PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: PIDA764 Public Disclosure Copy Project Name Liberia Health Systems Strengthening (P128909) Region AFRICA Country Liberia Sector(s) Central government administration (10%), Health (90%) Lending Instrument Specific Investment Loan Project ID P128909 Borrower(s) Ministry Of Finance Implementing Agency Ministry of Health and Social Welfare Environmental Category B-Partial Assessment Date PID Prepared/Updated 27-Feb-2013 Date PID Approved/Disclosed 28-Feb-2013 Estimated Date of Appraisal 01-Mar-2013 Completion Estimated Date of Board 30-May-2013 Approval Decision I. Project Context Public Disclosure Copy Country Context 1. Fourteen years of civil war destroyed Liberia’s basic infrastructure. The years of civil war (1989 - 1997 and 2001 - 2003) left Liberia one of the poorest countries in the world. The country’s level of poverty soared to 64 percent in 2003, and the Gross Domestic Product (GDP) per capita declined to approximately US$151 from a peak of US$1,217 in real terms in 1981. The war had a devastating effect on many of the systems that contribute to good health: basic housing, water, electricity, sanitation, roads, education, and health care. 2. Liberia remains fragile, but there are signs of improvement. According to the 2011 UNDP Human Development Report’s Human Development Index (HDI), Liberia ranked 182nd out of 187 countries, and 13th out of the 15 ECOWAS member countries included in the report. Average life expectancy in Liberia is 56.8 years - up from 42 years at the end of the civil war (WHO 2006), the adult literacy rate is 55 percent and the combined gross school enrollment is 57 percent. Liberia’s 2011 Human Development Index (HDI) of 0.329 is below the average of 0.456 for countries in the low human development group, and below the average of 0.463 for countries in Sub-Saharan Africa. 3. Liberia has begun the transition from humanitarian aid to development. Despite overwhelming challenges, the Government of Liberia (GoL)- with support from its development Page 1 of 7 partners- has begun the transition from emergency rehabilitation to development. This process has been aided by relative political stability, significant donor contributions, and strong annual economic growth averaging 6.4 percent per year from 2004 to 2008. Once, and still, a country rich Public Disclosure Copy in natural resources, it is only beginning its recovery from a 90 percent decline in its gross national income (GNI) per capita that occurred between 1987 and 2003. Liberia’s 2010-estimated per-capita GDP was US$247- almost 40 percent higher than at the end of the war. Liberia also recently completed the Heavily Indebted Poor Countries process, and a total external debt burden of US $4.6 billion (equivalent to 800 percent of GDP) was cancelled by June 2010. II. Sectoral and Institutional Context 4. The civil war destroyed Liberia’s health system. Much of the physical infrastructure and equipment that was crucial to the health sector was destroyed during the war- many hospitals and clinics were burned to the ground, very few county hospitals had fully functional laboratories, most county hospitals and health centers were without running water, electricity, or functioning basic sanitary systems, and many health professionals, especially physicians, left the country, resulting in a severe shortage of human resources. An already dire situation was further aggravated by a lack of transportation and other communication systems, and reflected in limited access to health services by 41percent of the population. 5. Despite impressive gains in overall health systems management and in health services delivery since the end of the war, Liberia continues to face significant challenges in improving maternal and child health outcomes, as well as other health-related Millennium Development Goal (MDG) outcomes. Post-conflict conditions place Liberia at the bottom of global rankings for maternal and child health (MCH). The maternal mortality ratio (MMR) remains high, but has declined from close to 1000 per 100,000 births in 2007, to an estimated 770 per 100,000 in 2010. Gains, however, remain skewed in favor of urban populations. For example, 63 percent of deliveries in urban areas are facility-based compared with 25 percent in rural areas; similarly 77 percent of urban deliveries are by a skilled service provider compared with only 32 percent of rural deliveries. Public Disclosure Copy While over one in ten children will die before the age of five, infant and under five mortality rates have almost halved to 71 and 110 per 1,000 births respectively over the last 20 years due to improved access resulting from the GoL’s free health care (FHC) policy , and restoration of a number of key child health services like immunizations. Malaria, however, continues to be a major source of morbidity and mortality; 38 percent of outpatient attendance and 42 percent of inpatient deaths was attributable to malaria in 2007. 6. Health financing constraints and sustainability are significant concerns. As Liberia’s health system continues its recovery from the devastating effects of the recent civil war, the direction and incentives of recovery efforts have shifted from those supporting emergency humanitarian relief to those aiming to develop sustainable systems of service delivery. External assistance from multilateral and bilateral donors, as well as from international NGOs, has been substantial in supplementing the resources of the GoL. Thus, while the GoL’s budgetary allocation to health has now reached about US$12 per capita per year (roughly 9 percent of the total government budget), external assistance is estimated to account for roughly three times that much. According to the 2007/8 National Health Accounts (NHA), 72 percent of total health institutional expenditure (THIE) came from donors. Donor funding increased to 85 percent of THIE by 2009/10. Most of these external funds were- and continue to be- directed to the primary health care (PHC) level. While total health expenditures in Liberia are substantial, the GOL and Ministry of Health and Social Welfare (MoHSW) are very likely to remain critically dependent on external assistance in the medium term Page 2 of 7 (and even long term)—and are likely to need such assistance to meet the estimated costs of implementing the 10-year National Health and Social Welfare Policy and Plan (NHSWPP) 2011-2021, and the country’s free health care policy. Public Disclosure Copy 7. Despite high estimates of total national health spending per capita, present inefficiencies in resource allocation undermine the overall ability to improve the quality of care at secondary hospitals. Whilst a majority of external funding goes to the PHC-level (including from USAID and pool fund donors), there has been some concentration of public health system resources at JFK Hospital, the country’s only tertiary (referral and teaching) hospital. Specifically, 23 percent of the total health sector budget was allocated to JFK Hospital in 2009/10 and 19 percent in 2010/11. It accounts, on average, for roughly three-fourths of all resources devoted to inpatient services. Given an expansion of access at health clinics and health centers to low cost and high impact interventions, as well as continued and focused public financing to the tertiary level, the next significant challenge in improving health outcomes, is improving the coverage of quality services at rural and semi-urban secondary-level hospitals. Currently, however, hospitals receive no major support from external donors. 8. Improving the quality of care at hospitals is a key next step in rebuilding Liberia’s health system. Hospitals in Liberia remain in generally poor physical condition; are understaffed with insufficient numbers of productive, responsive, and competent staff in key areas of competence; and, have long waiting times and a lack of equipment and drugs. As a consequence, hospitals in general provide low quality of care. This is reflected in high levels of post-surgery complications and infection rates; low quality data on clinical outcomes, very limited maternal and child death audits; and no systematic use of clinical guidelines and protocols. Notably, accreditation scores on the quality of services are worse in secondary vis a vis primary facilities. Poor quality is a particularly critical concern at the severely resource-constrained hospital-level in Liberia because it can obviate all the implied benefits of good access and effective treatment, frustrate the positive achievements at the primary health care system by not being able to respond to referral patients with Public Disclosure Copy complications, and lead to sub-optimal and wasteful use of resources. 9. A core challenge to improve the quality of service delivery at the hospital level, is the shortage of higher level health worker cadres, in particular outside of Monrovia. Liberia is home to approx. 0.5 doctors, nurses and midwifes per 1000 population, far below the World Health Organization’s (WHO) 2.3 per 1000 benchmark associated with achieving an 80 percent coverage rate of deliveries. Whilst the number of lower level cadres, particularly nurses and midwives has been steadily increasing since 2000 (due to concerted investment into their production and work at primary care levels), growth in the number of physicians remains low. Low levels of production (approximately 10-15 physicians annually) together with high rates of earlier outmigration (63.3 percent are estimated to have previously migrated abroad) help to explain why only about 90 medical doctors (0.03 per 1000 population) were counted in a health worker census in 2009. Moreover, perhaps not surprisingly given rural/urban disparities in health outcomes, a significant number of higher level health cadres (particularly doctors) work in the country’s capital, Monrovia (Montserrado county). Consequently, hospitals and health facilities outside of Montserrado face the brunt shortage of medical doctors, coupled with significantly worse physical infrastructure and equipment at health facilities. Whereas Montserrado County for example, is home to 48 medical doctors – with more than half of which are located in the urban teaching hospital in Monrovia (JFK hospital), neighboring counties such as Bong and Margibi have only 5 and 4 physicians, respectively, and rural marginalized counties such as Lofa, Nimba and Maryland have 9, 5 and 6 Page 3 of 7 physicians respectively. 10. Another critical health system challenge at the level of hospitals is the lack of health Public Disclosure Copy workers with certified skills and competencies to treat maternal, neonatal and child health (MNCH) complications. Physicians and other health workers lack the basic skills required to adequately treat complicated MNCH cases at the hospital level. At present, there is a virtual absence of qualified obstetricians, pediatricians, surgeons or infectious disease physicians in Liberia. This situation stems from both a shortage of academic teaching faculty, and the absence of a formalized and accredited medical residency program which can enable medical school graduates to become board certified in particular clinical priority areas, especially the MDG-related areas of pediatrics, obstetrics and infectious disease, as well as surgery. The lack of specialized MDG-related faculty also restricts other low-level health cadres (including nurses, midwives and physician assistants) from upgrading their competencies to include more complex, hospital relevant skill sets through in- service training. At present, professional development opportunities are often ad hoc, and follow donor program priorities such as HIV/AIDS and Malaria. Aside from the resulting skills shortage, there is global evidence that a lack of opportunities for health workers to professionally advance their skills and careers is linked to both outmigration (as medical graduates pursue training abroad), and overall reduced health worker motivation (affecting the extent to which health workers apply themselves to their job and task at hand). 11. In order to improve the efficiency, effectiveness, and quality of care at the secondary hospital level, the country is developing a system to upgrade health worker skills and competencies, and shifting towards improved provider-accountability for results (i.e. improved quality of care). The MOHSW is tasked to develop a Graduate Medical Residency Program (GMRP) to facilitate in- country specialization of core MDG-related hospital-level competencies for recent medical school graduates, as well as physicians currently employed in the labor market. This process requires both a critical stream of specialist faculty to support the program, as well as upgrading teaching facilities. In addition to the development of an MDG-related GMRP, the GoL is also moving towards Public Disclosure Copy provider-accountability for improvements in quality through performance-based financing (PBF) at the hospital level. The shift towards PBF is influenced by experiences in a number of high, middle and low-income countries that performance-based approaches, in which providers receive incentives based on performance, can improve provider accountability for improved quality of health services. Evidence shows that performance-based approaches can be effectively deployed to: (i) clearly signal health priorities and ensure that there is adequate focus on corresponding interventions; (ii) ensure that health facilities focus on delivering targeted and cost-effective health services; (iii) strengthen monitoring and evaluation systems; (iv) empower decision-makers in the field to set priorities and improve health facilities according to more local needs; (v) motivate staff to change behavior and improve performance; and, (vi) increase provider autonomy and enhancing accountability for better results. The latter can stimulate innovations in an effort to overcome implementation constraints. 12. Liberia does have experience with performance-based approaches, but hospitals have been left behind. It is important to note that performance-based approaches are not new to Liberia. Rather, most donors have supported Performance-based contracting (PBC) (using implementing partners) at the primary care level. In fact, about 65 percent of primary-level facilities receive financial and other support from USAID, the Pool Fund donors and the European Union (EU) through this modality. Conversely, as previously noted, hospitals receive no major support from external donors, and have no performance based incentive schemes (for staff or otherwise) to improve performance, and offset low salary levels and difficult working conditions. As a Page 4 of 7 consequence, the continuing disparities in funding coupled with a weak focus on MDG results at the secondary hospital level, compromises both service delivery and health worker performance. Public Disclosure Copy III. Project Development Objectives The Project Development Objective (PDO) is to improve the quality of maternal health, child health, and infectious disease services in selected secondary-level health facilities. IV. Project Description Component Name Component 1: Strengthening the institutional foundations needed to improve the quality of selected health interventions at target facilities Component 2: Improving health worker competencies to address key health-related concerns at target facilities Component 3: Project Management V. Financing (in USD Million) For Loans/Credits/Others Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) 10.00 Health Results-based Financing 5.00 Financing Gap 0.00 Total 15.00 VI. Implementation 13. The HSSP Coordination Office within the Project Management Unit (PMU) of the MOHSW will have direct responsibility and oversight for overall project coordination and management. Specifically, the HSSP Coordination Office will work closely with the PBF Unit and Public Disclosure Copy GMRP Council (GMRPC) to coordinate the overall project (both the PBF and training components); organize technical support and capacity building (e.g. capacity building of the Liberia Medical and Dental Council (LMDC), and target facilities); and provide overall financial oversight of the project for both the PBF and training components. The HSSP Coordination Office will have direct responsibility for coordinating the procurement of related goods, services, and any civil works at the central level (e.g. international faculties for the training component, and TA). 14. Component 1: Implementation arrangements for improving quality of care through a PBF approach will span three levels - county-level, central-level, and health facility levels, and will ensure that there is separation of functions between: a) the regulator (MOHSW- Dept. of Health Services, and CHSWT at the county-level); b) the fund holder for payment (Office of Financial Management (OFM)); c) the purchaser (MOHSW- Dept of Administration); d) verifiers (LMDC and Community Based Organizations (CBOs)); and, e) providers of health services. The PBF component complements the results-based financing approaches currently being implemented by the Pool Fund, and other donors. 15. At the central level, the PBF Unit will be the technical focal point, and will be expected to work closely with the HSSP Coordination Office, M&E Unit, OFM and other relevant units on oversight, payment, PBF data management, and in facilitating counter-verification. Incentive Page 5 of 7 payments will flow directly from OFM to health providers. In addition, semi-annual counter- verification will be led by 2-3 faculty members hired by the GMRPC. Public Disclosure Copy 16. To safeguard the institutional sustainability introduced by the project (under both components 1 and 2), significant local capacity will be developed over the course of project implementation, including in relevant MOH units (e.g. the Dept. of Administration and PBF unit), LMDC, the specialized and affiliated teaching hospitals, and the GMRPC. 17. Component 2: The GMRPC will be responsible for coordinating and managing the graduate medical residency program, and scaling up teaching capacity. This will ensure that a system is developed which can be seamlessly scaled-up and maintained by local counterparts. Specifically, the GMRPC will be responsible for tasks including the recruitment of faculty, and development of residency curricula and standards. It will be supported by the West Africa College of Physicians and Surgeons, which falls under the authority of the West African Health Organization (WAHO), and the Ghana College of Physicians and Surgeons. They will work jointly to, inter alia, accredit the GMRP nationally, while gradually progressing towards regional WAHO accreditation standards and the Ghana College of Surgeons Accreditation standards. 18. The GMRPC is headed by a President, and includes the Dean of the Liberia College of Medicine (COM), and liaises with the academic chairs in Obstetrics, Pediatrics, Surgery and Infectious Diseases (amongst others), as well as the concomitant chiefs of department at the JFK Teaching Hospital. They will work closely together and with the HSSP Coordination Office and other relevant agencies to develop and implement all key program activities related to the GMRP. This includes: sourcing and hiring of relevant faculty; academic and clinical supervision of faculty and residents; administering rural incentives for rotation; and overall program monitoring including relevant indicators under the PBF quantity and quality checklists. 19. Overall administration of the in-service training sub-component will also fall under the Public Disclosure Copy GMRPC, which, jointly with the LMDC, the representative body for all health professions in Liberia. Specialized Faculty recruited under the GMRP will follow in-service training curricula and guidelines developed by the LMDC. The LMDC is represented in the GMRP Council. The GMRP Council is also tasked with overall coordination and administration of training during project implementation. 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 ✖ Physical Cultural Resources OP/BP 4.11 ✖ Indigenous Peoples OP/BP 4.10 ✖ 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 ✖ Page 6 of 7 VIII.Contact point World Bank Contact: Rianna L. Mohammed-Robert Public Disclosure Copy Title: Senior Health Specialist Tel: 473-2355 Email: rmohammed@worldbank.org Borrower/Client/Recipient Name: Ministry Of Finance Contact: Amara Konneh Title: Minister for Finance Tel: Email: akonneh@mopea.gov.lr Implementing Agencies Name: Ministry of Health and Social Welfare Contact: Dr. W. T. Gwenigale Title: Minister of Health Tel: Email: wtgwenigale@moh.gov 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 Public Disclosure Copy Page 7 of 7