PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB7285 Project Name Additional Financing Health Sector Development Support Project Region AFRICA Country Zimbabwe Sector Health (70%); Public administration- Health (30%) Project ID P144532 Parent Project ID P125229 Borrower(s) REPUBLIC OF ZIMBABWE Implementing Agency CORDAID Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared April 10, 2013 Date of Appraisal May 7, 2013 Authorization Date of Board Approval June 28, 2013 1. Country and Sector Background (i) Zimbabwe is a landlocked country in Southern Africa with a population estimated at 12.6 million in 2010, of which the majority (65%) live in rural areas. The combined effects of the HIV/AIDS epidemic, which peaked in 1998, and of the socio economic and political crises of 2000-2008, caused large-scale disruptions to society and unravelled the impressive human development indicators the country had achieved from 1980 to the mid-1990s. The once well- organized public service delivery system went into steady decline from 2000, reaching a point of total collapse in 2008. The GDP fell by more than 35% during the eight year period, and hyperinflation peaked in September 2008 at about 500 billion percent before the introduction of the multiple currency regime. (ii) The historic power-sharing agreement between the Zimbabwe African National Union (Patriotic Front) (ZANU PF) and the two Movement for Democratic Change (MDC) formations signed on September 15, 2008 formed the basis of an Inclusive Government. In February 2009 the new Government introduced economic reforms to stabilize the economy. These reforms have had a substantial positive effect and the economy has begun to show some signs of recovery1. In addition, the Government has created an enabling environment for social sector ministries, in particular, to launch efforts to stabilize the humanitarian situation and restore delivery of basic services. 1 World Bank 2011 (iii) Various studies and surveys carried out in Zimbabwe over the last three years point towards inadequacies in the six health system building blocks (human resources; medical products, vaccines and technology; health financing; health information; service delivery; and leadership and governance) that are prerequisites for a functional health delivery system. Zimbabwe’s health system is characterized by: (i) a deficit of medical and managerial health professionals; (ii) inadequate provision and maintenance of medical supplies, equipment and infrastructure; and (iii) disrupted transportation and communications systems, especially at the primary care level. The human resource situation is particularly serious, with the system facing severe challenges in training, financing, monitoring, and retaining health workers. 2. Objectives To increase coverage of key maternal and child health interventions in targeted districts consistent with the Recipient’s ongoing health initiatives. The proposed additional financing for the Health Sector Development Support Project (HSDS) is US$ 20 million, and would bring the total project amount to US$ 35 million. 3. Rationale for Bank Involvement Before the onset of the socio-economic crisis in 2001, Zimbabwe had one of the best health systems in sub-Saharan Africa, with reliable infrastructure functional down to the village level. Thanks to an elaborate network of health facilities, up to 85 percent of Zimbabweans lived within 10 km of a health facility. However, gains in the health sector began to unravel during the economic and political crises, after which Zimbabwe’s per capita expenditure on health went into steady decline, particularly between 2005 and 2008. The current budgetary allocation for health is approximately US$ 19 per capita per annum against the World Health Organization’s recommendation of at least US$34. Zimbabwe’s health system today is faced with multiple challenges, including but not limited to: (i) a deficit of medical and managerial health professionals; (ii) inadequate provision and maintenance of medical supplies, equipment and infrastructure; and (iii) disrupted transportation and communications systems, especially at the primary care level. On the demand side, the decline in funding from central government has led to a gradual transfer of the financial burden to patients in the form of user fees. These fees constitute a large obstacle to the accessibility of health services for the poor. The 2007 Maternal and Perinatal Mortality Study conducted by the Ministry of Health and Child Welfare (MOHCW) shows, for example, that 39 percent of the population could not afford to pay hospital user fees. The Demographic and Health Survey (DHS) 2005/06, Multiple Indicator Monitoring Survey 2009 and the DHS 2010/11 all reflect growing gaps in access and utilization of health services between rural and urban populations and between the highest and lowest income groups of the population. In this context, the Bank has been supporting the Government to address health challenges and make progress towards MDGs 1c, 4 and 5 to reduce child mortality and improve maternal health through the HSDS Project with a Specific Investment Grant in the amount of US$ 15 million. This project was approved on March 3, 2011 by the Bank’s Executive Board2 and became effective on December 8, 2011 with a closing date of July 31, 2014. The Bank’s support through the HSDS Project is seen as an important instrument to: (i) increase demand and utilization of priority maternal and child health (MCH) services; (ii) strengthen performance of health facilities; and (iii) restore basic services that had collapsed during the economic and political crises. 4. Description The project’s technical design has three components: Component 1: Supply-side RBF and Demand-Side RBF a) Supply-side RBF: Results-based contracts with Provincial Health Executives, District Health Executives, District Hospitals, and Rural Health Centers for the delivery of a package of key maternal and child health services in 18 current project rural districts. 1. The project will continue to finance performance-based payments to Rural Health Centers (RHCs) and District Hospitals (DHs) on a fee-for-service basis, which will take into account the quantity and quality of services as well as the remoteness level of the facility. The fee levels are determined by a number of factors including: (a) income currently generated by user fees which will be forgone; and (b) public health goals. Monitoring will continue to take place to ensure adequate delivery of non-targeted services. Community surveys conducted with the support of Community Based Organizations (CBOs) and a counter verification agency (currently the University of Zimbabwe, Department Of Community Medicine) will be used to ensure there are no user fees charged to the patients for the services covered by the project. 2. The project will continue to strengthen the ability of the District Health Executives (DHEs) and Provincial Health Executives (PHEs) to supervise the quantity and quality of RHCs and DHs respectively, in the implementation of the agreed package of maternal and child health services. 2 The Board approved use of the Multi-donor Trust Fund for Health Results Innovation in Zimbabwe, on March 3, 2011. 3. Based on findings from the mid-term review of the project in February 2013, the current package of MCH services will be broadened. Possible additional interventions include: screening of cervical cancer using the low cost visual inspection with acetic acid (VIA) method, blood transfusion for relevant emergency obstetric care (EMoC), and post abortion care. The additional interventions and their costs will be finalized during the preparation phase for the Additional Financing. 4. The project will continue to support efforts to improve quality of maternal and child care in RHCs and DHs. Payment indicators for hospitals will be broadened to include additional quality of care indicators—which includes performance and completion of maternal and perinatal audits, management of gestational hypertension (which contributes to 11.5 percent of perinatal mortality), and interventions to strengthen management of pre or postnatal hemorrhage (which contributes to 14 percent of maternal mortality cases in Zimbabwe). b) Demand and supply-side RBF for low-income urban families (New Sub-component) 5. This urban sub-component of RBF introduces three new interventions in two low-income urban health districts, one from each of the two largest cities in Zimbabwe (Harare and Bulawayo): (i) a voucher mechanism targeted at the poorest 20 percent of households for free access to a package of maternal, new-born and family planning services; (ii) a performance-based payment mechanism which seeks to strengthen the quality of services offered by municipal health facilities; and (iii) a performance-based grant mechanism for CBOs which strengthens community involvement in building health awareness and health seeking. This sub-component will therefore aim to: (i) protect the urban poorest from financial catastrophe due to maternal/neonatal emergencies, (ii) improve quality of services in urban public facilities through incentivizing the quality indicators and (iii) improve health behaviors of the urban poor. 6. The voucher will entitle mothers and neonates to access free care from designated public health facilities. In the event a patient opts for a private provider in the selected urban health district, the voucher will constitute a subsidy towards the cost of accessing care from accredited private providers. 7. Counter verifications for both sub-components will be conducted ex-post in a sample of facilities by an independent organization (the University of Zimbabwe, Department of Community Medicine was awarded the tender to undertake counter verifications until July 2013). Regional CBOs will be contracted by the Project Implementing Entity (PIE) to conduct patient interviews to measure satisfaction. In addition, CBOs will verify the authenticity of self-reported health facility data on services provided in a given period. Internal verification for quantity of health services will be done by the PIE while internal verification for quality will continue to be led by District Health Executives and Provincial Executives. To complement internal and counter verifications, social accountability interventions such as the use of mobile phone texting by members of the community to a central number at the District Health Executive or PIE offices will be explored. Component 2 Management and Capacity Building in Results-Based Financing 8. This component will continue to support management and capacity building for HCCs, RHCs, DHEs, PHEs, DHs, and District Steering Committees for effective implementation of the RBF initiative. The component covers: (i) governance and strategic RBF management capacity for District Steering Committees; (ii) improvements of the Health Management Information System; (iii) institutionalization of an RBF and health financing institution in Zimbabwe; (iv) training for DHEs and PHEs on the use of the quality supervision tool and innovate ways to improve the verification and supervision process; and (v) mentoring and peer learning among RBF stakeholders to learn from implementation. Component 3 Monitoring and Documentation 9. This component will support monitoring, evaluation and documentation of the project. This component will finance the aggregation of results and the analysis of the data to monitor trends in coverage of services in project districts. The RBF program has been designed to enable learning through a rigorous impact evaluation3 combined with process and qualitative reviews to capture the effect of the program on health outcomes and various aspects of the health system. Equity will be assessed through household surveys and exit interviews during health facility assessments using an asset index to assess socio- economic status. 10. A key feature in the additional financing phase will be the rolling out of a process evaluation to strengthen learning from demand and supply side RBF intervention by the Government, Cordaid, health facility managers and the Bank. 5. Financing Source: ($m.) Borrower 1 Health Results-based Financing 20 Total 21 3 The impact evaluation will be financed through a separate Bank executed trust fund. 6. Implementation (i) Implementation arrangements for the Additional Financing will remain the same as those for the parent project with Cordaid serving as the Project Implementing Entity (PIE) for the project. In line with this, Cordaid will continue both purchasing and fund-holding functions in the 18 rural districts. The Ministry of Finance will second a team that will work closely with Cordaid on fund-holding aspects of the RBF mechanism with a view to promote ownership and skills transfer to the Government. In addition, during annual reviews of the project, assessments will be undertaken on roles and responsibilities to identify opportunities for further integration of the RBF into government structures. (ii) Cordaid will serve as the fund-holder for the urban sub-component. The urban sub- component will introduce a multi-sectoral element as reflected by key roles various ministries and municipalities will play. The Ministry of Labor and Social Services (MoLSS) will play a key role in targeting eligible households and in conducting community spot checks to ensure the voucher scheme is providing planned benefits. Municipalities will directly participate in both the voucher scheme and the performance based subsidies which will be based on pre-agreed quality indicators. City health managers from the City Health Services Departments will supervise the quality of services of their facilities and participating private health providers. Ministry of Local Government will oversee performance of local authorities and adherence to service delivery standards. MOHCW will continue to play the regulatory role as well as oversight of standards it sets at national level. 7. Sustainability The Government established a National Task Force to lead efforts to plan for sustaining of RBF. The Ministry of Finance already created a line item in the national budget to co-finance RBF. US$ 1 million was availed for 2013. The Bank is supporting the Government to plan for sustainability of the project. 8. Lessons Learned from Past Operations in the Country/Sector The key lesson learned from 22 months of implementing HSDS is that quality supervision tools should be modified over time. In early stages of the project, structural quality is more important. However, in later stages, modifications are necessary to focus the supervision tools on clinical quality of care to ensure that clinical quality improvements occur and are rewarded accordingly. In addition, quality supervision tools are an effective mechanism to enforce safeguards issues. Community engagement is important for the success of RBF. Building on successful engagement of the communities under the original project, efforts will be made to replicate the community model under the new urban sub-component of the project. 9. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Piloting the Use of Borrower Systems to Address Environmental and Social Issues in Bank-Supported Projects (OP/BP 4.00) Environmental Assessment (OP/BP 4.01) X Natural Habitats (OP/BP 4.04) X Pest Management (OP 4.09) X Physical Cultural Resources (OP/BP 4.11) X Involuntary Resettlement (OP/BP 4.12) X Indigenous Peoples (OP/BP 4.10) X Forests (OP/BP 4.36) X Safety of Dams (OP/BP 4.37) X Projects in Disputed Areas (OP/BP 7.60)* not eligible for piloting under OP 4.00 Projects on International Waterways (OP/BP 7.50) not eligible for piloting under OP 4.00 10. List of Factual Technical Documents National Health Care Management Waste Plan 2011 11. Contact point Contact: Ronald Upenyu Mutasa Title: Operations Officer Tel: (202) 458-7454 Fax: (202)-473-8216 Email: rmutasa@worldbank.org Implementing Agencies: Ministry of Health and Child Welfare Contact: Brigadier General (Dr.) Gwinji Title: Permanent Secretary 4th Floor, Kaguvi Building Harare Zimbabwe Tel: +263-4-798537-60 Fax: +263-4-729154/ 793634 Email: ggwinji@gmail.com * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas Cordaid Zimbabwe Contact: Ms. Arjanne Rietsema Title: Head of Mission 21 Argyle Road Avondale Harare Zimbabwe Tel: 263 (4) 735123 Email: arjanne.rietsema@cordaid.net 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop