Joint Technical Committee, comprised of two service providers and SOUL, in consultation with GPOBA/IFC on a no objection basis; ¾ monitoring and evaluation of the facilities and services for the purpose of accreditation by independent national/regional healthcare accreditation bodies; and ¾ monitoring and evaluation by the project implementation unit SOUL will be responsible for collating baseline data (including current utilization behavior) from communities during targeting and promotion activities, conducting surveys and comparison to baseline data and overall ongoing monitoring of the program. It will provide regular reports to GPOBA on overall program performance including quality of clinic and hospital service (based on random visits and patient and family satisfaction surveys, accuracy of targeting and utilization rates by targeted women and possible incidences of fraudulent behavior or abuse of the program. SOUL will also liaise with service providers and monitor clinical performance indicators e.g. percentage of births attended by skilled birth attendants. Disbursement of the GPOBA subsidy is subject to verification of the performance indicators by the independent verification expert. Based on approval of outputs by IVE, Page 21 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 21 the FA will release funds as will be specified in the Operations Manual and implementation agreements for the project. After the first six months, the progress of the pilot program will be reviewed and evaluated by the Joint Technical Committee and GPOBA/IFC and revised accordingly. C.4. Sustainability It is anticipated that successful implementation of the first phase may attract local private large corporate companies e.g. oil and industrial groupings to participate in the program. Specifically, it could provide a good demonstration of how private businesses in Yemen could make investments that are socially responsible and contribute to the health of poorer communities. At a later stage, the pilot may serve as a model that may be adopted by the Government of Yemen as well as attract other bilateral/multilateral donors and healthcare and finance providers to ensure sustainability. Further, as currently designed, the satellite clinics will be run as profit centers. The providers have agreed to deposit any profits in excess of 5% margin into an escrow account/fund to be used to fund any legitimate unexpected cost-overruns in the short-run e.g. larger than estimated percentage of women requiring more expensive complicated and tertiary care. In the long run, the main purpose of these funds would be to serve as a ‘sustainability fund’ that could attract co-financing. Scaling up of the Project: A successful first phase will also provide lessons for scale-up and replication of the program. It is expected that the program will first be scaled up within districts in Sana’a during early years and depending on progress, outcomes achieved and lessons learned, consideration given to scaling up to other surrounding governorates in Yemen. C.5. Critical risks Risk Mitigation Affordability and willingness to pay by customer Minimum user fees and inclusion of nutritional component (to attract and increase utilization) Reluctance of population to accept and use services SOUL through outreach, education and marketing campaigns will reach out to the target population Lack of qualified staff/capacity within NGO or service providers Initial model realistically designed considering current resources and capacity and feasible scale up options. Relevant capacity building could be envisaged after phase 1 Page 22 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 22 Inadequate control systems within the NGO External financial and organizational audit Collusive behavior of patients and service providers Service providers will be required to keep standardized medical records and provide them upon request for auditing. Random audit of claims database in order to identify claims patterns that might suggest collusive behavior Inaccurate targeting or use of the program by non-targeted Mitigation measures are being explored to track identities of targeted communities e.g. fingerprinting/eye scan with coded cards provided to women Measurement/verification of outputs Initial local research and implementation of program to aid establishment of baseline data. Tracking of defined performance indicators. Five elements of monitoring and evaluation and reporting by all. Review after first six months and detailed evaluation after one year Page 23 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 23 ANNEX 1. PROJECT COSTS & SCHEDULE Expenditure categories Local (US$) Foreign (US$) Total Cost (US$) Projected subsidy expenditure (GPOBA W3) 0 6,193,600 6,193,600 Program preparation start- up cost (W3) 38,500 38,500 GPOBA supervision 0 220,000 220,000 Fiduciary agent, independent verification and audit (GPOBA W3) 0 230,000 230,000 Total costs 0 6,682,100 6,682,100 Page 24 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 24 ANNEX 2. FINANCIAL MANAGEMENT Financial management clearance is forthcoming in the week June 4th, 2007. Page 25 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 25 ANNEX 3. DISBURSEMENT PLAN Services Invoiced Capital Costs Start up cost P rogram Administartion costs Signing of agreements 3 months later $35,000 at commissioning of satellite clinics 6 months later 1 First assessment covering Q1 of operations Payments based on Perfomance indicators for Q1 $35,000 if performance indicators are met. If not payment postponed to next IVA assessment Payments based on Perfomance indicators for Q1 9 months later 2 100% of invoices of Q2 100% of invoices of Q2 12 months later 3 Second assessment covering Q2 & Q3 of operations Payments based on Perfomance indicators for Q3 and adjustment to be made for Q2 payments Payments based on Perfomance indicators for Q3 and adjustment to be made for Q2 payments $38,500 Time Establishment of satellite clinics S ervice Providers (SGH & USTH) SOUL I VA Assessment # Quarter of operations # Page 26 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 26 ANNEX 4. PROCUREMENT A. General GPOBA will carry out the procurement of the Fiduciary Agent for the proposed project. The Fiduciary Agent will be responsible for procuring the External Auditor and the Independent Verification Expert. Project procurement will be conducted in accordance with the World Bank’s “Guidelines: Procurement under IBRD Loans and IDA Credits” dated May 2004, and the “Guidelines: Selection and Employment of Consultants by World Bank Borrowers,” both dated May 2004, and the provisions stipulated in the Grant Agreement. The general description of various contracts under different expenditure categories is below. B. Procurement Arrangements B.1. Yemeni NGO: The NGO will be responsible for community outreach, marketing and promotion of the program to the targeted communities. This function will include defining selection criteria for recipients of the program, actively identifying and targeting these recipients and conducting targeted community education campaigns as well as regular ongoing monitoring and evaluation of the program. It was decided that a local Yemeni NGO would be best placed to provide the above services given the nature of the program. Four Yemeni NGOs working in maternal care and having sufficient capacity for this program were identified as eligible and assessed using the following key criteria: ¾ Knowledge, competency levels, relevant experience in working with local Yemeni women from poorer communities including understanding of local culture, maternal and reproductive health issues and health services and research experience ¾ Local Reputation ¾ Independence and apolitical nature of organization including governance structures and financing sources ¾ Commitment and interest in participating in the program Based on the above criteria, SOUL was selected as the local NGO that best met with all the above criteria. In addition, two of the other NGOs were noted to have strong political affiliations and the third NGO was noted to have undergone recent acrimonious senior management changes and there were also some reputational concerns. The table below summarizes the findings of IFC field appraisal, exhibits the scoring of the NGOs against each of the selection criteria and shows the final ranking of the NGOs. Page 27 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 27 Criteria Max Points SOUL Assaleh Foundation for Development Family Care Association Islah Charitable Association Relevant Experience 35 30 20 25 25 Local Reputation 25 23 15 10 20 Independence 20 20 - 20 - Commitment and Interest in the program 20 20 10 10 18 Total Score 100 93 45 65 63 The good reputation and selection of SOUL was further endorsed by independent positive feedback received from a range of Yemeni stakeholders ranging from Government to private providers during a recent appraisal trip to Sana’a. B.2. Private Healthcare Providers (PHP) Based on the role required, the following selection criteria were defined: ¾ High quality of health facilities and services provided ¾ Availability of qualified staff ¾ Availability of quality equipment and supplies ¾ Capacity – staff and facilities ¾ Experience and knowledge of maternal care services ¾ Local knowledge of Yemeni maternal health issues ¾ Willingness to negotiate prices of services and offer cost-effective package pricing ¾ Commitment to development impact and interest in participating in this program During an IFC appraisal conducted last year, an assessment of the private health sector and private hospitals in Sana’a was conducted. Based on the above criteria, only two private Yemeni hospitals, the Saudi German Yemen Hospital and University of Science and Technology Hospital were identified as meeting all the criteria and hence have been selected as the appropriate service providers for the first phase of this program. A recent market survey conducted by IFC and a local NGO in Sana’a, based on the Mother-Baby package of services per client at the hospital level, estimated that average treatment costs per patient ranged from US$34 to US$65 for antenatal care, from US$68 to US$180 for normal delivery, and from US$298 to US$750 for emergency caesarian sections. Average costs per patient for treatment of anaemia, syphilis and gonnorrhoea were US$13 each. Internationally, the package pricing was also comparable e.g. costs of similar quality services by similar quality providers in India range from US$ 350-1,500. Summary of costs from five Yemeni hospitals (US$) Azal Hospital Saudi German Hospital UST Hospital German Yemen Hospital Mother Hospital Page 28 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 28 Antenatal Care 54 57 64 64 34 Delivery 155 180 149 180 68 Family Planning 18 29 20 20 12 Basic Package 227 266 233 264 114 C-Section 300 750 390 450 298 Weighted Average Cost 242 363 264 301 151 Quality and capacity assessment Poor quality of current facilities Good Good Lack of capacity Low quality care The table below summarizes the findings of IFC field appraisal, exhibits the scoring of the service providers against each of the selection criteria and shows the final ranking of the hospitals. Criteria Max Points SGH Azal Hospital USTH German Yemen Hospital Mother Hospital Quality of health facilities/ service provided 30 28 15 25 20 10 Availibility of qualified staff/ quality equipment 20 18 10 15 10 7 Capacity - (Staff & facilities) 15 15 - 13 5 - Local knowledge 10 5 10 8 8 10 Corporate social responsibility 10 9 - 8 - - Cost effictiveness 15 6 9 9 8 15 Total Score 100 81 44 78 51 42 Further, currently and in gene ral, the private health sector in Sana’a is mostly characterized by sub-standard quality services and facilities, have limited capacity and there is a paucity of qualified staff, equipment and supplies. Also, and importantly, the local communities were noted to have low confidence in these facilities and staff. A detailed appraisal and costing analysis of the service providers was conducted by the IFC appraisal team. The appraisal was conducted in Sana’a in September 2006) and May 2007 (Safe Motherhood program appraisal). A package price of US$150 was subsequently negotiated and agreed with the two selected service providers. While the package price agreed by the two providers is within range of pricing of other private Yemeni providers, the quality (services, staff, facilities, equipment) and capacity of the two service providers’ far exceed that of the other local hospitals. The contract documents for the Private Healthcare Providers will include performance specifications for the services, as will be specified in the Operations Manual and the Implementation Agreement. Page 29 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 29 It is envisioned that at a later stage, should the program be scaled up, other providers may become eligible and could participate in the program through a competitive process. This would apply for example to certain providers that were interested in the program but currently lack capacity or do not meet the quality standards. In the future, should these providers’ facilities be expanded and standards be upgraded, such providers could become eligible. B.3 Fiduciary Agent An independent credible organization will be contracted by GPOBA to verify hospital records and invoices and manage the flow of funds. GPOBA will disburse funds directly to the Fiduciary Agent which will disburse funds to the hospitals and the Yemeni NGO as per the contractual arrangements. The Fiduciary agent will be contracted post commitment approval through a competitive process in compliance with World Bank procurement guidelines. Detailed Terms of Reference for the Fiduciary Agent would be elaborated for appraisal. B.4 Independent Verification Expert The Fiduciary Agent with the Bank prior approval will hire an individual short term consultant or team of consultants to fulfill the work of the Independent Verification Expert. The Bank’s guidelines: Selection and Employment of Consultants by World Bank Borrowers,” dated May 2004 section 5 would be followed. B.5 Auditor The auditor will be competitively selected by the Fiduciary Agent. The Auditor will be selected according to the procedures agreed upon with the Government of Yemen. The audit review would be conducted annually and audit report will be submitted to the Bank before the end of each year C. Procurement Plan The procurement and consultant selection methods, estimated costs, prior review requirements, and time frame have been agreed upon. A detailed procurement plan would be included in the Operations Manual. D. Prior Review All contracts above US$ 50,000 are subject to Bank’s prior review all other contracts would be subject to post review. E. Operations Manual(OM) The Operations Manual (OM), prepared by GPOBA, will define the responsibility of each of the parties. The OM, as agreed between the Fiduciary Agent (FA) and GPOBA, will specify the terms for the contractual arrangements between: 1. GPOBA and the Fiduciary Agent (Grant Agreement) 2. FA and the External Audit (Consulting Agreement) 3. FA and the service providers SGH and USTH (Implementation Agreement) Page 30 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 30 4. FA and SOUL (Implementation Agreement) 5. FA and Independent Verification Expert (Consulting Agreement) The envisioned structure for the contractual arrangements is as follows: GPOBA Fiduciary agent Service Providers SGH & USTH SOUL Targeted Women (beneficiaries) External Audit Independent Verification Outreach and Ma rketing Service delivery Page 31 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 31 ANNEX 5. ENVIRONMENT AND SOCIAL SAFEGUARDS The project does not trigger the World Bank social safeguard policies (OP 4.10 and OP 4.12) as the project does not involve acquisition of land nor affects Indigenous Peoples (the satellite clinics will be located in Sana’a). Environment Assessment: Awaiting clearance by IFC Environment specialists. A formal statement from IFC will be provided that documents its due diligence process and any conditions imposed on the project to ensure compliance with all applicable IFC Performance Standards (such as the project Action Plan). Such compliance statement will be in lieu of compliance with the Bank safeguard policies, and will be for internal use by GPOBA only unless otherwise agreed with IFC, and will be treated as a deliberative document by GPOBA and IFC under their disclosure policies. Page 32 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 32 ANNEX 6. RESULTS FRAMEWORK AND MONITORING MECHANISM Based on approval of outputs by independent verification expert, the Fiduciary Agent will release funds as will be specified in the Operations Manual and implementation agreements for the project. Main output: To achieve approximately 40,800 safe child birth deliveries attended by skilled birth attendants amongst the target population over the project period. Page 33 GPOBA Commitment Paper: Queen of Sheba Safe Motherhood Program Yemen June 20, 2007 33 ANNEX 7. PROJECT PREPARATION & SUPERVISION Institutions responsible for project preparation: 1) IFC (GPOBA) 2) SGH and USTH: Primary contacts: Dr. Salah Hamed (SGH), Prof. Dr. Husni Al-Goshae (USTH) 3) Implementing agency: SOUL Primary contact: Dr. Arwa Yahya Al-Deram World Bank Group team Name Title Unit Carmen Nonay TTL GPOBA Olaf Smulders STC GPOBA Samantha Naidoo Investment Officer IFC Salah-Eddine Kandri Senior Investment Officer IFC Mikael Sehul Mengesha Procurement Specialist WB Jamal Abdulla Abdulaziz Procurement Specialist WB Josephine Masanque FM Specialist WB Ai Chin Wee Senior Operations Officer WB Meskerem Brhane Senior Social Development Specialist WB Ghada Youness Legal Staff WB Disbursement Lars Johannes Peer Reviewer GPOBA Advisory Team: Name Title Role Unit Patricia Veevers- Carter Program Manager Peer Review/ Advisory GPOBA/FEU Irving Kuzynski Panel of Experts Advisory GPOBA Alejandro Jadresic Panel of Experts Advisory GPOBA