Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD3344 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT PROJECT PAPER ON A PROPOSED ADDITIONAL FINANCING IN THE AMOUNT OF US$200 MILLION (INCLUDING AN IBRD LOAN AND SUPPORT FROM THE GLOBAL CONCESSIONAL FINANCING FACILITY) TO THE HASHEMITE KINGDOM OF JORDAN FOR THE EMERGENCY HEALTH PROJECT June 7, 2019 Health, Nutrition, and Population Global Practice Middle East and North Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Exchange Rate Effective April 30, 2019 Currency Unit = Jordan Dinars (JOD) JOD 0.709 = US$1 US$ = SDR 1 FISCAL YEAR January 1–December 31 ABBREVIATIONS AND ACRONYMS AB Audit Bureau BOD Burden of Disease CPF Country Partnership Framework COA Chart of Accounts CSB Civil Service Bureau DA Designated Account DLI Disbursement-Linked Indicator EA Environmental Assessment ECD Early Childhood Development FM Financial Management GBV Gender-Based Violence GCFF Global Concessional Financing Facility GFMIS Government Financial Management Information System GFSM Government Finance Statistics Manual GOJ Government of Jordan GRM Grievance Redress Mechanism GRS Grievance Redress Service HCI Human Capital Index HNP Health, Nutrition and Population ICU Internal Control Unit IFR Interim Financial Report IPF Investment Project Financing IsDB Islamic Development Bank JEHP Jordan Emergency Health Project JHFR Jordan Health Fund for Refugees M&E Monitoring and Evaluation MOF Ministry of Finance MOH Ministry of Health MOI Ministry of Interior MOPIC Ministry of Planning and International Cooperation NCD Non-communicable Disease NGO Nongovernmental Organization PDO Project Development Objective PHC Primary Health Care POM Project Operations Manual PPSD Project Procurement Strategy for Development STA Single Treasury Account STEP Systematic Tracking of Exchanges in Procurement TA Technical Assistance TOR Terms of Reference UHC Universal Health Coverage UN United Nations UNFPA United Nations Population Fund UNHCR United Nations High Commission for Refugees UNICEF United Nations Children’s Fund USAID U.S. Agency for International Development UVE Utilization Verification Entity WHO World Health Organization Regional Vice President: Ferid Belhaj Country Director: Saroj Kumar Jha Senior Global Practice Director: Timothy Grant Evans Practice Manager: Ernest E. Massiah Task Team Leader(s): Fernando Montenegro Torres Hashemite Kingdom of Jordan Emergency Health Project Additional Financing TABLE OF CONTENTS I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ................................................ 6 II. DESCRIPTION OF ADDITIONAL FINANCING ......................................................................... 11 III. KEY RISKS....................................................................................................................... 17 IV. APPRAISAL SUMMARY..................................................................................................... 18 V. SUMMARY TABLE OF CHANGES .......................................................................................... 27 VI. DETAILED CHANGE(S) ....................................................................................................... 27 VII. RESULTS FRAMEWORK AND MONITORING .......................................................................... 30 The World Bank Jordan Emergency Health Project Additional Financing (P170529) BASIC INFORMATION – PARENT (Jordan Emergency Health Project - P163387) Country Product Line Team Leader(s) Jordan IBRD/IDA Fernando Montenegro Torres Project ID Financing Instrument Resp CC Req CC Practice Area (Lead) P163387 Investment Project GHN05 (9320) MNC02 (399) Health, Nutrition & Financing Population Implementing Agency: Ministry of Planning and International Cooperation ADD_FIN_TBL1 Is this a regionally tagged project? Bank/IFC Collaboration No Original Environmental Approval Date Closing Date Current EA Category Assessment Category 13-Jun-2017 29-Jun-2019 Not Required (C) Not Required (C) Financing & Implementation Modalities Parent [ ] Multiphase Programmatic Approach [MPA] [ ] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Disbursement-Linked Indicators (DLIs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [✓] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [✓] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) Development Objective(s) The Project development objective (PDO) is to support the Government of Jordan in maintaining the delivery of primary and secondary health services to poor uninsured Jordanians and Syrian refugees at Ministry of Health Page 1 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) facilities. Ratings (from Parent ISR) RATING_DRAFT_NO Implementation Latest ISR 16-Oct-2017 10-May-2018 14-Nov-2018 18-Dec-2018 Progress towards achievement of PDO S MU MU MS Overall Implementation Progress (IP) S MU MU MS Overall Safeguards Rating Overall Risk M h S S BASIC INFORMATION – ADDITIONAL FINANCING (Jordan Emergency Health Project Additional Financing - P170529) ADDFIN_TABLE Urgent Need or Capacity Project ID Project Name Additional Financing Type Constraints P170529 Jordan Emergency Health Restructuring, Scale Up Yes Project Additional Financing Financing instrument Product line Approval Date Investment Project IBRD/IDA 24-Jun-2019 Financing Projected Date of Full Bank/IFC Collaboration Disbursement 31-Oct-2023 No Is this a regionally tagged project? No Financing & Implementation Modalities Child Page 2 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) [ ] Series of Projects (SOP) [ ] Fragile State(s) [✓] Disbursement-Linked Indicators (DLIs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [✓] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [ ] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [ ] Contingent Emergency Response Component (CERC) Disbursement Summary (from Parent ISR) Net Source of Funds Total Disbursed Remaining Balance Disbursed Commitments IBRD 36.10 34.92 1.18 97 % IDA % Grants 13.90 13.41 0.49 96 % PROJECT FINANCING DATA – ADDITIONAL FINANCING (Jordan Emergency Health Project Additional Financing - P170529) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFi n1 SUMMARY (Total Financing) Proposed Additional Total Proposed Current Financing Financing Financing Total Project Cost 50.00 200.00 250.00 Total Financing 50.00 200.00 250.00 of which IBRD/IDA 36.10 141.10 177.20 Financing Gap 0.00 0.00 0.00 DETAILS - Additional Financing NewFinEnh1 World Bank Group Financing Page 3 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) International Bank for Reconstruction and Development (IBRD) 141.10 Non-World Bank Group Financing Trust Funds 58.90 Concessional Financing Facility 58.90 COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [ ✔ ] No Does the project require any other Policy waiver(s)? [ ] Yes [ ✔ ] No INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population Contributing Practice Areas Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks Gender Tag Does the project plan to undertake any of the following? a. Analysis to identify Project-relevant gaps between males and females, especially in light of country gaps identified through SCD and CPF Yes Page 4 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or men's empowerment Yes c. Include Indicators in results framework to monitor outcomes from actions identified in (b) Yes PROJECT TEAM Bank Staff Name Role Specialization Unit Fernando Montenegro Team Leader (ADM GHN05 Torres Responsible) Procurement Specialist (ADM Samira Al-Harithi Procurement Specialist GGOPM Responsible) Financial Management Senior Financial Management Jad Raji Mazahreh GGOMN Specialist (ADM Responsible) Specialist Amer Abdulwahab Ali Al- Environmental Specialist (ADM Environmental Specialist GENME Ghorbany Responsible) Social Specialist (ADM Senior Social Development Deborah Beth Berger GSU05 Responsible) Specialist Claire Louise Greer Team Member Operations Specialist GHN05 Concepcion Aisa Otin Team Member Senior Financial Officer FABBK Fatima-Ezzahra Mansouri Team Member Program Assistant GHN05 Maiada Mahmoud Abdel Team Member Finance Officer WFACS Fattah Kassem Natalia Robalino Team Member Senior Counsel LEGAM Takahiro Hasumi Team Member Health Specialist GHN05 Extended Team Name Title Organization Location Page 5 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING A. Introduction 1. This Project Paper seeks the approval of the Board of Executive Directors to provide Additional Financing (AF) in the amount of US$200 million to the ongoing well-performing Jordan Emergency Health Project (JEHP) (P163387) to support the Hashemite Kingdom of Jordan. The proposed AF builds on JEHP performance and rapid implementation progress. The amount of US$200 million is financed by a US$141.1 million IBRD loan and US$58.9 million grant from the Global Concessional Financing Facility (GCFF, see Box 1). Box 1. Global Concessional Financing Facility The GCFF is a partnership sponsored by the World Bank, the United Nations (UN), and the Islamic Development Bank Group (IsDB) to mobilize the international community to address the financing needs of middle-income countries hosting large numbers of refugees. By combining donor contributions with multilateral bank loans, the GCFF enables eligible middle-income countries that are facing refugee crises to borrow at below-regular multilateral development bank rates for providing global public good. The GCFF represents a coordinated response by the international community to the Syrian refugee crisis, bridging the gap between humanitarian and development assistance and enhancing the coordination between the UN, donors, multilateral development banks, and benefitting (host) countries. The GCFF includes Jordan, Lebanon, and Colombia as benefitting countries. The GCFF is currently supported by Canada, Denmark, the European Commission, Germany, Japan, Netherlands, Norway, Sweden, the United Kingdom, and the United States. 2. The JEHP was approved by the Board of Executive Directors on June 13, 2017 and declared effective on July 26, 2017. The financing amount was US$50 million, consisting of a non-concessional portion of US$36.1 million (IBRD loan) and a concessional portion of US$13.9 million (GCFF). In addition, the IsDB extended US$100 million parallel financing, including US$21.0 million GCFF-financed funds. IsDB financing will end on June 30, 2019. The GCFF, IBRD, and IsDB provide resources to support the Government of Jordan (GOJ) in maintaining the delivery of primary and secondary health care services to Syrian refugees and poor uninsured Jordanians (the target population) at Ministry of Health (MOH) facilities and to increase the medium- to long-term sustainability of the health system. Funds under Component 1 were disbursed against the delivery of health services verified by an independent Utilization Verification Entity (UVE). Component 2 finances the UVE’s activities and consultancies on health care costing and basic training on health economics and financing. 3. Parent project performance. The project development objective (PDO) of the JEDP is to support the GOJ in maintaining the delivery of primary and secondary health services to poor, uninsured Jordanians and Syrian refugees at MOH facilities. The parent project has been rated Moderately Satisfactory for both progress towards achieving the project development objective and implementation progress since December 2018 to date. It was rated Moderately Unsatisfactory from May to December 2018, largely due to: (i) the GOJ’s introduction of a cost-sharing policy of 80 percent for Syrian refugees that created financial barriers for them to access health services, and (ii) implementation delays for technical assistance (TA) activities under Component 2. In particular, delivery of technical assistance (TA) Page 6 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) activities under Component 2 was delayed as agreement on terms of references (TORs) took longer than expected. The procurement process for capacity building activities, including selection of a firm to undertake a costing study on non-communicable diseases (NCD) prevention and planned trainings on health financing and economics, research methodology and scientific writing and data collection, is underway. 4. The parent project ratings were upgraded following implementation of the agreed actions by the Borrower: (i) change of the cost-sharing policy to its original 20 percent for Syrian refugees, and (ii) progress made on delivery of TA activities.1 The PDO continues to be highly relevant and all planned activities are expected to be delivered prior to the proposed closing date of October 31, 2023. The amount disbursed by the project to date is 96.66 percent (with full disbursement under Component 1). The project supported financing of human resources needed to deliver primary and secondary health care at MOH facilities, despite tight fiscal constraints. In addition, the project introduced a more detailed monitoring system for delivery of services, independent verification tracks and records actual services delivered, disaggregated by gender and target populations. The most recent annual data from this monitoring system covers November 2017 to October 2018 and shows that the number of services delivered to the target population was on target (2.1 million primary health services and 2.9 million secondary services). When disaggregated by population group, data for the above period suggest that the targets for Syrian refugees were not met. This was largely due to the decreased demand by Syrian refugees due to the financial barriers resulting from the change in their co-payment rate, which was rolled back in March 2019 (see paragraph 3)2. B. Background and Rationale for the Proposed Additional Financing 5. Country context. Despite substantial economic and social progress, Jordan faces a protracted crisis hosting Syrian refugees, combined with constraints in its fiscal space. The GOJ is committed to taking actions on its commitments for universal health coverage (UHC) and human capital investment for all population groups. The GOJ has been providing public services to Syrian refugees, which has added to fiscal stress and increased demand for public services such as education, health, and wastewater management. 6. According to the latest census, the Syrian population in Jordan is 1.3 million, of which 670,238 are registered as refugees by the United Nations High Commissioner for Refugees (UNHCR). The remaining Syrians are considered to have either been living in Jordan for several generations or were living in Jordan before the Syrian crisis. Of the total number of refugees, about 19 percent live in camps (for example, Za’atari, Al Azraq) and the rest live in the community.3 About 96.8 percent of interviewed Syrian refugees responded that they have service cards issued by the Ministry of Interior (MOI).4 This allows 1 In line with World Bank Instructions: Additional Financing for Investment Project Financing, the World Bank management authorized the preparation of the proposed AF on March 28, 2019, notwithstanding that the parent project was not rated Moderately Satisfactory or better rating during the previous 12 months. 2 The updated annual data on health services will be published in in June 2019. 3 HCR. 2019. Syria Regional Refugee Response. Available: https://data2.unhcr.org/en/situations/syria/location/36. 4 HCR. 2018. Health Access and Utilization Survey: Access to Healthcare Services Among Syrian Refugees in Jordan. https://reliefweb.int/report/jordan/health-access-and-utilization-survey-access-healthcare-services-among-syrian-refugees. Page 7 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) them access to several benefits, including highly discounted care at MOH facilities. The large number of Syrian refugees, of which 75 percent are women and children, has significant implications for the Jordanian health system, and with over 80 percent living below the national poverty line, they are considered an extremely vulnerable group. 7. Limited access to key quality health services for vulnerable populations (including Syrian refugees) can produce negative consequences not only for non-Jordanians but also for Jordanians. For example, children without full vaccinations pose the risk of epidemic for the entire population living in Jordan. Lack of birth documents creates inefficient management of public services. In addition, complicated interventions (such as late stage cancer treatment) lead to higher health care costs and put fiscal pressure on the GOJ, rather than saving money from prevention and early diagnosis. 8. The MOH is in charge of stewardship of the entire health sector and is also a major provider of primary and secondary health care services in the public sector. These services are critical for prevention and early detection of infectious diseases as well as NCDs. The MOH has developed a large nationwide network of primary health care (PHC) facilities, including some comprehensive PHC facilities with basic specialties (including mental health). Specialized inpatient and outpatient health services are delivered at MOH hospitals, and private hospitals and clinics (both for-profit and not-for-profit) such as the King Hussein Cancer Center, the University of Jordan Hospital, and the Royal Medical Services (for military personnel and their families). The GOJ also provides a form of social insurance for civil servants (Civil Insurance Program) contracting with public and private providers. Individuals who face catastrophic out- of-pocket health expenditures can petition the Royal Court for subsidization of specific health care services on a case-by-case basis. As some waiting lists increased with the influx of refugees, the GOJ has used the existing contracts with public and private hospitals to provide inpatient and outpatient care alternatives for insured patients with urgent and expensive health care needs but also for Syrian refugees (particularly for treatment of cancer at not-for-profit facilities). 9. In terms of financial protection, before the refugee crisis, Jordan had reduced regressive health care out-of-pocket payments by half—from 42 percent to 24 percent of total health spending (2003– 2013). However, increased demand limited the GOJ’s ability to provide financial protection for all.5 From 2012 to 2014, the GOJ allowed registered Syrian refugees to pay the same rate as insured Jordanians at MOH facilities, which rendered health services as almost free. This led to a steep increase in demand for health services by Syrian refugees. While access to free health services helped meet the needs of Syrian refugees in their first years of the crisis, it was fiscally unsustainable, and in November 2014, the MOH required Syrian refugees to pay the same co-payment rate as poor uninsured Jordanians (20 percent of the prices listed for MOH services). In February 2018, a new policy came into effect, which substantially increased the co-payment rate for Syrian refugees to 80 percent of the price of services delivered by the MOH. This new co-payment policy created financial barriers for Syrian refugees to access health care and decreased their utilization of public facilities (mainly PHC services). The World Bank and development partners immediately engaged in discussions with the GOJ to explore options to reduce barriers for Syrian refugees to access to health care services provided by the MOH. It was agreed that the U.S. Agency for International Development (USAID) and the Government of Denmark would establish a multi-donor 5 Amnesty International. 2017. Living in the Margins: Syrian Refugees in Jordan Struggle to Access Health Care. Amman. Page 8 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) account, named the Jordan Health Fund for Refugees (JHFR). The World Bank provided technical inputs on estimating health care costs for Syrian refugees. On December 16, 2018, the GOJ and donors signed a joint financing agreement to create the JHFR to finance some inputs and investments needed to provide services for Syrian refugees. The disbursement of donor contributions from the JHFR was contingent on the reversal of the co-payment policy to the pre-2018 rate. On March 25, 2019, the Jordanian Cabinet made the decision to reverse the co-payment policy for Syrian refugees from 80 percent to 20 percent, the same as for poor uninsured Jordanians. 10. Climate change. The impacts of climate change6 are expected to exacerbate the demand for key health services, particularly due to increased incidences of waterborne diseases, infectious diseases, malnutrition, cardiovascular, and respiratory diseases. The impacts of climate change are also expected to further undermine existing health systems, social protection systems, water and food supplies, and infrastructure. The AF will support the delivery of primary and secondary health services to the target population that are the most vulnerable to the impacts of climate change (i.e., poor uninsured Jordanians and Syrian refugees). This will increase the resilience of these groups, and the health sector more generally, to climate change. Additionally, it directly contributes to climate adaptation objectives in the health sector set out in Jordan’s Intended Nationally Determined Contribution and the National Climate Change Policy (2013–2020). 11. Pre-existing inefficiencies in the health system have been exacerbated by the tight fiscal space that Jordan is facing and prolonged recovery from the economic slowdown of recent years. Higher demand for costly services needs to be addressed to create a sustainable UHC system. The health system in Jordan, similar to many other health systems globally, is plagued by several issues related to technical and allocative efficiency, including highly fragmented insurance pools without an adequate balance of revenues and expenditures, and multiple payers and purchasers, including the Royal Medical Service, MOH, and private sector providers. In addition, there is very little data available on critical components of the health system, including costing of the services delivered at primary and secondary health care facilities or usage of services by diagnosis, gender, or income group. As a positive result of the JEHP, the MOH has started generating new aggregated data that helps monitor the use of services by the target population, but the system still needs to be strengthened as the MOH needs population health management data for public policy decision making. 12. Boosting human capital of young Jordanians is a key priority for the GOJ. The Human Capital Index (HCI) for Jordan is slightly lower than the regional average (overall HCI = 0.56) but higher than that for the same income groups. Health-related indicators (adult survival rate, under-five mortality, and stunting under five years old) show relatively good outcomes.7 This is largely due to the comprehensive 6 Jordan is highly vulnerable to the impacts of climate change; especially increased frequency and severity of extreme weather events, including extreme high temperatures, flash floods, landslides, and droughts. As one of the driest countries in the world, water scarcity in Jordan is also expected to increase due to climate change. This will have an impact on the health sector. For example, limited access to clean water contributes to increased incidences of waterborne diseases (typhoid, fever, cholera, Hepatitis A and E, giardiasis, and bilharzia); food-borne diseases through crop contamination; increased food insecurity; and malnutrition. This vulnerability is further exacerbated by the influx of refugees into Jordan. 7 The World Bank Group. Human Capital Index: Jordan. https://databank.worldbank.org/data/download/hci/HCI_2pager_JOR.pdf. Page 9 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) health service package provided in Jordan for key health services, including mother and child health care. However, to boost human capital of the younger generations in Jordan, the GOJ has identified two priority areas to boost human capital: early childhood development (ECD) and NCDs. Strategic investment in these two priority areas through PHC strengthening would produce desirable health outcomes (healthy population), health financing efficiency (healthy economy), and human capital development (healthy workforce for the next generation). 13. Concessional support is vital to move from a humanitarian to a development response. Since 81 percent of Syrian refugees live outside of camps, public health services are the backbone of Jordan’s response to the refugee crisis for the health sector. Public resources are strained, and the fiscal space is limited. The combination of limited service delivery capacity and fiscal pressures keep undermining the sustainability of the health system and the goal of UHC, as well as its ability to provide services at low cost. This can have implications for investments in human capital for new generations living in Jordan and for the efficient control and cost containment of NCD burdens, which affect both Syrian refugees and Jordanians. The proposed AF has been prepared and will be implemented in accordance with paragraph 12, section III of the World Bank Policy for Investment Project Financing (IPF), Projects in Situations of Urgent Need of Assistance or Capacity Constraints. The use of condensed procedures under the proposed AF stems from the urgent need to address the challenges for health service delivery and health outcomes in Jordan, generated by the Syrian refugee crisis, which threatens to reverse gains made by the Jordanian health sector, exacerbates the existing fiscal constraints and erodes institutional capacity in the public health system. Thus, the project responds to the impact of conflict (in Syria) and the ensuing ‘fragility within a non-fragile state’ situation, a result of the refugee influx. Sustainability of health system gains over the last decade is at risk without financial and technical support as MOH line item budgets have been reduced. The refugee crisis has also affected the system in other ways—the percentage of uninsured Jordanians has increased and the goal of attaining UHC by 2030 is, therefore, further away.8 Without financial and technical support to the sector, access to health care for vulnerable populations may deteriorate in the short- to medium term. 14. The proposed AF contributes to the World Bank Group twin goals of eliminating extreme poverty and boosting shared prosperity in a sustainable manner, and corporate and regional priorities. It contributes to the implementation of the World Bank Group’s enlarged Middle East and North Africa Strategy by: (a) supporting resilience to systematic shocks due to the inflow of refugees and internally displaced persons, and (b) addressing gaps in human capital, including modernization of the health system, pursuit of UHC, and provision and maintenance of basic health services for refugees and host communities. In addition, the AF also contributes directly to the first pillar of the World Bank Group Gender Strategy (FY16–23) on narrowing gaps in human endowment by improving maternal health outcomes. 15. As with the parent project, the proposed AF is aligned with the principles of the World Bank Group’s Jordan Country Partnership Framework (CPF). The CPF (Report 102746-JO)9 defines the World Bank Group’s engagement with Jordan. The main goal of the CPF is to renew the country’s social contract 8 High Health Council (Government of Jordan). 2015. The National Strategy for Health Sector in Jordan, 2015–2019. Amman. 9 The World Bank Group. 2016. Country Partnership Framework for the Hashemite Kingdom of Jordan for the Period FY17 –FY22. Page 10 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) and promote social and economic inclusion. The CPF also plans to analyze the impact of the refugee crisis on the country’s financial sustainability, which is supported through the component on institutional capacity to improve the health system’s efficiency. By safeguarding the sustainability of public health services and focusing on vulnerable populations, the proposed operation is fully aligned with the CPF. 16. The AF contributes to the Health, Nutrition, and Population (HNP) Global Practice’s aim of assisting countries in accelerating progress toward achieving UHC. Attaining UHC entails both increasing access to quality services and improving financial protection.10 The proposed AF supports the delivery of primary and secondary public health services to the target population, and thus contributes to these goals. 17. Under the proposed AF, the following changes will be introduced to the parent project: • The JEHP closing date (currently June 29, 2019) will be extended to match the closing date of the proposed AF, i.e. to October 31, 2023. • The results framework will be modified to reflect the updated baseline and targets for PDO indicators. The original baselines and targets were based on 2015 data, before the MOH introduced a monitoring system to track disaggregated data by facilities and governorates, and before independent verification was implemented. The new baselines and targets are based on the latest data available from the MOH monitoring system (before the increase in co-payments for Syrian refugees was introduced). II. DESCRIPTION OF ADDITIONAL FINANCING 18. The changes to the parent project introduced by the proposed AF will help ensure a stronger focus on monitoring results, maintain service delivery to the target population (poor uninsured Jordanians and Syrian refugees), and strengthen a sustainable health system for UHC. Component 1 will allow for rapid disbursement of funds to cover part of the GOJ’s health care costs to provide primary and secondary health services to the target population. Component 2 will support the GOJ’s commitment to UHC and as an early adopter of the Human Capital Project. Thus, the AF will: (a) allow the GOJ to foster human capital outcomes with an emphasis on PHC (mother and child health care and NCDs); (b) support the GOJ in improving the coverage and quality of services provided to the target population; and (c) assist the GOJ in introducing activities to improve critical interventions for PHC, with emphasis on NCDs and ECD. 19. Component 1: Results-based financing to deliver health care services at primary and secondary care facilities of MOH for the target population (US$190 million). Component 1 is funded by a US$133.946 million IBRD loan and a U$56.054 million GCFF grant. Component 1 will reimburse the GOJ through results-based financing for health services provided to Syrian refugees and poor uninsured Jordanians at primary and secondary MOH health care facilities nationwide. The services covered include the package of primary and secondary inpatient and outpatient health care services delivered by the MOH. The disbursements will be based on verification of: (a) the number of health services provided to 10 The World Bank Group. 2016–2020. Priority Directions for the Health, Nutrition and Population Global Practice. Page 11 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) the target population verified by an independent UVE, and (b) the expenditures incurred by the GOJ to deliver these services verified by the Jordan Audit Bureau (AB). 20. The AF will fund part of the cost of delivering health care services to the beneficiaries, which will be up to US$12 per primary care service and US$63 per secondary care service. The costs will mainly cover the MOH’s expenditures for key recurrent expenditures such as human resources and operating costs of health facilities, including rental and utilities (water, electricity, and fuel). The AF will not finance the cost of procurable medical items, such as vaccines, medicines, equipment, X-Ray plaques, or lab reagents that will continue to be financed by the GOJ and other donors (USAID and the European Union). 21. The operational definition of a service delivered is either a visit to an outpatient facility (first or second levels of care) for medical, emergency, or diagnostic services (lab tests, X-rays, etc.) or a hospital discharge. A ‘PHC service’ is defined as a PHC service delivered, for example, one antenatal care visit for a pregnant woman. The package of primary health services includes: (a) mother and child health care services; (b) malnutrition prevention and treatment; (c) integrated management of childhood health; (d) treatment of communicable diseases; and (e) prevention, early detection, and management of NCDs. Based on MOH service delivery data from November 2017 to January 2018,11 the current utilization rates of primary health services among the target population account for about 23 percent of the total utilization of these services at MOH facilities. Based on the same utilization rate during the above period, it is estimated that the MOH will provide approximately 135,000 services delivered to registered Syrian refugees and 2.5 million services delivered to poor uninsured Jordanians at PHC facilities annually. 22. A ‘secondary health care service’ is considered to be a specialized service delivered in outpatient or inpatient hospitals such as the delivery of a baby or cancer treatment. Secondary health services include both outpatient and inpatient health care services received by the target population at the 33 MOH hospitals in Jordan. The current utilization rates of secondary health services among the target populations account for about 41 percent of the total utilization of these services at MOH hospitals. Based on the utilization rates from November 2017 to January 2018, it is estimated that the MOH will provide approximately 103,000 services to Syrians and 1.8 million services to poor uninsured Jordanians at secondary care facilities annually. 23. A portion of the AF will retroactively finance primary and secondary health care services already delivered to the target population. This will be financed under Component 1 and will cover health care expenditures that: (a) were incurred prior to the signing date of the Loan Agreement but on or after June 30, 2018, and (b) were not financed by the final IsDB disbursement tranche. Based on the estimated 11As described in paragraph 18, the baselines and targets for PDO-level indicators will be revised based on the latest service delivery data available. Data from November 2017 to January 2018 is used for the following reasons: (a) this is the latest data showing service delivery to the target population when the same co-payment rate (20 percent) was applied to the entire target population; (b) the increased co-payment rate of 80 percent for Syrian refugees was in effect from February 2018 to March 2019, which resulted in lower utilization of services by Syrian refugees; therefore, service delivery data during this period would not provide best estimates for the remaining project period; and (c) 20 percent co-payment would be applied to the target population during the remaining project period. Page 12 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) amount of eligible expenditures and service utilization by the target population, the retroactive financing under the proposed AF will not exceed US$30 million. 24. It is critical to provide financing for human resources in public facilities delivering subsidized health services to reduce the financial burden that vulnerable groups with higher risk of the negative health impact due to climate changes. Health services provided by the MOH include key interventions to address significant burden of disease (BOD) and associated risks that stem from or are exacerbated by climate change in Jordan, including management of NCDs such as hypertension, diabetes, and cancer. In addition, the interventions are designed to enhance healthier lives throughout the life cycle with improved mother and child health and ECD interventions. 25. The remaining funds under Component 1 will finance the delivery of primary and secondary health care services to the target population incurred by the GOJ during the AF period. Funds will be disbursed by advances that cover six consecutive months. 26. Component 2: Improving coverage and quality of the primary health care services (US$9.647 million). Component 2 is funded by US$6.801 million IBRD loan and U$2.846 million GCFF grant. Component 2 aims to support the MOH in strengthening PHC services by incorporating a family health model and emphasizing human resource development. By enhancing the capacity of the MOH to maintain provision of adequate health services to vulnerable women, mothers and children, this component will respond directly to closing gender gaps in access to human endowments. This will be achieved by introducing non-scalable disbursement-linked indicators (DLIs) to measure progress in terms of the following achievements: (a) an assessment of gaps in human resources and skills needed to incorporate a family health model (integrated people-centered health services) based on the World Health Organization (WHO) framework,12 (b) an implementation plan to address the gaps, and (c) evaluation of the first-year implementation results of the human resources capacity building and training activities. Subcomponent 2.2 will finance the cost of an independent verification of the services utilized by the target population during the AF period, project management, and other key activities to improve MOH capacity. 27. Subcomponent 2.1: Supporting MOH in strengthening Primary Health Care services by incorporating a family health model and emphasizing human resource development, through, inter alia, a comprehensive assessment of gaps in human resources and skills needed to incorporate a national family health services model based on WHO’s recommendations (US$9 million). This subcomponent aims to strengthen PHC services by expanding the introduction of a family health model, with emphasis on human resource development. The proposed family health model is part of envisioned improvements for quality of care by the MOH. Subcomponent 2.1 seeks to finance and incentivize the MOH to ensure that PHC services incorporate WHO recommendations on people-centered integrated health services using evidence-based approaches, such as proactive health promotion and prevention community outreach and population health management through risk assessment and case management (for example, including an adequate number of female community health volunteers). The AF strengthens two key health-related areas of human capital investment: (a) ECD for the first critical 1,000 days (targeting 12 World Health Organization. 2019. Framework on Integrated People-Centered Health Services. https://www.who.int/servicedeliverysafety/areas/people-centred-care/framework/en/. Page 13 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) pregnant women, mothers, and children, including through nutrition, growth monitoring, parent counseling, early stimulation, etc.), and (b) preventive/early detection interventions that contribute to minimize the BOD of NCDs (i.e., diabetes, hypertension, and cancer). Introducing a family health model aligns with GOJ priorities, including its commitment to the Human Capital Project as an early adopter. Furthermore, global evidence suggests that benefits will be higher among the most vulnerable population groups, including Syrian refugees and poor uninsured Jordanians. For example, this will include improving prevention, early diagnosis and treatment of breast cancer, the largest burden of NCDs for women. This will potentially: (i) improve health outcomes for Syrian refugees who will receive earlier stage diagnosis at PHC centers, and (ii) increase the number of antenatal care visits, particularly during the first fourth months of pregnancy, thus improving health outcomes for both mothers and children. 28. Funds will be disbursed once achievement of the following DLIs are verified by the World Bank. The proposed DLIs, estimated timeline, and allocation of financing amounts are detailed in Table 1. Table 1: Disbursement-Linked Indicators DLI Source of Type Verification Baseline Timeline Amount (US$) Data DLI 1: Assessment of PHC coverage and quality gaps DLI #1.1: From the Non- MOH MOH US$776,091,777 Year 2 1,000,000 baseline of scalable expenditure Budget (JOD 550,419,700), US$776,091,777 (JOD framework Directorate MOH current and 550,419,700) (MOH’s and capital expenditures in the Ministry of expenditures, 2017 budget), MOH Finance 201713 receives additional (MOF) budget of approved US$1,000,000 in the annual Jordanian fiscal year budget 2020 following declaration of effectiveness of the project DLI #1.2: MOH Non- Primary World Bank No assessment Year 2 1,000,000 completes an scalable Health Care assessment of gaps in Department human resources and MOH skills needed to incorporate a nationwide family health services model based on WHO recommendations including: (a) mother 13 General Budget Department. General Budget Law 2019. http://www.gbd.gov.jo/GBD/en/Budget/Ministries/general-budget- law-2019. Page 14 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) DLI Source of Type Verification Baseline Timeline Amount (US$) Data and child health, nutrition, growth, and development monitoring; and (b) prevention and early diagnosis of diabetes, hypertension, and breast cancer DLI 2: Development of an implementation plan to improve quality and coverage of PHC DLI #2.1: From the Non- MOH MOH US$776,091,777 Year 3 1,000,000 baseline of scalable expenditure Budget (JOD 550,419,700), US$776,091,777 (JOD framework Directorate MOH current and 550,419,700) (MOH’s and MOF capital expenditures in the approved expenditures, 2017 2017 budget) MOH annual receives an additional budget budget of US$1,000,000 in the second consecutive Jordanian fiscal year following declaration of effectiveness of the project DLI #2.2: MOH Non- Primary World Bank No implementation Year 3 2,000,000 develops and scalable Health Care plan approves a costed and Department phased MOH implementation strategy with an M&E system, incorporating feedback and inputs from all health directorates and development partners DLI.3: Human resources capacity building to improve outcomes in PHC DLI #3.1: From the Non- MOH MOH US$776,091,777 Year 4 2,000,000 baseline of scalable expenditure Budget (JOD 550,419,700), US$776,091,777 (JOD framework Directorate MOH current and 550,419,700) (MOH’s and MOF capital expenditures in the approved expenditures, 2017 2017 budget) MOH annual receives additional budget budget of US$2,000,000 in the third consecutive Jordanian fiscal year following declaration of effectiveness of the Page 15 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) DLI Source of Type Verification Baseline Timeline Amount (US$) Data project DLI #3.2: MOH Non- Primary World Bank Implementation End of 2,000,000 provides report on scalable Health Care plan activities not Year 4 Year 1 implementation Department yet launched d results of the human resources capacity building and training activities as designed in the implementation strategy under DLI #2.2 29. Subcomponent 2.2: Providing technical assistance and capacity building to strengthen the institutional capacity of Jordan; and financing the cost of an independent verification of the services utilized by the target population at MOH facilities (US$0.647 million). This subcomponent will finance TA activities to improve performance and management of the public health system. This includes health information systems to improve the accuracy of the monitoring of services delivered to the target population (e.g., Syrian refugees), human resources for health, health insurance financing (balancing revenues and expenditures to improve sustainability), and strategic purchasing for services in the private sector. The subcomponent would finance activities to increase MOH capacity to: (a) maintain a grievance redress mechanism (GRM), and (b) strengthen the health system’s response to gender-based violence (GBV), through the development and dissemination of materials (specific activities to be identified based on international best practices and the local context). It will also finance general coordination and project management to strengthen the capacity of a Coordination Unit at the MOH, and the cost of an independent verification of the use of services under Component 1. As one of the disbursement conditions stipulated in the Loan Agreement, these funds cannot be made available until the respective allocations under the parent project have been fully disbursed. Combining undisbursed funds under Component 2 of the parent project (US$1.16 million) and funds under subcomponent 2.2 of the proposed AF, the project will finance a total of US$1.8 million to strengthen MOH technical and managerial capacity to improve the efficiency of the health system in Jordan. 30. In Jordan, 21 percent of ever married women ages 15–49 have experienced physical violence. However, only one in five women (19 percent) who have experienced any physical or spousal sexual violence has sought help to stop the violence. Women under 25 and Syrian women are less likely to seek help.14 The GOJ has built capacities and systems to provide gender-sensitive services to those in need, such as Syrian refugees and poor uninsured Jordanians. For example, the National Council for Family Affairs developed a multisectoral National Protection Framework on family violence and GBV survivors can receive clinical services at MOH facilities. Although the parent project planned to provide TA for supply-side capacity building (mainly through training on GBV and barriers to access), supply-side interventions have been supported by development partners, such as the United Nations Children’s Fund 14DOS (Department of Statistics) and ICF International. 2019. Jordan Population and Family Health Survey 2017–2018. Amman, Jordan, and Rockville, Maryland, USA. Page 16 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) (UNICEF) and United Nations Population Fund (UNFPA). This support includes a comprehensive national- level review of GBV services (multi-sectoral including health), development of training manuals for MOH service providers, capacity-building training for service providers on GBV. Therefore, based on consultations with the MOH and development partners, the AF will support provision of psychosocial support and service delivery by health professionals to survivors of violence (for example, through targeted outreach by PHC teams and training of PHC service providers on what has worked in countries with similar cultural and ethnic characteristics and GBV, using relevant international best practices).15 The World Bank will work closely with development partners, including local civil society organizations that target women and populations exposed to GBV, to ensure coordination and avoid duplication. 31. In addition to the proposed activities under the AF, complementary analytical work will be conducted in parallel to strengthening of MOH capacity, to provide sustainable, high-quality health services to all population groups in Jordan. This TA will include: (a) a costing study on NCDs (under Component 2 of the parent project), and (b) a study on access and quality-related barriers to health services for vulnerable populations (including Syrian refugees). These two studies will provide in-depth information for the MOH to strategize on efficient investment to reduce significant cost drivers in Jordan and to improve the quality of health care provided at MOH facilities. 32. The Ministry of Planning and International Cooperation (MOPIC) will be the implementing agency for the proposed AF, in coordination with designated focal points in the MOH. Project implementation will be managed through a Coordination Unit to be established within the MOH. The Coordination Unit, acting as the project coordinator, will have dedicated staff, including a project coordinator, a financial management (FM) specialist, and a procurement specialist. Subcomponent 2.2 will finance individual consultants and procure goods and services (as deemed necessary) to improve capacity within the Coordination Unit. The planned support is intended to strengthen general coordination and project management capacity at the MOH. MOPIC will be responsible for overall implementation of project activities, including monitoring and evaluation (M&E), FM, and procurement functions. III. KEY RISKS A. Overall Risk Rating and Explanation of Key Risks 33. The overall risk to the achievement of the project objective is rated Substantial. Financial and technical support to the Jordanian health sector through the proposed AF and the multi-donor JHRF will help address the risk of deteriorating access to health care for vulnerable populations, including policy reversal. The key risks that may impede the implementation of the project are macroeconomic risks and risks linked to the geographic and regional context. This section describes the risks which are rated substantial and associated risk mitigation measures. 15 Garcia-Moreno, et al. 2014. The Health Systems Response to Violence Against Women. The Lancet Series. Violence Against Women and Girls Volume 385, Issue 9977. According to the study, there is no one model for a delivery of a health-care response to violence against women; countries ought to tailor their approach based on resources and availability of specialized violence- support services. Page 17 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) 34. Macroeconomic risk. The macroeconomic risk is rated Substantial. Economic indicators for 2018 further revealed the country’s macroeconomic weaknesses and vulnerabilities, stemming from sizable external and internal imbalances that generate large external financing needs. In addition, the GOJ’s efforts to keep debt dynamics sustainable hinges on continued fiscal consolidation, which has an impact on the population. Poor macroeconomic performance could pose a risk to the PDO if domestic revenues underperform and the GOJ is required to reduce public spending to meet its deficit targets. However, as part of its agreement with the International Monetary Fund under the Extended Financing Facility program and the World Bank-financed Second Equitable Growth and Job Creation Development Policy Financing, the GOJ has committed to a gradual and sustainable reduction in fiscal deficit through increases in revenues and efficiencies in expenditures. In terms of risk mitigation, on the expenditure side, the GOJ has committed to a prudent expenditure policy through: (i) continuing the streamlining of non-priority current spending; (ii) prioritizing social and capital spending; (iii) arresting the accumulation of fuel, health, and water-sector arrears; and (iv) continuing support for Syrian refugees. 35. Other risks (geopolitical). Other risks, such as geopolitical and regional risks are rated Substantial. The ongoing Syrian conflict, insecurity, violence in Iraq, and Israeli-Palestinian tension compound the risks to Jordan in terms of a potential destabilizing impact, toll on the economy, and provision of public services. Keeping these risks in mind, the project has been designed to be simple and fast disbursing against health services delivered. IV. APPRAISAL SUMMARY A. Economic and Financial (if applicable) Analysis 36. Public health services are well suited to cover the project’s target population. The project focuses on highly vulnerable population groups: Syrian refugees (who live mostly below the poverty line), and poor uninsured Jordanians, who are typically unemployed or out of the labor force. International experience has shown that private insurance is often not able to provide adequate coverage to poor and informal workers so public intervention is warranted.16 In addition, Jordan’s public health system provides over 60 percent of hospital beds, and practically all primary care services.17 Therefore, the nationwide network of MOH health care providers is in a unique position to respond to the refugee crisis, and to play a critical role in moving from a humanitarian to a developmental approach and strengthening an integrated public system to achieve UHC and human capital investment commitments. 37. The proposed AF aims to support the MOH’s vision for improving quality of health services with an emphasis on the first level of care and interventions that enhance health system sustainability. The MOH has limited fiscal space to maintain current service levels to the target population. This results from macroeconomic pressures (including lower GDP growth and higher debt-to-GDP ratio), high public spending in health, and increased health care demand. Using concessional financing, the proposed AF will 16 Bitran, R. Couverture maladie universelle et le défi de l’emploi informel : enseignements tirés des pays en développe ment. Publication autorisée, January 2014. 17 Ajlouni, M. 2011. Jordan Health System Profile 2010. World Health Organization - Eastern Mediterranean Office Region (EMRO). Amman (Jordan). Page 18 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) support the acceleration and expansion of a family health model that can improve health outcomes and reduce the BOD in Jordan. It will address the growing expenditures for costly NCD treatment, particularly breast cancer in women and colon cancer in men. PHC can play a key role in the prevention and early detection of NCDs. This can result in: (a) better quality of life and survival rates for patients, and (b) more manageable treatments that enhance the efficiency of health sector performance. Jordan’s demographic and epidemiological profile is shifting from predominantly younger people and infectious diseases toward an older population with NCDs as the main cause of morbidity and mortality. B. Technical 38. The proposed AF is designed to strike a balance between the urgent needs of the health sector and to build a foundation for a sustainable approach to UHC. The AF aims to strengthen health system performance by improving the MOH’s approach to the delivery of health services. It is a shift from a focus on curative and low levels of prevention with late diagnosis of NCDs toward a system that prioritizes health promotion, prevention, and early diagnosis (for example, the family health approach). This approach will foster, accelerate, and expand more effective PHC nationwide, as well as better human capital development impacts and improved health outcomes. The implementation and financing mechanisms under the AF consider the urgent needs in the sector, the implementation capacity of the MOH, and the epidemiological and demographical profiles of the target population. Using government systems to deliver the family health approach for improving quality of PHC services is the most cost- effective, fit-for-purpose implementation arrangement for the AF. 39. The proposed AF features several ingredients for success. These include the GOJ’s commitment to UHC and equity principles for the health system, as well as inclusive policies for refugees to access the same package of services available to Jordanian nationals at MOH facilities; the strong record of MOPIC in managing World Bank-financed projects; reliance on government health system structures with regard to financing and service provision; a streamlined FM system; and a greater emphasis on results. The proposed AF design builds on global and country-specific experience and will be supported through World Bank TA and implementation support. C. Financial Management 40. Due to the emergency nature of the AF, the FM approach was streamlined and based on simplified ex ante requirements while relying more heavily on ex post requirements as additional fiduciary controls and reviews. 41. The parent JEHP’s FM performance has been rated Satisfactory. JEHP staffing arrangements were adequate, the verification of utilization of services by the target population conducted by UVE was acceptable, in addition to the financial verification conducted by the Jordan AB. The parent project’s financial reports were submitted on time in an acceptable format and content and sound internal controls and external audit arrangements were in place. 42. The bulk of the proposed AF will fund part of the cost for delivering health services to the beneficiaries: only costs related to the target population will be financed by the AF. The cost of eligible primary and secondary health services will be calculated by dividing total actual expenditures incurred/paid by the GOJ for each period by the total number of health services provided to the target Page 19 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) population in the same period. The costs will cover the MOH’s expenditures for key recurrent expenditures such as human resources and operating costs of health facilities, including rental and utilities (water, electricity, and fuel), i.e. selected budget line items as defined in the Loan Agreement. As with the parent project, the AF does not finance the costs of medical items such as vaccines, medicines, equipment, or consumables. The unit cost of delivering one primary or secondary health service will be calculated by dividing the total actual costs paid by the MOH by the number of health services delivered to the target population at MOH facilities. The cost of primary and secondary health services provided to the target population will be estimated by multiplying the cost per unit of services by the number of primary and secondary care services delivered at MOH facilities. 43. Under Component 1 (reflected in Category 1 in the Loan Agreement Withdrawal Schedule), two semiannual disbursements will take place, and each disbursement will cover six months of recurrent non- medical expenditures for delivering health care services. A Health Care Service Delivery Expenditure Report, using the inputs from verifications conducted by the Jordan AB and UVE, will be submitted to the Bank no later than six months after the end of the corresponding period, with an exception under the first two advances. The AB and UVE will verify the outputs and the actual amount due and will submit their reports to the World Bank through MOPIC. 44. Disbursements under subcomponent 2.1 (reflected under Category 2 in the Loan Agreement Withdrawal Schedule) will be based on the respective DLIs. Disbursements will be made against actual expenditures only when related DLIs have been achieved and verified. Disbursements under Category 2 will be contingent upon the GOJ furnishing evidence satisfactory to the World Bank that it has achieved the respective DLIs and these will be verified by the World Bank and the MOH Budget Directorate. Reconciliation against actual expenditures will be incurred during the same period. Application for withdrawal of amounts allocated to individual DLIs will be sent to the World Bank any time after the World Bank has notified the GOJ in writing that it has accepted evidence of achievement of the DLIs. The withdrawal amount against the DLIs achieved will not exceed the amount of the financing confirmed by the World Bank for the specific DLIs, which will be up to the lesser of the actual expenditure incurred or the DLIs achieved and the verified respective allocation. 45. The proposed AF will follow the same FM arrangements as under the parent project, including with respect to FM responsibilities, which will be managed by the same qualified financial officer seconded from the MOPIC Accounting Department. Two new Designated Accounts (DAs) will be used to receive AF proceeds, DA-A will be used to receive funds for Component 1 and subcomponent 2.1, while DA-B will be used for subcomponent 2.2. The funds received in DA-A will be eventually credited to the Government Single Treasury Account (STA). Semiannual unaudited IFRs will be submitted to the World Bank within 45 days after the end of each semester. Disbursements under Component 1 are based on a verification of: (a) the number of health services provided to the target population during a six-month period, verified by the UVE, and (b) the actual expenditures incurred by the GOJ during the same six-month period to deliver these services verified by the Jordan AB. An annual audit of project financial statements will be required and will be conducted by the Jordan AB. The project’s annual audited financial statements will be due six months after the end of each year. Page 20 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) D. Procurement 46. All goods, non-consulting services, and consulting services required for the management of the project and to be financed out of the AF proceeds shall be procured in accordance with the requirements set forth in the ”World Bank Procurement Regulations for Borrowers under Investment Project Financing,” dated July 1, 2016, revised in August and November 2018. Additionally, the “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants” (dated October 15, 2006 and revised in January 2011 and as of July 1, 2016) will apply to the project. The provisions of the Procurement Plan for the project (dated May 21, 2018 and provided for under Section IV of the Procurement Regulations) may be updated from time to time in agreement with the World Bank. 47. Similar to the parent project, the AF includes provisions for TA training workshops, selection of a number of international and national experts, supply of office equipment, etc. 48. The overall procurement risk rating is Moderate, given limited procurement activities. The following measures are proposed to mitigate procurement-related risks: (a) using the Procurement Plan as a monitoring tool for timely processing of activities; (b) systematizing record keeping and initiating electronic archiving of procurement processing; (c) enhancing capacity of appropriate support (staff, training, and tools); (d) recruiting a qualified and experienced procurement officer familiar with the World Bank’s Procurement Regulations and Guidelines; and (e) preparing the TORs for the required consulting services in advance. Market Analysis Summary 49. Consultants. The required consultants for auditing are consulting firms working in the fields of health management information systems, strategic purchasing for services in the private sector, and capacity building. Jordan has many experienced local firms with these skills. Additional consultancy contracts are expected to be few, mostly for individual consultants, where both local and international capacity may be tapped into, as needed. 50. Methods of procurement. Selection methods and arrangements: procurement methods available under the World Bank Procurement Regulations and as agreed in the Procurement Plan will be used by the implementing agency. 51. Goods and non-consulting services. No purchase of equipment or goods is expected under the project. However, if small items were needed, a Request for Quotations and Direct Selection will be used. 52. Consulting services. The project is expected to use request for proposals with the following selection methods: (a) Quality- and Cost-Based Selection, (b) Selection under a Fixed Budget, (c) Least- Cost Selection, (d) Selection Based on the Consultants’ Qualifications, (e) Direct Selection (old single sourcing), and (f) Selection of Individual Consultants. 53. Prior review thresholds. Based on the procurement assessment and risk rating, the project shall be subject to Moderate risk prior review thresholds as defined under the World Bank Procurement Framework. Therefore, most contracts, with exception of TORs, are expected to be post review. Hands- on assistance will be provided by World Bank staff as needed. Page 21 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) 54. Systematic Tracking of Exchanges in Procurement (STEP). The Procurement Plan for the AF will be updated by MOPIC through STEP. It will define the market approach options, the selection methods and contractual arrangements, packaging to implement procurement activities efficiently and effectively, and shall determine the World Bank’s prior/post review requirements. The updated Procurement Plan covering at least 18 months of project implementation will be attached to the Loan Agreement. 55. Project Procurement Strategy for Development (PPSD). MOPIC shall prepare a PPSD according to the Procurement Regulations, and the agreed PPSD including the Procurement Plan should be available before signing of the AF Loan Agreement. 56. Frequency of post procurement review. The post procurement review is foreseen to be held once a year. In the post procurement review, a minimum sample of 10 percent of contracts or at least one contract eligible for post review shall be covered. E. Gender 57. Analysis. Global evidence suggests that primary care and targeted maternal interventions such as antenatal care can reduce maternal and child mortality rates by 5 to 40 percent.18 However, in Jordan, fewer pregnant women today receive adequate care during their first trimester, with a 6-percentage point drop in only a five-year period. Between 2012 and 2017/18, the rate of pregnant women having their initial antenatal visit during their first trimester dropped from 91 to 84.8 percent.19 Furthermore, while antenatal coverage is high overall in Jordan, receiving adequate care (following WHO guidelines of recommended timing and number of visits) varies significantly by region, nationality, education, and income. For example, 69 percent of pregnant women in the lowest quintile receive adequate care compared to 89 percent among those in highest quintile. By nationality, 82 percent of Jordanians had at least seven or more antenatal care visits as compared to 62 percent of Syrian women. Fewer Syrian women (83.2 percent) received their initial antenatal visit during their first trimester, compared with the national average (84.8 percent).20 Thus, there is a significant gap in accessing to antenatal care services for Syrian refugee women compared with Jordanian women. 58. Action. This AF aims to ensure that essential health services are readily available for men and women of the vulnerable groups. It will do so by improving PHC through expanding a family health model, where vulnerable populations will be prioritized to receive adequate health services based on their needs. 18 Bhutta, Zulfiqar A., Ali, Cousens, Ali, Haider, Rizvi, Okong, Bhutta and Black. 2008. “Alma-Ata: Rebirth and Revision 6: Interventions to Address Maternal, Newborn, and Child Survival: What Difference Can Integrated Primary Health Care Strategies Make?” The Lancet 372.9642 (2008): 972. Rosero-Bixby, Luis. 1986. “Infant Mortality in Costa Rica: Explaining the Recent Decline. ” Studies in Family Planning 17.2 (1986): 57–65. Macinko, James, Frederico C. Guanais, and Maria De Fátima Marinho De Souza. 2006 "Evaluation of the Impact of the Family.” 19 Department of Statistics (DOS) and ICF International. 2019. Jordan Population and Family Health Survey 2017–2018. Amman, Jordan, and Rockville, Maryland: DOS and ICF International. 20 Department of Statistics (DOS) and ICF International. 2019. Jordan Population and Family Health Survey 2017 –2018. Amman, Jordan, and Rockville, Maryland: DOS and ICF International. According to the nationwide statistics, 82 percent of Jordanian women had at least seven antenatal care visits as compared to 74 percent of women of other nationalities and 62 percent of Syrian women. Page 22 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) The global evidence suggests that the strongest mechanism to improve health problems for women, including mother and child health care, is an improved PHC system. The WHO has advocated for a new model of PHC (sometimes referred to as a Family Health Model) and various OECD countries have implemented the WHO framework of patient-centric integrated services. These new approaches to PHC contribute to the reduction of inequalities that stem not only from gender differences, but also from the intersectionality of gender with poverty, ethnicity and women with different cultural or national backgrounds. Family health teams at MOH facilities identify various populations at risk to prioritize women’s health, to reduce gender inequalities by collecting data on households and families from the catchment areas, and to identify early risks and interventions. Drawing from good community model health practices in Costa Rica and Djibouti, the project will work with female community health volunteers through this Family Health Model to raise awareness among all key reference points for both female and male community members around the importance of early antenatal care, and to communicate services available at PHCs. This ensures that pregnant women will have the information needed to access earlier antenatal care and an adequate monitoring system can be implemented for at-risk pregnancies, including specialist referrals. In addition, the model will strengthen core health system functions (for example, human resources for health and information systems) for a stronger PHC system with the right balance between prevention, promotion and inpatient and outpatient care.21 For example, in Nordic countries22, Canada23, Spain24, and Chile25 an intervention that is considered to have a major positive impact in reducing social and gender inequalities in health is a family health model of PHC, which includes social determinants of health and identification of key vulnerable groups. Identifying the health needs of, and prioritizing interventions for vulnerable populations, such as pregnant women, is expected to improve access to antenatal care services. 59. M&E. The AF will monitor access to antenatal care services for Syrian refugees. Specifically, it will measure increases in the proportion of pregnant Syrian refugee women accessing their first antenatal care visits during the first trimester. The data will be collected from the next round of the Jordan Population and Family Health Survey (using the 2017/2018 survey data as a baseline). F. Social (including Safeguards) 60. The project is expected to contribute to positive social outcomes by maintaining access to primary and secondary health care services for the target population. The activities under the AF are the same as under the parent JEHP. Involuntary Resettlement (OP/BP 4.12) is not triggered for the AF, because 21 https://www.who.int/servicedeliverysafety/areas/people-centred-care/framework/en/. Accessed May 2018. 22 Olsen, Anell et al. “General practice in the Nordic countries.” Nordic Journal of Health Economics, Vol. 4 (2016), No. 1, pp. 56- 67. 23 Warlmels, Johnston & Turmey. “Improving team-based care for children: shared well child care involving family practice nurses.” Prim Health Care Res Dev. 2017 Sep; 18(5): 507–514. 24 “Avanzando hacia la equidad: Propuesta de Politicas e Intervenciones para Reducir las desigualdades sociales en salud en España. Comisión para Reducir las Desigualdades Sociales en Salud en España.” Ministerio de Política Social, May 2010. 25 “Chile, a good place of birth: Maternal and infant morbidity and mortality at global and national level” Revista Médica Clínica Las Condes (Elsivier). Volume 25, Issue 6, November 2014, Pages 874-878. Page 23 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) there is no land acquisition, or economic or physical displacement that will result from the project activities. 61. The potential adverse risks associated with the project relate to barriers to access to health care services being provided, particularly for vulnerable groups. The project, by design, is already targeting vulnerable populations of uninsured Jordanians, a portion of whom are poor, and Syrian refugees, most of whom are poor women and children and are extremely vulnerable. The parent project was successful in meeting its accessibility targets. Component 1 will continue to maintain access to primary and secondary services at significantly reduced costs, while ensuring quality through verified audits. 62. The project design is gender-sensitive and aligns well with the World Bank Gender Strategy which focuses, among other things, on improving gaps in human endowments. The GOJ has built capacities to provide gender-sensitive services to those in need, such as Syrian refugees and the poor uninsured Jordanians. The JEHP planned to provide TA for supply-side capacity building (mainly through training on GBV and barriers to access), the supply-side interventions have been well developed and supported by other development partners, such as UNICEF and UNFPA. Undisbursed funds under the parent project, which account for some of the undisbursed balance under the JEHP, initially planned to deliver supply-side interventions, will be used to strengthen health system’s response to GBV based on MOH’s priorities and potential shortcomings to address GBV. 63. Other risks relate to ineffective identification and communication to the target populations that may result in lack of demand for the services available. Uninsured Jordanians such as single-headed households and those who may be discouraged from seeking health care due to out-of-pocket payments, may not seek access to health care services. For the same reason, Syrian refugees, particularly those not holding the MOI service cards, may also face difficulties accessing health care services. 64. The mitigation measures include working with development partners and supporting new MOH outreach and communications activities to inform the target population about the new co-payment policies for Syrian refugees and, in collaboration with other relevant stakeholders (e.g., Health Directorates, UNHCR, health centers in locations with high presence of Syrian refugees, local nongovernmental organization [NGOs], and international donors) to disseminate information about the rights of Jordanians and Syrian refugees including on access to health services. For example, USAID, the Government of Denmark, and UNHCR are collaborating on a communication campaign. The campaign will include where and how to access health services and the changes introduced with regard to co-payments. Under the AF, the World Bank will collaborate and support these ongoing efforts. The GRM is in place and is accessible to the public through a hotline and website. The MOH tracks the number of complaints received, the number of complaints resolved, and the number of complaints in process. 65. Extensive consultations with relevant beneficiaries and stakeholders were conducted during the parent project implementation and design of the AF. These included discussions with patients and health providers at a comprehensive PHC center in Amman; director of the Maternal and Child Health Department (including family violence unit) at the MOH; bilateral agencies (USAID and the Government of Denmark); UN Agencies (UNFPA, UNICEF, WHO, and UNHCR); and international and local NGOs. Page 24 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) G. Environment (including Safeguards) 66. According to OP 4.01 on Environmental Assessment (EA), the AF is classified as Environmental Category C. Interventions to be supported by the AF are expected to have minimal or no direct environmental impacts. Similar to the parent project, the AF will not support civil works or construction, and will not fund any medical consumables (for example, vaccination kits, vials, and syringes), equipment, goods, or works. If the scope of the AF is revised to include any of the above, then the project will be subject to EA reclassification. 67. The AF was screened for climate and disaster risk and found to be at high risk from extreme temperature, precipitation, and drought. Mean annual temperature in Jordan is projected to increase by 2°C by 2050 with a higher projected rate of warming in the summer. This is coupled with a projected increase in the frequency of heat waves. The total annual hot days of temperature above 35°C will rise by 34.5 days by 2050. Annual precipitation rates show an increase in interannual rainfall variability, but overall have decreased at most meteorological stations in Jordan and mean annual precipitation is expected to continue to fall by −7.4 mm by 2050. The variability and expected increases in extreme weather events will have implications for flooding in Jordan. 68. The changes in extreme temperature may induce heat stress among the project's target population. Incidents of flooding already claim lives and destroy agricultural lands and infrastructure. Conversely, the projected increase in interannual rainfall variability is likely to exacerbate drought risk in the future as well. The combined effect of increasingly limited access to clean water contributes to increases incidences of waterborne diseases (typhoid, fever, cholera, Hepatitis A and E, giardiasis, and bilharzia); food-borne diseases through crop contamination; increased food insecurity; and malnutrition. The GOJ has been providing public services to Syrian refugees, who added to fiscal stress and increased demand for public services. The impacts of climate change are expected to exacerbate the demand for key health services, which, if pushed beyond capacity, may produce negative consequences for the health treatment of populations that are most vulnerable and least resilient to the impacts of climate change. Additionally, if costs are high for the delivery of key health services, the most vulnerable will be the least able to adapt to and cope with climate-induced shocks. With increasing risk of extreme weather disruption, risk to social stability will increase. 69. The AF will contribute to enhanced climate adaptation and resilience through the following activities. The project directly contributes to climate adaptation objectives of the health sector of Jordan’s Intended Nationally Determined Contribution and the National Climate Change Policy (2013–2020). 70. Component 1 provides funds to reduce financial barriers of highly vulnerable groups supporting access to primary and secondary health services. Increased health service access will be critical during climate change-induced extreme weather events and will particularly enhance the ability of the target beneficiaries, who are among the most climate vulnerable populations (Syrian refugees and poor uninsured Jordanians). 71. Component 2 uses non-scalable DLIs to accelerate progress toward sustainable UHC and to foster human capital development. Each of these will enhance population-level climate adaptation and resilience to climate change. Specifically, under subcomponent 2.1 (US$9 million), support for sustainable UHC will reward improved coverage and strengthened PHC services, through expansion of the family Page 25 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) health model, while fostering human capital development will target pregnant women, mothers, and children as one of its key health aims. Additionally, strengthening of primary health care will strengthen day-to-day health resilience to climate change through enhanced community access to services and increased utilization of health care. This will increase overall population resilience and the health sector more generally, to climate change. H. World Bank Grievance Redress 72. Communities and individuals who believe that they are adversely affected by a World Bank (WB) supported project may submit complaints to existing project-level grievance redress mechanisms or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate GRS, please visit http://www.worldbank.org/en/projects- operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org. Page 26 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) V SUMMARY TABLE OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Implementing Agency ✔ Project's Development Objectives ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Financial Management ✔ Procurement ✔ VI DETAILED CHANGE(S) COMPONENTS Current Component Name Current Cost Action Proposed Component Proposed Cost (US$, (US$, millions) Name millions) Results based financing to 48.00 Revised Results-based financing 238.00 deliver health care services to deliver health care at primary and secondary services at primary and care facilities of MOH for secondary care facilities the target population of MOH for the target population Independent verification 2.00 Revised Improving coverage and 11.64 and institutional capacity quality of the primary building to improve health care services efficiency of health services delivered Page 27 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) TOTAL 50.00 249.64 LOAN CLOSING DATE(S) Ln/Cr/Tf Status Original Closing Current Proposed Proposed Deadline Closing(s) Closing for Withdrawal Applications IBRD-87680 Effective 29-Jun-2019 29-Jun-2019 31-Oct-2023 29-Feb-2024 TF-A5308 Effective 29-Jun-2019 29-Jun-2019 31-Oct-2023 29-Feb-2024 Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative 2017 0.00 0.00 2018 0.00 0.00 2019 0.00 0.00 2020 101,160,020.00 101,160,020.00 2021 47,162,000.00 148,322,020.00 2022 19,162,000.00 167,484,020.00 2023 32,161,000.00 199,645,020.00 2024 0.00 199,645,020.00 SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Latest ISR Rating Current Rating Political and Governance ⚫ Moderate ⚫ Moderate Macroeconomic ⚫ Substantial ⚫ Substantial Sector Strategies and Policies ⚫ Moderate ⚫ Moderate Technical Design of Project or Program ⚫ Moderate ⚫ Moderate Institutional Capacity for Implementation and ⚫ Moderate ⚫ Moderate Sustainability Fiduciary ⚫ Substantial ⚫ Moderate Environment and Social ⚫ Low ⚫ Low Stakeholders ⚫ Substantial ⚫ Moderate Page 28 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) Other ⚫ High ⚫ Substantial Overall ⚫ Substantial ⚫ Substantial LEGAL COVENANTS2 LEGAL COVENANTS – Jordan Emergency Health Project Additional Financing (P170529) Sections and Description The Borrower shall: (a) cause the Audit Bureau to be responsible to conduct the Expenditure Verifications; (b) furnish the Expenditure Verification to the Bank no later than six (6) months after each Reported Period; (c) hire, no later than three (3) months after the Effective Date, and shall thereafter maintain, throughout Project implementation, the UVE, to conduct the Utilization Verification. The Borrower shall furnish Utilization Verification Audits no later than six (6) months after each Reported Period; and (d) furnish the Health Care Service Delivery Expenditure Report to the Bank, no later than six (6) months after each Reported Period. The Borrower shall open a dedicated special account within the Central Bank of Jordan for the exclusive benefit of MOH and transfer, from the Borrower’s budget, on an annual basis, and by no later than September 30, 2019 in the first year of the Project, and by no later than June 30 thereafter, an amount of $7,500,000 for each of the four years of implementation of the Project, on terms and conditions acceptable to the Bank, for the purpose of providing health care services for Syrian refugees. Conditions Page 29 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) VII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Jordan RESULT_NO_PDO Jordan Emergency Health Project Additional Financing Project Development Objective(s) The Project development objective (PDO) is to support the Government of Jordan in maintaining the delivery of primary and secondary health services to poor uninsured Jordanians and Syrian refugees at Ministry of Health facilities. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 PDO Indicators (Action: This Objective has been Revised) Maintaining number of health services delivered at MOH secondary health care facilities to target populations (Number 1,905.00 1,905.00 1,905.00 1,905.00 (Thousand)) Action: This indicator has been Revised Number of health services delivered at MOH secondary health care facilities 792.00 792.00 792.00 792.00 to poor uninsured Jordanians, male (Number (Thousand)) Action: This indicator has been Revised Number of health services delivered at MOH secondary health care facilities to poor uninsured Jordanians, female 1,009.00 1,009.00 1,009.00 1,009.00 (Number (Thousand)) Mar 20, 2019 Page 30 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Action: This indicator has been Revised Number of health services delivered at MOH secondary health care facilities 46.00 46.00 46.00 46.00 to registered Syrian refugees, male (Number (Thousand)) Action: This indicator has been Revised Number of health services delivered at MOH secondary health care facilities to registered Syrian refugees, female 58.00 58.00 58.00 58.00 (Number (Thousand)) Action: This indicator has been Revised Maintaining number of health services delivered at MOH primary health care 2,670.00 2,670.00 2,670.00 2,670.00 facilities to target populations (Number (Thousand)) Action: This indicator has been Revised Number of health services delivered at MOH primary health care facilities to poor uninsured Jordanians, male 1,115.00 1,115.00 1,115.00 1,115.00 (Number (Thousand)) Page 31 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Action: This indicator has been Revised Number of health services delivered at MOH primary health care facilities to 1,420.00 1,420.00 1,420.00 1,420.00 poor uninsured Jordanians, female (Number (Thousand)) Action: This indicator has been Revised Number of health services delivered at MOH primary health care facilities to registered Syrian refugees, male 59.00 59.00 59.00 59.00 (Number (Thousand)) Action: This indicator has been Revised Number of health services delivered at MOH primary health care facilities to 76.00 76.00 76.00 76.00 registered Syrian refugees, female (Number (Thousand)) Action: This indicator has been Revised Completion and dissemination of a health sector roadmap to improve the efficiency No No Yes Yes of services delivered (Yes/No) Rationale: Action: This indicator has been Marked for Deletion This indicator is marked for deletion as the roadmap has already been delivered by the MOH with support from other development partners. Page 32 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Results based financing to deliver health care services at primary and secondary care facilities of MOH for the target population (Action: This Component has been Revised) Grievances registered related to delivery of project benefits that are actually 100.00 100.00 100.00 100.00 addressed (Percentage) Action: This indicator has been Revised People who have received essential health, nutrition, and population (HNP) 0.00 1,101,290.00 services (CRI, Number) Number of children immunized (CRI, 0.00 1,101,290.00 Number) Review of the existing GRM mechanism No review conducted of the existing Review conducted of the existing (Text) GRM system GRM system Rationale: Action: This indicator is New Independent review of the existing GRM mechanism conducted Percentage increase in proportion of pregnant Syrian women accessing their 83.2% 84.8% first antenatal care visits during the first trimester (Text) Page 33 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Rationale: Action: This indicator is New Measures the increase in the proportion of pregnant Syrian refugee women accessing their first antenatal care visits during the first trimester. IO Table SPACE Monitoring & Evaluation Plan: PDO Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Governorate Maintaining number of health services Target will be maintained Every 6 Directorate of Primary health delivered at MOH secondary health care within 5% +/- the baseline months Health Care, MOH directorates facilities to target populations value of 1,905,000 Number of health services delivered Target will be maintained Governorate Every 6 Directorate of Primary at MOH secondary health care within 5% +/- the baseline health months Health Care, MOH facilities to poor uninsured value of 792,000: (752,000 directorates Jordanians, male – 832,000 Number of health services delivered Target will be maintained Governorate Every 6 Directorate of Primary at MOH secondary health care within 5% +/- the baseline health months Health Care, MOH facilities to poor uninsured value of 1,009,000: directorates Jordanians, female (959,000 – 1,059,000) Number of health services delivered Target will be maintained Every 6 Governorate Directorate of Primary at MOH secondary health care within 5% +/- the baseline months health Health Care, MOH facilities to registered Syrian refugees, value of 46,000: (44,000 – directorates Page 34 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) male 48,000) Number of health services delivered Target will be maintained Governorate Every 6 Directorate of Primary at MOH secondary health care within 5% +/- the baseline health months Health Care, MOH value of 58,000: (55,000 – facilities to registered Syrian refugees, directorates female 61,000) During the AF Governorate Maintaining number of health services period:Target will be Every 6 Directorate of Primary health delivered at MOH primary health care maintained within 5% +/- months Health Care, MOH directorates facilities to target populations the baseline value of 2,670,000 Target will be maintained Governorate Number of health services delivered Every 6 Directorate of Primary within 5% +/- the baseline health at MOH primary health care facilities months Health Care, MOH value of 1,115,000: directorates to poor uninsured Jordanians, male (1,059,000 – 1,170,000) Target will be maintained Governorate Number of health services delivered Every 6 Directorate of Primary within 5% +/- the baseline health at MOH primary health care facilities months Health Care, MOH value of 1,420,000: directorates to poor uninsured Jordanians, female (1,349,000 – 1,491,000) Target will be maintained Governorate Number of health services delivered Every 6 Directorate of Primary within 5% +/- the baseline health at MOH primary health care facilities months Health Care, MOH value of 59,000: (56,000 – directorates to registered Syrian refugees, male 62,000) Target will be maintained Governorate Number of health services delivered Every 6 Directorate of Primary within 5% +/- the baseline health at MOH primary health care facilities months Health Care, MOH value of 76,000: (72,000 – directorates to registered Syrian refugees, female 80,000) Page 35 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) Completion and dissemination of a health Every year MOH MOH sector roadmap to improve the efficiency of services delivered ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Directorate of Controls and Grievances registered related to delivery Every 6 Internal MOH of project benefits that are actually months Auditing, addressed MOH Ministry of Yearly Health Ministry of Health People who have received essential MOH Data Ministry of Health, Childhood Childhood Immunization health, nutrition, and population (HNP) by calendar Jordan Immunization records. services year. records. Ministry of Yearly Health Ministry of Health MOH data Childhood Childhood Immunization Ministry of Health. Number of children immunized by calendar Immunization records. year. records. Page 36 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) An independent review of Once (year MOH MOH Directorate MOH Review of the existing GRM mechanism the existing GRM system 4) will be conducted Jordan Population and Family Health Increase in the proportion Survey,Depart of pregnant Syrian women Percentage increase in proportion of ment of Jordan Population and accessing their first Every 5 pregnant Syrian women accessing their Statistics, Family Health Survey, Ministry of Health antenatal care visits during years first antenatal care visits during the first using the Department of Statistics the first trimester, above trimester 2017/2018 the baseline 83.2% survey data as (2017/2018) to 84.8%. baseline, 83.2% ME IO Table SPACE Page 37 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) Disbursement Linked Indicators Matrix DLI I N0068 5433 A CTI ON DLI 1 Assessment of PHC coverage & quality gaps Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 2,000,000.00 0.00 Baseline No assessment Year 1 0.00 MOH completes an assessment of gaps in human resources and skills needed to Year 2 incorporate a nationwide family health 2,000,000.00 services model based on WHO recommendations Year 3 0.00 Year 4 0.00 Action: This DLI is New Page 38 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) DLI I N0068 5920 A CTI ON DLI 1.1 Additional MOH budget allocation Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome No Text 1,000,000.00 0.00 US$776,091,777 (JOD 550,419,700), MOH Baseline current and capital expenditures, 2017 Year 1 0.00 MOH receives additional budget of US$1,000,000 in the Jordanian fiscal year 2020 Year 2 1,000,000.00 following declaration of effectiveness of the project Year 3 0.00 Year 4 0.00 Action: This DLI is New DLI I N0069 5560 A CTI ON DLI 1.2 MOH completes an assessment Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 1,000,000.00 0.00 Baseline No assessment Page 39 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) Year 1 0.00 MOH completes an assessment of gaps in human resources and skills needed to Year 2 incorporate a nationwide family health 1,000,000.00 services model based on WHO recommendations Year 3 0.00 Year 4 0.00 Action: This DLI is New DLI I N0068 5462 A CTI ON DLI 2 Development of an Implementation Plan to Improve Quality & Coverage of PHC Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 3,000,000.00 0.00 Baseline No implementation plan Year 1 0.00 Year 2 0.00 MOH develops and approves a costed and Year 3 phased implementation strategy with an M&E 3,000,000.00 system Page 40 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) Year 4 0.00 Action: This DLI is New DLI I N0068 5921 A CTI ON DLI 2.1 Additional MOH budget allocation Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome No Text 1,000,000.00 0.00 US$776,091,777 (JOD 550,419,700), MOH Baseline current and capital expenditures, 2017 Year 1 0.00 Year 2 0.00 MOH receives an additional budget of US$1,000,000 in the second consecutive Year 3 1,000,000.00 Jordanian fiscal year following declaration of effectiveness of the project Year 4 0.00 Action: This DLI is New Page 41 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) DLI I N0069 5581 A CTI ON DLI 2.2 MOH develops an implementation plan Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 2,000,000.00 0.00 Baseline No implementation plan Year 1 0.00 Year 2 0.00 MOH develops and approves a costed and Year 3 phased implementation strategy with an M&E 2,000,000.00 system Year 4 0.00 Action: This DLI is New DLI I N0068 5435 A CTI ON DLI 3 Human resources Capacity Building to Improve Outcomes in PHC Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 4,000,000.00 0.00 Human resources capacity building and Baseline training plan completed, and evaluation finalized Page 42 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) Year 1 0.00 Year 2 0.00 Year 3 0.00 MOH provides report on Year 1 implementation results of the human Year 4 4,000,000.00 resources capacity building and training activities Action: This DLI is New DLI I N0068 5922 A CTI ON DLI 3.1 Additional MOH budget allocation Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome No Text 2,000,000.00 0.00 US$776,091,777 (JOD 550,419,700), MOH Baseline current and capital expenditures, 2017 Year 1 0.00 Year 2 0.00 Year 3 0.00 Year 4 MOH receives additional budget of 2,000,000.00 US$2,000,000 in the third consecutive Page 43 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) Jordanian fiscal year following declaration of effectiveness of the project Action: This DLI is New DLI I N0069 5573 A CTI ON DLI 3.2 MOH provides report on results Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 2,000,000.00 0.00 Implementation plan activities not yet Baseline launched Year 1 0.00 Year 2 0.00 Year 3 0.00 MOH provides report on Year 1 implementation results of the human Year 4 2,000,000.00 resources capacity building and training activities Action: This DLI is New Page 44 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) Verification Protocol Table: Disbursement Linked Indicators DLI_T BL_VERIFICATI ON DLI 1 Assessment of PHC coverage & quality gaps MOH completes an assessment of gaps in human resources and skills needed to incorporate a nation-wide family health services model based on WHO recommendations including (i) mother and child health, nutrition, growth and development Description monitoring,); and, (ii) prevention and early diagnosis of diabetes, hypertension and breast cancer Primary Health Care Department, MOH Data source/ Agency World Bank Verification Entity Review by World Bank Procedure DLI_T BL_VERIFICATI ON DLI 1.1 Additional MOH budget allocation DLI#1.1: From the baseline of US$776,091,777 (JOD 550,419,700) (MOH’s expenditures in the2017 budget), MOH receives Description additional budget of US$1,000,000 in the first Jordanian fiscal year 2020 following declaration of effectiveness of the project MOH expenditure framework and Ministry of Finance (MOF) approved annual budget Data source/ Agency MOH Budget Directorate Verification Entity MOH Budget Directorate confirms that the intended additionality from the baseline is reflected Procedure DLI_T BL_VERIFICATI ON DLI 1.2 MOH completes an assessment Page 45 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) MOH completes an assessment of gaps in human resources and skills needed to incorporate a nation-wide family health services model based on WHO recommendations including (i) mother and child health, nutrition, growth and development Description monitoring,); and, (ii) prevention and early diagnosis of diabetes, hypertension and breast cancer Primary Health Care Department, MOH Data source/ Agency World Bank Verification Entity Review by World Bank Procedure DLI_T BL_VERIFICATI ON DLI 2 Development of an Implementation Plan to Improve Quality & Coverage of PHC MOH develops and approves a costed and phased implementation strategy with a M&E system, incorporating feedback and Description inputs from all health directorates and development partners Primary Health Care Department, MOH Data source/ Agency World Bank Verification Entity Review by World Bank Procedure DLI_T BL_VERIFICATI ON DLI 2.1 Additional MOH budget allocation From the baseline of US$776,091,777 (JOD 550,419,700) (MOH’s expenditures in the 2017 budget) MOH receives additional Description budget of US$1,000,000 in the second consecutive Jordanian fiscal year following declaration of effectiveness of the Project Data source/ Agency MOH expenditure framework and MOF approved annual budget Page 46 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) MOH Budget Directorate Verification Entity MOH Budget Directorate confirms that the intended additionality from the baseline is reflected Procedure DLI_T BL_VERIFICATI ON DLI 2.2 MOH develops an implementation plan MOH develops and approves a costed and phased implementation strategy with a M&E system, incorporating feedback and Description inputs from all health directorates and development partners Primary Health Care Department, MOH Data source/ Agency World Bank Verification Entity Review by World Bank Procedure DLI_T BL_VERIFICATI ON DLI 3 Human resources Capacity Building to Improve Outcomes in PHC MOH provides report on year 1 implementation results of the human resources capacity building and training activities as Description designed in the implementation strategy under DLI 2.2 Primary Health Care Department Data source/ Agency World Bank Verification Entity Review by World Bank Procedure DLI_T BL_VERIFICATI ON Page 47 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) DLI 3.1 Additional MOH budget allocation From the baseline of US$776,091,777 (JOD 550,419,700) (MOH’s expenditures in the 2017 budget) MOH receives additional budget of US$2,000,000 in the third consecutive Jordanian fiscal year following declaration of effectiveness of the Project Description MOH expenditure framework and MOF approved annual budget Data source/ Agency MOH Budget Directorate Verification Entity MOH Budget Directorate confirms that the intended additionality from the baseline is reflected Procedure DLI_T BL_VERIFICATI ON DLI 3.2 MOH provides report on results MOH provides report on year 1 implementation results of the human resources capacity building and training activities as Description designed in the implementation strategy under DLI 2.2 Primary Health Care Department Data source/ Agency World Bank Verification Entity Review by World Bank Procedure Page 48 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) Annex 1: Financial Management 1. The World Bank updated the assessment of the FM systems that was conducted during the preparation of the ongoing JEHP. The assessment concluded that, with the implementation of agreed- upon actions, the proposed FM arrangements will satisfy the minimum requirements under the World Bank Policy on Investment Project Financing. The FM risk is rated Moderate. 2. Project expenditures and funds flow arrangements. The bulk of the AF proceeds will finance part of the cost for delivering health care services to the target populations, which will be up to US$12 per beneficiary for primary care and US$63 per beneficiary for secondary care. The costs will mainly cover the MOH’s expenditures for key recurrent nonmedical expenditures, such as human resources and operating costs of health facilities, including rental and utilities (water, electricity, and fuel). As with the ongoing JEHP, the AF will not finance the cost of medical items such as vaccines, medicines, equipment, or consumables. The unit cost of delivering one primary or secondary health service will be calculated by dividing the total actual costs paid by the MOH by the number of health services delivered to the target population at MOH facilities. The cost of primary and secondary health services provided to the target population will be estimated by multiplying the cost per unit of services by the number of primary and secondary care services delivered at MOH facilities. 3. Two DAs will be used to receive the AF proceeds. One DA-A will be used to receive funds under Component 1 and subcomponent 2.1, while the DA-B will be used to receive the funds under subcomponent 2.1. The DA-A funds will be ultimately credited to the STA at the Central Bank of Jordan (CBJ). For Component 1, up to US$30 million is envisaged as part of the retroactive financing for primary and secondary health care services eligible expenditures, as long as they were made before the signing of the Loan Agreement but on or after June 30, 2018, and were not financed by the ongoing JEHP. 4. Under Component 1 (reflected in Category 1 in the Loan Agreement Withdrawal Schedule), two semiannual disbursements will take place, and each disbursement will cover six months of recurrent nonmedical expenditures. Each disbursement will be verified by the Jordan AB and UVE within 6 months following each reported period, with an exception for the first two advances. The AB and UVE will verify the outputs and the actual amount due and will submit their reports to the World Bank through MOPIC. 5. Disbursements under subcomponent 2.2 (reflected under Category 2 in the Loan Agreement Withdrawal Schedule) will be based on respective DLIs. Disbursements will be made against actual inputs (i.e., expenditures) only when related DLIs have been achieved and verified. Disbursements under Category 2 will be contingent upon the GOJ furnishing evidence satisfactory to the World Bank that it has achieved the respective DLIs and these will be verified by the World Bank team. Reconciliation against actual expenditures will be incurred during the same period. Applications for withdrawal of amounts allocated to individual DLIs may be sent to the World Bank any time after the World Bank has notified the GOJ in writing that it has accepted evidence of achievement of the DLIs. The withdrawal amount against the DLIs achieved will not exceed the amount of the financing confirmed by the World Bank for the specific Page 49 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) DLIs, which will be up to the lesser of the actual expenditure incurred or the DLIs achieved and the verified respective allocation. 6. The AF proceeds will be disbursed in accordance with the World Bank’s disbursements guidelines. This will be outlined in the Disbursement Letter and in accordance with the World Bank’s Disbursement Guidelines for projects. The project will follow IFR-based disbursement. Therefore, requests for payments will be initiated through the use of withdrawal applications either for direct payments, reimbursements, and replenishments to the DA. All withdrawal applications will include appropriate supporting documentation. The documentation supporting expenditures (including the financial audit report of retroactive financing) will be retained at the MOH and readily accessible for review by the external auditors and World Bank supervision missions. All disbursements will be subject to the provisions of the Loan Agreement and disbursement procedures as defined in the Disbursement Letter. 7. FM implementation arrangements. MOPIC will continue to manage the FM and disbursement functions of the AF. The current financial officer from the MOPIC Finance Department will continue to follow on the project’s FM and disbursement issues. In addition, a part-time financial officer will be hired at the MOH to work closely with MOPIC/financial officer on providing necessary financial information and documentation. 8. Planning and budgeting through the use of the existing GFMIS system. MOPIC and the MOH use systems for budget classification and a Chart of Accounts (COA) that conforms to international standards and deploys a basic, but effective, results-oriented budgeting framework, which provide the means to track government spending. Line ministries, including the MOH, have a robust classification system broadly consistent with the Government Finance Statistics Manual (GFSM) 2001. This system includes administrative, economic, functional, geographical, and program classifications. These classifications are included in the current COA allowing for all transactions to be reported in accordance with the appropriate standards. A GFMIS is used for budget preparation. 9. Accounting and financial reporting. Much like other line ministries in Jordan, the MOH has a cash basis for accounting. The Government adopts a COA that is compatible with GFSM 2001. The MOF has rolled out the GFMIS to all line ministries in Jordan, including the MOH and MOPIC. The current GFMIS implementation uses a subset of the functionalities of the underlying application software. The current core application software comprises: (a) Hyperion for budget preparation; (b) ORACLE financials for budget execution; and (c) software for interfacing with other software for debt management, payroll, bank reconciliation, and revenue management. The GFMIS is fully used for budget execution. Yet, for budget preparation, there are manual interventions with various information and communication technology tools being used. MOPIC will be responsible for preparing the semiannual IFRs and annual project financial statements. For annual financial reporting of the project, it is proposed to rely on existing arrangements to capture financial transactions. However, annual and semiannual financial reporting will be generated using Excel sheets. The IFRs will be submitted by MOPIC to the World Bank within 45 days after the end of the concerned period. Page 50 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) 10. Internal controls and internal audit. Budget execution controls are implemented and applied consistently by MOPIC and the MOH in accordance with the applicable Financial Bylaw (1994) and its Amendment (2015), and the Financial Control Bylaw (2011) and its Amendment (2015). The budget execution systems at MOPIC and the MOH implement prescribed controls, which include: (a) technical approval by the beneficiary department; (b) finance staff checking and approval; (c) periodic, ad hoc reviews by resident internal auditors; and (d) exercise of an expenditure controlling function by the MOF’s financial controllers assigned to respective spending units. The MOF assigned financial controllers to oversee transaction-based compliance controls over payments, recording of transactions, and production of periodic and final accounts by responsible entities. In practice, no payments can be authorized and processed before financial controllers verify and sign off on payment vouchers. In addition to resident financial controllers from the MOF, MOPIC and the MOH have internal auditors who mainly perform the job of internal/financial controllers. Internal audit activities are primarily confined to ex ante review of receipts, expenditure vouchers, and disbursements. Ex ante controls are performed by financial controllers and internal auditors. 11. Payroll. Because salaries and wages make up a significant part of the cost of primary and health services provided by the MOH and financed by the project, a review of diagnostic public financial management reports and an assessment of the MOH payroll system was conducted. According to the 2017 Public Expenditure and Financial Accountability Assessment for Jordan, the controls over payroll were rated as ‘A’, with a key role being played by the Internal Control Unit (ICU) in each ministry, including the MOH. The ICU exercises a preaudit role that involves the review of individual salaries and ensures compliance with the bylaw. It submits four reports per year to the MOF and the AB of Jordan and informs the Civil Service Bureau (CSB). Payroll audits are carried out by both the CSB and the AB. The CSB’s role relates to administrative matters such as whether the MOH is following the performance appraisal system correctly and matching job descriptions correctly to posts. Employing the International Organisation of Supreme Audit Institutions (INTOSAI) standards, the AB carries out an annual payroll audit of all ministries including the MOH using a specially developed audit program that incorporates a system review, sampling, and review of the regulatory framework. 12. The payroll system in place has a good degree of integration and reconciliation between the position controls, personnel records, and payroll registers. The payroll system at the MOH follows the CSB’s instructions and is in line with the national financial law and internal controls regulation, in addition to instructions issued by the MOF. The Human Resources Department at the MOH is responsible for receiving and entering the information for the appointed employee into the automated human resources database system. The Human Resources Department safeguards the information and the data entry through an automated system with record archival both in the system and in paper files. Human resources input in the system is subject to both automated and human checks. A payroll schedule is prepared on a monthly basis and subject to several layers of approvals (payroll officer, head of Payroll Unit, department manager (budget holder), Internal Control Department, MOF financial controller, and FM manager). Salaries are transferred to employees’ personal bank accounts. Monthly reconciliations are prepared in the system and shared with the ICU and MOF representative. Daily time attendance sheets, based on an Page 51 of 52 The World Bank Jordan Emergency Health Project Additional Financing (P170529) automated attendance register, are maintained by the attendance supervisor, who reports absences to HR and the responsible department. Supervisors confirm that they strictly ensure all employees are in place and functional. For additional assurance over payroll, the external auditor hired for the project will also provide an opinion on the internal controls over payroll at the MOH and the MOH hospitals and centers that provide primary and secondary services financed by the loan. 13. External verification and auditing. The project will have three types of audits: (a) an expenditure verification to check the eligibility of expenditures made, which will be carried out by the AB within six months of each advance; (b) a utilization verification to track the delivery of health services to the target populations, which will be carried out by a UVE, within six months of each advance; and (c) annual financial statement audit due six months after the end of each year, which will be carried out by the AB. The latter’s scope of work will also include providing an audit opinion on the internal controls over payroll at the MOH and the MOH hospitals and centers that provided primary and secondary services financed by the loan. Page 52 of 52