Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD923 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT PAPER ON A PROPOSED ADDITIONAL CREDIT IN THE AMOUNT OF SDR 13 MILLION (US$20 MILLION EQUIVALENT) WITH AN ADDITIONAL GRANT FROM THE HEALTH RESULTS INNOVATION TRUST FUND (HRITF) IN THE AMOUNT OF US$20 MILLION . TO THE . REPUBLIC OF CAMEROON . FOR THE HEALTH SECTOR SUPPORT INVESTMENT PROJECT May 30, 2014 Health, Nutrition and Population (AFTHW) Country Department AFCC1 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 March 31st, 2014) Currency Unit = XAF XAF 475 = US$1 US$1 = SDR 0.64698537 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AEDES European Agency for Development and Health AF Additional Financing ASLO Association Locale (Local Association) CBO Community-based organization CHW Community health worker DALY Disability-Adjusted Life Years ECAM3 Third Cameroon Household Survey EPA Enhanced Program Assessment FBO Faith Based Organization FM Financial Management FSPS Fonds Spéciaux de Promotion de la Santé (Special Funds for Health Promotion) GDP Gross Domestic Product HF Health facility HRITF Health Results Innovation Trust Fund IDA International Development Association IP Indigenous People IPPF Indigenous Peoples Planning Framework MCH Maternal and Child Health MINEPDED Ministry of Environment, Nature Protection and Sustainable Development MWMP Medical Waste Management Plan MOH Ministry of Health MDG Millennium Development Goals NGO Non-governmental organization ORAF Operational Risk Assessment Framework PBF Performance Based Financing PDO Project Development Objective PIU Project Implementation Unit PPA Performance Purchasing Agency PPP Purchasing Power Parity TB Tuberculosis 2 UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WB World Bank WFP World Food Program Vice President: Makhtar Diop Country Director: Gregor Binkert Sector Manager: Trina S. Haque Task Team Leader: Gaston Sorgho 3 CAMEROON ADDITIONAL FINANCING – CAMEROON HEALTH SECTOR SUPPORT INVESTMENT PROJECT (P146795) CONTENTS Project Paper Data Sheet 5 Project Paper I. Introduction 16 II. Background and Rationale for Additional Financing 17 III. Proposed Changes 21 IV. Appraisal Summary 27 Mandatory Annexes 1. Revised Results Framework and Monitoring Indicators 36 2. Operational Risk Assessment Framework 41 3. Country Map 46 LIST OF FIGURES Figure 1: PBF service delivery arrangements ............................................................................... 25 Figure 2: Institutional Arrangements for implementation ............................................................ 28 Figure 3: Fund flows for IDA ....................................................................................................... 31 Figure 4: Fund Flows for Trust Funds .......................................................................................... 31 LIST OF TABLES Table 1: Health Project Key indicators for Littoral, North-West, South-West and East regions of Cameroon…………………………………………………………..……………….…………………...........20 Table 2: Target population, Northern Regions, Cameroon........................................................... 25 Table 3: Project outcome indicators ............................................................................................. 26 Table 4: Costs by component........................................................................................................ 27 4 ADDITIONAL FINANCING DATA SHEET Cameroon Additional Financing to Cameroon Health Sector Support Project ( P146795 ) AFRICA AFTHW . Basic Information – Parent Parent Project ID: P104525 Original EA Category: B - Partial Assessment Current Closing Date: 31-Jan-2016 Basic Information – Additional Financing (AF) Additional Financing Project ID: P146795 Scale Up Type (from AUS): Regional Vice President: Makhtar Diop Proposed EA Category: B - Partial Assessment Expected Effectiveness Country Director: Gregor Binkert 21-Aug-2014 Date: Sector Director: Tawhid Nawaz Expected Closing Date: 31-Dec-2017 Sector Manager: Trina S. Haque Report No: PAD923 Team Leader: Gaston Sorgho Borrower Organization Name Contact Title Telephone Email Ministry of Public Health 237-22-22-35-25 Project Financing Data – Parent ( Cameroon Health Sector Support Investment (SWAP)- P104525 ) Key Dates Approval Effectiveness Original Revised Project Ln/Cr/TF Status Signing Date Date Date Closing Date Closing Date Effectiv P104525 IDA-44780 24-Jun-2008 30-Oct-2008 03-Mar-2009 31-Mar-2014 31-Jan-2016 e P104525 TF-58012 Closed 28-Feb-2007 28-Feb-2007 28-Feb-2007 07-Dec-2007 07-Jun-2008 Disbursements % Cancelle Disburse Undisbur Project Ln/Cr/TF Status Currency Original Revised Disburse d d sed d Effectiv P104525 IDA-44780 USD 25.00 25.00 0.00 19.49 4.00 77.95 e P104525 TF-58012 Closed USD 0.50 0.24 0.26 0.24 0.00 100.00 5 Project Financing Data – Additional Financing Additional Financing to Cameroon Health Sector Support Project ( P146795 ) [ ] Loan [X] Grant [ ] IDA Grant [X] Credit [ ] Guarantee [ ] Other Total Project Cost: 40.00 Total Bank Financing: 40.00 Financing Gap: 0.00 Financing Source – Additional Financing (AF) Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) 20.00 HRITF 20.00 Total 40.00 Policy Waivers Does the project depart from the CAS in content or in other significant No respects? Explanation Does the project require any policy waiver(s)? No Explanation Team Composition Bank Staff Name Title Specialization Unit Aissatou Chipkaou Operations Analyst Operations AFTHW Daniele A-G. P. Jaekel Operations Analyst Operations AFTHW Gaston Sorgho Team Lead, Lead Public Public Health AFTHD Health Specialist Faly Diallo Finance Officer Finance CTRLA Kouami Hounsinou Senior Procurement Procurement AFTPW Messan Specialist Emeran Serge M. Senior Environmental Environment AFTN1 Menang Evouna Specialist Enagnon Ernest Eric Financial Management Financial Management AFTMW Adda Specialist Natalie Tchoumba Program Assistant Task Management, AFCC1 Bitnga Operational Support 6 Omer Ramses Zang Consultant Statistics AFTHW Sidjou Paul Jacob Robyn Co-Team Lead, Health Public Health AFTHW Specialist Haoussia Tchaoussala Procurement Specialist Procurement AFTPW Lucienne M. M'Baipor Senior Social Social Development AFTCS Development Specialist Nneoma Veronica Counsel Counsel LEGAM Nwogu Non Bank Staff Name Title Office Phone City Locations Country First Administrative Location Planned Actual Comments Division Cameroon South-West South-West Region X Province Cameroon North-West North-West Region X Province Cameroon North Province North Province X Cameroon Littoral Province Littoral Region X Cameroon Far North Far North X Cameroon East East X Cameroon Adamaoua Adamaoua X Institutional Data Parent ( Cameroon Health Sector Support Investment (SWAP)-P104525 ) Sector Board Health, Nutrition and Population Sectors / Climate Change Sector (Maximum 5 and total % must equal 100) Major Sector Sector % Adaptation Mitigation Co- Co-benefits % benefits % Health and other social services Health 60 Public Administration, Law, and Central government 20 7 Justice administration Health and other social services Other social services 10 Public Administration, Law, and Sub-national 10 Justice government administration Total 100 Themes Theme (Maximum 5 and total % must equal 100) Major theme Theme % Human development Health system performance 25 Human development Tuberculosis 25 Human development Child health 25 Human development Population and reproductive health 13 Human development HIV/AIDS 12 Total 100 Additional Financing Additional Financing to Cameroon Health Sector Support Project ( P146795 ) Sector Board Health, Nutrition and Population Sectors / Climate Change Sector (Maximum 5 and total % must equal 100) Major Sector Sector % Adaptation Mitigation Co- Co-benefits % benefits % Health and other social services Health 70 Public Administration, Law, and Central government 20 Justice administration Public Administration, Law, and Sub-national 10 Justice government administration Total 100 I certify that there is no Adaptation and Mitigation Climate Change Co-benefits information applicable to this project. Themes Theme (Maximum 5 and total % must equal 100) 8 Major theme Theme % Human development Health system performance 25 Human development Population and reproductive health 25 Human development Child health 25 Human development Tuberculosis 13 Human development HIV/AIDS 12 Total 100 Summary of Proposed Changes The overall objective of this Additional Financing, which does not differ from the original project, is to improve health outcomes among women and children in targeted areas of Cameroon. To that end, the PDO also remains the same and it is to increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases. A grant from the Health Results Innovation Multi Donor Trust Fund (HRITF) of US$20 million will be used in the original project areas for two purposes: (i) to scale-up the activities of the project in the 26 districts currently implementing Performance-Based Financing (PBF) through extending PBF to the impact evaluation control group facilities) and (ii) to allow for the impact evaluation to be completed and results used to fine tuning PBF national strategy. The proposed Additional Financing will help to better align IDA’s support to Cameroon’s health system with an enhanced focus on results. It will also support the Government’s commitment to improve access to quality health services for women and children in rural areas with a focus on the poor. The requested IDA Additional Financing of US$20 million will support scale-up of Performance Based Financing to additional target populations in the poorest regions of Cameroon. Building on the successful PBF pilot in 26 health districts currently included in the operation, the government is keen to expand this initiative to the Northern Regions of the country (Adamaoua, North and Far-North). The proposed IDA credit will support a range of activities under Components 1 and 2 in the northern regions. Component 1 will provide PBF payments to health facilities and community health workers in the targeted regions conditional on the quantity and quality of services delivered, while Component 2 will provide support for institutional strengthening. The proposed components are as follows: Component 1: District Service Delivery (Total: US$35 million: US$20 million IDA Additional Financing (AF) and HRITF US$15 million). In the 26 districts currently covered by the Project and the eight additional departments where PBF will be scaled-up, this component will provide PBF payments: (i) to health facilities in the targeted regions conditional on the quantity and quality of services delivered via in- clinic activities and/or via health-outreach activities, and (ii) to community health workers for providing selected basic health services as well as ensuring community organization to support positive health behavior. 9 Contracted health facilities will use PBF payments to (i) increase the quality and the quantity of (a) health services provided at the facility level and (b) health services provided at the community level to women and children (in collaboration with community health workers) through outreach campaigns; and to (ii) provide financial incentives to health facility staff based on performance achieved. Community health workers who are sub-contracted by health facilities with PBF contracts, will use PBF payments to (i) increase the quantity and the quality of (a) selected basic health services for common illnesses such as malaria, acute respiratory infections and diarrheal illnesses, (b) outreach activities in support to facility-based health workers, and (c) referrals of community members to health facilities for illness episodes that cannot be treated at the community level; and to (ii) keep a certain percentage of the payment as a bonus which will be based on their performance. Out of the US$35 million for Component 1, US$4 million will finance national procurement and ex-post verification activities (conducted by an independent third party, i.e. an external evaluation agency). Component 2: Institutional strengthening (Total: HRITF US$5 million). The component supports institutional strengthening at national, regional, and district levels, particularly focusing on PBF contract design and management and establishing a unified health management and geographic information system to generate up to date, reliable, financial and programmatic data. The Component also supports project management and implementation. Change in Implementing Agency Yes [ ] No [ X ] Change in Project's Development Objectives Yes [ ] No [ X ] Change in Results Framework Yes [ X ] No [ ] Change in Safeguard Policies Triggered Yes [ ] No [ X ] Change of EA category Yes [ ] No [ X ] Other Changes to Safeguards Yes [ ] No [ X ] Change in Legal Covenants Yes [ ] No [ X ] Change in Loan Closing Date(s) Yes [ X ] No [ ] Cancellations Proposed Yes [ ] No [ X ] Change in Disbursement Arrangements Yes [ ] No [ X ] Reallocation between Disbursement Categories Yes [ ] No [ X ] Change in Disbursement Estimates Yes [ X ] No [ ] Change to Components and Cost Yes [ ] No [ X ] Change in Institutional Arrangements Yes [ ] No [ X ] Change in Financial Management Yes [ ] No [ X ] Change in Procurement Yes [ ] No [ X ] Change in Implementation Schedule Yes [ ] No [ X ] 10 Other Change(s) Yes [ ] No [ X ] Development Objective/Results PHHHDO Project’s Development Objectives Original PDO To increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases. Change in Results Framework PHHCRF Explanation: Due to the increase in the targeted population and extension of project closing dates, the Results Framework indicator end targets have been revised. Compliance PHHHCompl Covenants - Additional Financing ( Additional Financing to Cameroon Health Sector Support Project - P146795 ) Source of Finance Description of Funds Agreement Date Due Recurrent Frequency Action Covenants Reference Conditions PHCondTbl Source Of Fund Name Type IDA External Evaluation Condition of Disbursement Description of Condition The Recipient shall recruit, not later that nine (9) months after the Effective Date and thereafter maintain, throughout Project implementation, external auditors, with qualifications, experience, and terms of reference satisfactory to the Association, for purposes of the third-party verification of the Health Services Package to be carried out under Part 1.C of the Project. FA, Schedule 2, Section I.G.4.(a) Finance PHHHFin Loan Closing Date - Additional Financing ( Additional Financing to Cameroon Health Sector Support Project - P146795 ) Source of Funds Proposed Additional Financing Loan Closing Date Health Results-based Financing 31-Dec-2017 Loan Closing Date(s) - Parent ( Cameroon Health Sector Support Investment (SWAP) PHHCLCD - P104525 ) Explanation: The closing date for the IDA Credit and HRITF Grant will both be December 31, 2017 in order to allow for complete roll-out and implementation of Performance-Based Financing in targeted regions. Status Original Closing Current Closing Proposed Closing Previous Closing Ln/Cr/TF Date Date Date Date(s) 11 31-Mar-2014, 31- IDA-44780 Effective 31-Mar-2014 31-Mar-2016 31-Dec-2017 Jan-2016 TF-58012 Closed 07-Dec-2007 07-Jun-2008 29-Oct-2008 Change in Disbursement Estimates (including all sources of Financing)PHHCDE Explanation: Disbursement %(Type Source of Category of Allocation Currency Total) Fund Expenditure Proposed Proposed Health Results Innovation TF USD 20,000,000.00 50.00 Trust Fund 0.00 0.00 TF USD Total: 20,000,000.00 IDA XDR Additional Financing 13,000,000.00 50.00 0.00 0.00 IDA XDR Total: 13,000,000.00 Appraisal Summary PHHHAppS Economic and Financial Analysis PHHASEFA Explanation: Investing in mother and child health services will be critical to ensure access to quality services for direct beneficiaries. The economic justification relies on the disproportionate burden of maternal and neonatal morbidity and deaths in Cameroon and the fact that affordable and cost-effective interventions to prevent these avoidable deaths are well-established. Evidence for low-income countries suggests that improved coverage with a package of interventions directed to mother and child is extremely cost-effective (US$82- 142 per DALY averted). The interventions proposed under this project are all considered global “best buys”. The Performance-Based Financing approach has demonstrated its effectiveness and efficiency in addressing health system bottlenecks in the context of Cameroon. Technical Analysis PHHASTA Explanation: The HRITF trust fund will finance the scale up of implementation of Performance-Based Financing in the current 26 districts until December 31, 2017. The current implementation arrangements, which have worked well, will be maintained for the proposed Additional Financing. Project implementation will continue to be coordinated by the Project Implementation Unit (PIU) and supported where appropriate by consultants recruited under the project. Early on in implementation the international NGOs (AEDES and Cordaid) contracted to play the role of Performance Purchasing Agencies (PPA) will transfer capacity and ownership of the PPA role to the Regional Funds for Health Promotion in the North-West, South-West and East regions, as is the case in the Littoral region, where the PPA responsibilities have been implemented by 12 the Regional Fund for Health Promotion since January 2011. During the project preparation stage, the project team worked with the main actors in the field to fine-tune the project objectives, approach and institutional framework that will enable effective implementation of the project in the north of Cameroon. The team also (i) collected additional information on the health situation in the three regions, including a mapping of health facilities, (ii) assessed the potential population and geographical coverage that could be attained given the financial envelope and length of the project, and (iii) held technical working group sessions to further develop the PBF, community health worker and targeting of the poor components of the intervention. For the extension to the northern regions of the country through the IDA Additional Financing, the project will recruit locally-based NGOs that have the organizational capacity and strong experience in the health sector in the Northern Regions to serve as PPAs. The project will then build the capacity of the recruited NGOs to play the role of PPAs. Project preparation resources will be used to cover the training of those NGOs and their field trips to visit and learn from the Regions where the project is already operating successfully. Social Analysis PHHASSA Explanation: The Government prepared and disclosed an Indigenous Peoples Planning Framework (IPPF) in 2008 to ensure that the Indigenous People located in the East region would benefit from the project. Consultations with beneficiaries, the Government, the Performance Purchasing Agency in the East region, and local community-based organizations hired to conduct client satisfaction surveys have all confirmed that Indigenous Peoples in the East region have been benefiting from the intervention in several ways: (i) improved availability and quality of health services, community outreach campaigns by local health agents and community leaders for improved health knowledge and health-seeking behavior, with a focus on vulnerable populations; (ii) inclusion of specific components of the intervention to push for increased access to and utilization of health services among vulnerable groups through targeted subsidies at the point of service delivery; and (iii) supervision and implementation support activities to monitor and assess if the health intervention was benefitting vulnerable groups and indigenous peoples. The PPA in the East region has maintained a continuous dialogue with indigenous groups in the region to assess their perception of the intervention and incorporate their recommendations into their PBF approach tailored for the East region. The IPPF which was prepared, consulted upon, and disclosed in April 2008 under the original project remains valid for this AF. During implementation of the parent project, the borrower implemented measures to ensure that Indigenous Peoples (IPs) in the project area were informed about project activities, consulted about their preferences as project beneficiaries, and able to benefit from the health services provided by the project (through pre-paid enrollment in health care mutual or direct assumption of health care costs). A social audit will be conducted during implementation of the Additional Financing to assess in-depth perceived and real benefits of the project among the indigenous populations in the targeted regions. In addition, an Indigenous Peoples Plans (IPPs) will be prepared to ensure that: free, prior and informed consultations leading to broad community support are held; the IPs are not adversely affected by the project; they receive culturally appropriate benefits from the project; there is a grievance redress mechanism; and, there is monitoring and evaluation of the projects impacts on and benefits for IPs. Institutional arrangement: The Ministry of Public Health has a unit that is responsible for environmental issues which works in close collaboration with the Ministry of Environment, Nature Protection and Sustainable Development (MINEPDED). The Unit has well trained staff and when necessary seeks support from MINEPDED or external consultants. It was agreed that the same arrangement will be maintained 13 during the implementation of the Additional Financing period. The project is expected to have a positive social impact by improving access to health care services for poor and vulnerable households. Component 1 (through the payment for performance) will provide incentives for health facilities to target vulnerable groups in their catchment areas and subsidized care to these groups, leading to improved financial access for the poor and vulnerable. PBF subsidies will also aim to reduce staff absenteeism and to improve staff responsiveness with patients. As a result, health facilities with PBF contracts will in turn provide more and better care for marginalized populations and also improve medical waste management. The improved management of Medical waste will be a PBF indicator. The project will have a positive impact on gender in Cameroon. Given that the project objective is to improve maternal and child health in target areas, improving women’s health is an essential component of the intervention. Particular attention will also be given to ensuring active participation of women in project areas through the use of Community-based organizations (CBO) (local NGOs, women’s groups, agricultural groups, etc.). The project is expected to have a positive impact not only on pregnant women but on all women, as PBF subsidies will improve the quality of care for the identified package of health services essential for the general population. Consultation and disclosure: The IPPF and Medical Waste Management Plan (MWMP) were originally discussed at in-country workshops with key stakeholders and local media covered the dissemination prior to the launch of the parent project. The documents were disclosed in-country on April 4th, 2008 and at the Infoshop on April 3rd, 2008. During the project re-launch, the IPPF and the MWMP will be shared by the main stakeholders. During the project implementation the PIU and Performance Purchasing Agency managers will do a social audit to assess the implication of the action plan of the IPPF during the previous phase and to draw an action plan from the lessons learned to improve the project’s actions in favor to IP. The PIU will consult and organize knowledge sharing sessions on the waste management best practices. During implementation support missions, the World Bank environmental and Social safeguards team will ensure that the main stakeholders are consulted and also that the environmental and social indicators are integrated in the PBF payments criteria. Environmental Analysis PHHASEnvA Explanation: The Additional Financing will not change the environmental category of the project, which remains Category B as it is not anticipated that the project activities will have large scale negative impacts. The AF triggers the same two safeguards policies that the parent project triggered: OP/BP. 4.01 - Environmental Assessment and OP/BP 4.10 - Indigenous peoples. The Government has prepared and disclosed the Medical Waste Management Plan (MWMP) in 2008 with an action plan. The assessment of the MWMP’s implementation was satisfactory as most of the actions proposed were implemented including follow-up workshops. It was therefore agreed that the same document will be maintained and its implementation consolidated. It was also agreed that the Medical Waste management Plan prepared in 2008 will need an update early on during project implementation to define more concretely what will be implemented in the new project areas sites. During the update process, all relevant stakeholders will be consulted. Risk PHHASRisk Explanation: The introduction of PBF in the 26 districts currently targeted by the operation has led to enhanced accountability and brought providers closer to the communities they service. However contextual factors in 14 the newly targeted areas (health-seeking behaviors, financial and geographic barriers, low health workforce density, unfamiliar with PBF approach) may have some impact on the implementation of the project at start-up. A number of mitigating measures are already in place or in the process of being implemented to improve operational and governance systems, including: (i) extensive knowledge and lessons learned from several years of experience with PBF in Cameroon (ii) linking with the safety net program to improve financial access and healthy lifestyle behaviors, (iii) use of the substantial and growing community of Cameroonian PBF experts to quickly transfer capacity to newly targeted stakeholders ; and (iv) use of strong advocates and technical experts of PBF within the Ministry of Health to facilitate smooth scaling-up. 15 I. Introduction 1. This Project Paper seeks the approval of the Executive Directors to provide an additional credit in an amount of US$20 million IDA Credit to the Cameroon Health Sector Support Investment Project. The Project Development Objective (PDO) of this operation, which does not differ from the original project, is to increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases. 2. The Health Sector Support Investment Project is supply-side oriented and involves contracting health facilities to provide key maternal and child health services to target populations in their vicinity through Performance-Based Financing. The Project Development Objective is to increase utilization and improve the quality of health services with a particular focus on maternal and child health and communicable diseases. Health services that are targeted by the intervention include, but are not limited to, outpatient consultations, immunization of children, antenatal care services, assisted deliveries, family planning services, and prevention and treatment services for HIV/AIDS, malaria and tuberculosis. 3. The original project was first restructured in June 2011 as PBF could not be implemented as originally planned as the institutional setting for the component, to use the "Fonds Spéciaux de Promotion de la Santé" (FSPS) (Special Fund for Health Promotion) as the main vehicle to purchase services provided by health centers at different levels, was neither operational nor feasible. The mandate of FSPS was not revised by December 2009 to meet the conditions of eligibility as set in the Financing Agreement and their status at the time did not allow them enough autonomy (from the health services) to be credible "Performance Purchasing Agencies” (PPAs). In addition, the FSPS did not have the technical capacity to develop PBF as expected. To remedy the situation, the restructuring allowed the Government to bring in experienced institutions to help implement PBF while FSPS will be learning the “how to” of PBF with those institutions. 4. The original project was restructured a second time in March 2014. The changes included in the restructuring were as follows: (i) a first extension of the Project closing date by 22 months, to January 31, 2016, to ensure that the project meets its development objectives; (ii) adjustment of disbursement arrangements; and (iii) revision of four Results Framework indicators from proportions to absolute numbers. The project development objective (PDO) remained unchanged. The institutional, financial, procurement and safeguards arrangements also remained unchanged. 5. This requested IDA Additional Financing of US$20 million will support the scale-up of Performance Based Financing (PBF) in Cameroon. The trust fund will finance the extension of the project departments with high levels of chronic poverty in the regions of Adamaoua, North and Far-North. The Trust Fund will mainly support a range of activities of the project by providing PBF payments to health facilities in the targeted regions conditional on the quantity and quality of services delivered. The extension will increase the size of the population covered by the project from 2.5 million to 4.6 million. 16 6. The Project will also be supported by a grant from the Health Results Innovation Multi Donor Trust Fund (HRITF) of US$20 million that will be used in the original project areas to scale-up the activities of the project (extension of PBF to health facilities in the control groups of the impact evaluation). As the impact evaluation was not planned during the initial project preparation phase (2008) and only began its implementation in 2011, more time and resources are needed to run the project in order to carry a proper impact evaluation. Specifically, the impact evaluation will be completed during the first quarter of 2015 when the endline baseline survey is completed. Scale-up activities will include extending PBF to health facilities currently not covered by PBF in the 14 health districts included in the impact evaluation, as they are included in the control groups of the impact evaluation. Thus, contracting of health facilities under PBF will increase by 50% in these fourteen districts. The closing date is December 31, 2017, which will allow for further attainment of results and completion of the impact evaluation that will contribute to evidence-based decision making in Cameroon’s health sector, in particular for scaling-up PBF nationwide. 7. The Additional Financing is consistent with OP/BP 10.00, which states that Additional Financing is justified to support the scaling-up of activities. The proposed Additional Financing of the project would enable the project to meet its development objectives and contribute to Cameroon’s health sector goals. 8. The proposed operation is fully in line with the Bank’s Country Assistance Strategy for the Republic of Cameroon (2010-2013), in particular through improving service delivery (one of the two strategic themes) and stimulating demand-side governance and transparency through the strengthening of civil society organizations. II. Background and Rationale for Additional Financing in the amount of $20 million 9. Cameroon’s average GDP growth in real terms has stood between 3.5 and 4.5 percent over the last five years, with GDP per capita (PPP) estimated at $2,400 in 2012. The Cameroonian economy is relatively diversified: the tertiary sector represented 43 percent of Gross Domestic Product (GDP) in 2012 agriculture and the manufacturing sector 18 percent each, and oil and mining 9 percent. Cameroon has considerable natural resources, including oil, timber, and export crops such as coffee, cotton, and cocoa. Natural gas, bauxite, diamonds, gold, iron, and cobalt are all relatively untapped resources. Cameroon’s oil production is fairly modest and dwindling. The sector’s contribution to GDP growth has essentially been negative for the last years, but this may change as oil production is currently increasing and oil prices remain high. 10. In 2012, Cameroon was ranked 150th out of 187 countries on the Human Development Index. With an index of 0.495, slightly better than in 2011 (0.492), the country was situated slightly above the average of countries with low human development (0.456) and countries in Sub-Saharan Africa (0.475). The gross school enrolment rate stands at 60.4 percent, with an overall education index of 0.520. The education sector accounts for 3.7 percent of GDP. The health index (life expectancy) is situated at 0.499, with health expenditures amounting to 1.3 percent of GDP. 17 11. Cameroon’s poverty rate barely changed between 2001 and 2007. The third household survey released by Cameroon’s National Institute of Statistics (NIS) estimates that 39.9 percent of the population was living below the poverty line in 2007, for a total of nearly 7.1 million poor Cameroonians. The incidence of poverty stood at 40.2 percent in 2001. Large geographical poverty rate disparities were found in 2007, as was already the case in 1996 and 2001. Poverty is predominant in rural areas and in the northern regions of the country, with poverty levels of 67 and 64.3 percent respectively for the Far North and the North regions. Existing data also highlight strong socioeconomic disparities and show that over time poverty has decreased in urban areas while continuing to increase in rural areas. The latest household survey in 2007 finds that 55 percent of rural families are poor, as opposed to 12 percent in urban areas. Approximately 87 percent of the poor live in rural areas. 12. Cameroon is not on track to achieve the Millennium Development Goals (MDGs). For example, in order to achieve MDG 4 (Reduce Child Mortality), the mortality rate for children under five would have to fall to 45 deaths per 1,000 live births by 2015. In Cameroon, one woman dies every two hours from complications of pregnancy or childbirth, and one in 127 pregnancies is fatal. Cameroon has the 18th-highest maternal mortality rate in the world, ranked just between the Republic of Congo and Angola. Achievement of the goal to reduce the maternal mortality rate (MDG 5), which would have to fall from 690 deaths per 100,000 live births to 170 deaths per 100,000 live births by 2015, remains unlikely. While the incidence of underweight children would also have to decrease by nearly half, from 17 percent to 9 percent, by 2015, the situation has actually worsened over the past five years. 13. Disparities between the rural (disparities in the North and Far North regions are shrinking) and urban areas are significant for all health indicators, with mortality levels higher among lower socioeconomic groups. All mortality indicators are lower in rich households than in poor households. Only 80 in 1,000 children born in rich households die before the age of five. However, the under-five mortality rate is more than twice as high in poor households. The age of the mother is also a determining factor. One in six children born to mothers under 20 years of age dies before the age of five, while one in eight children of mothers aged 20 to 29 years dies during childbirth. The prevalence of early marriage is significantly higher among the poor and in the Northern regions of Cameroon, which contributes to a higher mortality rate in these population groups. 14. Significant progress has been made to reduce infant and under-five child mortality in many regions, but major geographic discrepancies remain. The greatest reductions in child mortality were observed in the East (90 per 1,000 live births) and the South (50 per 1,000 live births), while the rate hardly changed in Douala and Yaoundé. Child mortality remains nevertheless extremely high in the poorest parts of the country, such as the North or the Far North, where close to 20 percent of the children born die before their fifth birthday (191 deaths and 168 deaths per 1,000 live births in the North and the Far North, respectively). Geographically, the Northern Regions have the fewest assisted deliveries. Between the two most recent Demographic and Health Surveys (2004 and 2011), the percentage of childbirth deliveries that were assisted by a health professional increased on average from 61.7 percent to 63.6 percent. In the Far North, however, only 21.8 percent of births were attended by skilled personnel, compared to 93 percent in the Littoral and 91.6 percent in the West. 18 Original Project 15. The original Cameroon Health Sector Support Investment Project is a five-year US$25 million project, which aims to provide key maternal and child health services to target populations in their vicinity through Performance Based Financing (PBF). It received Board approval on May 29th, 2008 and became effective in March 2009. The project underwent a Level-2 restructuring on June 13th, 2011 and again in March 2014, with a revised closing date of January 31st, 2016. The Project Development Objective is to increase utilization and improve the quality of health services with a particular focus on maternal and child health and communicable diseases. Health services that are targeted by the intervention include, but are not limited to, outpatient consultations, immunization of children, antenatal care services, assisted deliveries, family planning services, and prevention and treatment services for HIV/AIDS, malaria and tuberculosis. In addition to improving utilization of quality health services to the general population, due to the abovementioned inequities in health outcomes in Cameroon, the project maintains a specific focus on improving access to and utilization of essential health services for vulnerable populations. The original project includes two components: 16. Component 1: District Service Delivery (US$20 million). The component supports channeling financial resources to districts and health facilities (public and private) through Performance Based Financing. PBF is being implemented to address critical impediments confronting the delivery of services at the district level. These challenges include the (i) scarcity of funds to meet operating expenses, (ii) lack of focus on achievement of results and lack of accountability mechanisms of the district health system; and (iii) modest managerial capacity at the district level. 17. Component 2: Institutional Strengthening (US$5 million). The component supports institutional strengthening at national, regional, and district levels, particularly focusing on PBF contract design and management and establishing a unified health management and geographic information system to generate up to date, reliable, financial and programmatic data. 18. The original project became effective in March 2009 but until restructuring in July 2011, the project could not be implemented as planned because the institutional setting was neither operational nor feasible given the country context. Since restructuring of the project in 2011, the project PDO, financial management and implementation outcomes have been rated satisfactory after being rated unsatisfactory for the first two years of the project’s life cycle. According to the latest ISR (May 2014), project performance is rated Satisfactory for progress towards achievement of the PDO, Overall Implementation Progress, and Overall Safeguards Rating, while the Overall Risk Rating is rated Moderate. PDO indicators show that the project has already surpassed four of the five PDO indicator targets and is on track to meet the fifth. After significant time without substantial disbursement (less than 5%), disbursement has reached 80% after three years effective implementation (following the restructuring). The Mid-Term Review of the project, which was conducted from May 6 to May 17, 2013, identified that (i) the 19 institutional framework put in place as a result of the restructuring of the project has been appropriate and (ii) performance of both the Government and the World Bank is satisfactory as major activities are carried out without delay since restructuring. 19. The original project is currently implementing PBF in public, private and faith-based organization (FBO) facilities across 26 districts in the Littoral, North-West, South-West and East regions of Cameroon, covering a total population of approximately 2.5 million. 20. The quality and utilization of maternal and child health services has increased substantially since the launching of PBF. The table below shows trends for several key indicators using operational data from contracted health facilities. The number of health facilities achieving an average score of 75% of the quality index of services has increased by almost 3 times since the 3rd quarter of 2012, from 9.3% to 24.6%. The number of children completely vaccinated has more than doubled, and the number of children who received one dose of vitamin A by their first anniversary has also more than tripled. Key maternal health indicators have substantially increased in volume. The number of pregnant women receiving at least one antenatal care and the number of women who were attended by a skilled provider during delivery have more than doubled. The increase of new acceptors of modern contraceptive methods has also been substantial (Multiplier of 1.8). In terms of curative care, the number of outpatient consultations delivered to the general population, as well as among the poor, have at least tripled over each period considered (Multiplier of 2.1 over 4 quarters and multiplier of 2.0 over 3 quarters, respectively). Management tools used within the PBF framework have also assisted health facilities in improving governance of health facilities, and efficiencies in their use of financial resources generated through service delivery. Table 1: Health Project Key indicators for Littoral, North-West, South-West and East regions of Cameroon Indicators Q2- Q3- Q4- Q1- Q2- Performance 2012 2012 2012 2013 2013 multiplier (Q3- 2012; Q2-2013) 1 Child Health Number of children immunized 5364 16400 15899 14652 17289 1.1 Children by the first anniversary who have received 7825 18318 35846 18474 41258 2.3 one dose of Vit. A in the last six months Maternal health Pregnant women receiving at least one antenatal care 8153 31382 32032 39218 40230 1.3 Number of births attended by skilled professional 3903 8875 10030 9898 11185 1.3 New acceptors of modern contraceptive methods 731 2268 3950 3705 4019 1.8 Curative care New outpatient consultations 56387 114598 190932 207004 237600 2.1 Consultations provided to people from the poorest 0 7 2845 3928 5786 2.0 quintile Quality of care Health facilities achieving an average score of 75% 5.3 9.3 14.4 12 24.6 2.6 of the quality index of services Source: Aggregated operational data from 2nd quarter 2012 up to 2nd Quarter 2013. 1 Note: Performance multipliers are the number of times by which the volume of services has increased on a period for targeted areas of the project in the four regions. The baseline considered for performance multipliers is 3rd quarter of 2012 when all the regions have at least started paying for performances. The multiplier of the indicator “Consultations provided to people from the poorest quintile” is computed only on the last 3 quarters since the clarification of the targeting to the PPAs. 20 21. The World Bank team and the Government of Cameroon are jointly conducting an impact evaluation linked to the Project, with the policy objectives of (a) identifying the impact of PBF on maternal and child health (MCH) service coverage and quality, (b) identifying key factors responsible for this impact, and (c) assessing the cost-effectiveness of PBF as a strategy to improve coverage and quality. The impact evaluation, conducted in fourteen out of the twenty- six pilot districts, uses an experimental design to test whether PBF leads to improved maternal and child health outcomes. The Cameroon experience of conducting a large-scale public randomization ceremony in each of the three regions included in the impact evaluation has been identified as a best practice. Data collection for the IE baseline survey was conducted from March to June 2012. The endline survey is planned to be completed in late 2014 in order to ensure that a full two-years of PBF implementation has been completed in each of the three regions. The Additional Financing will allow continuation of PBF implementation in all 26 districts, including the 14 that are included in the impact evaluation. 22. The Ministry of Public Health has budgeted resources for the PBF operation in the Littoral region starting in the 2014 fiscal year. Specifically, the Ministry will cover all output costs (i.e. purchasing of services from contracted facilities: close to US$2 million). This engagement is a good example of the momentum and buy-in that PBF is gaining in Cameroon. III. Proposed Changes 23. The overall objective of this Additional Financing, which does not differ from the original project, is to improve health outcomes among women and children in targeted areas of Cameroon. To that end, the PDO is to increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases. The requested IDA Additional Financing of US$20 million will support scale-up of Performance Based Financing to additional target populations in the poorest regions of Cameroon. Building on the successful PBF pilot in 26 health districts currently included in the operation, the Government is keen to expand this initiative to the Northern Regions of the country (Adamaoua, North and Far-North). The proposed IDA credit will support a range of activities under Components 1 and 2 in the northern regions. Component 1 will provide PBF payments to health facilities and community health workers in the targeted regions conditional on the quantity and quality of services delivered, while Component 2 will provide support for institutional strengthening. 24. A US$20 million allocation from the Health Results Innovation Multi Donor Trust Fund (HRITF) will be used in the original project areas for two purposes: (i) to scale-up the activities of the project in the 26 districts currently implementing PBF through extending PBF to the impact evaluation group facilities) and (ii) to allow for the impact evaluation to be completed and results used to fine tuning the PBF national strategy. The proposed Additional Financing will help to better align IDA’s support to Cameroon’s health system with an enhanced focus on results. It will also support the Government’s commitment to improve access to quality health services for women and children in rural areas with a focus on the poor. 21 The proposed components are as follows: 25. Component 1: District Service Delivery (Total: US$35 million: US$20 million IDA Additional Financing (AF) and HRITF US$15 million). In the 26 districts currently covered by the Project and the eight additional departments where PBF will be scaled-up, this component will provide PBF payments: (i) to health facilities in the targeted regions conditional on the quantity and quality of services delivered via in-clinic activities and/or via health-outreach activities, and (ii) to community health workers for providing selected basic health services as well as ensuring community organization to support positive health behavior. 26. Contracted health facilities will use PBF payments to (i) increase the quality and the quantity of (a) health services provided at the facility level and (b) health services provided at the community level to women and children (in collaboration with community health workers) through outreach campaigns; and (ii) provide financial incentives to health facility staff based on performance achieved. 27. Community health workers who are sub-contracted by health facilities with PBF contracts, will use PBF payments to (i) increase the quantity and the quality of (a) selected basic health services for common illnesses such as malaria, acute respiratory infections and diarrheal illnesses, (b) outreach activities in support to facility-based health workers, and (c) referrals of community members to health facilities for illness episodes that cannot be treated at the community level; and (ii) keep a certain percentage of the payment as a bonus which will be based on their performance. 28. Out of the US$35 million for Component 1, US$4 million will finance national procurement and ex-post verification activities (conducted by an independent third party, i.e. an external evaluation agency). 29. Component 2: Institutional strengthening (Total: US$5 million: HRITF US$5 million). The component supports: (i) institutional strengthening and training at national, regional, district, health facility and community levels, particularly focusing on PBF contract design, management and implementation; (ii) establishing a unified health management and geographic information system to generate up to date, reliable, financial and programmatic data; and (iii) project management and implementation. 30. IDA Additional Financing and revised closing dates for original project: In March 2014 the closing date of the original project was extended for an additional 22 months to January 31, 2016. The closing date of the IDA Additional Financing will be December 31, 2017. 31. HRITF grant: The HRITF trust fund will have a closing date of December 31, 2017. 32. PBF payments will be provided to health centers which will provide services either via in-clinic activities and/or via health-outreach activities. Contracted health facilities will use PBF payments to strengthen the quality of care provided to users of the health centers and provide financial incentives to health facility staff based on performance achieved. Community health 22 workers will be incentivized through PBF payments to provide outreach and referral services to women and children in targeted communities. 33. Particular challenges in the targeted Northern Regions of Cameroon include: high chronic poverty headcounts and substantial barriers to facility-based services (limited staffing in facilities, long distance to facilities, rough terrain, economic and cultural factors). The human resources to address health challenges in the north of Cameroon are substantially different from the situation in the current project areas (particularly Littoral, North-West and South-West). Not only is the health worker density lower in the north, but managerial and clinical capacity for service delivery are weaker, in part augmented by difficulties in retaining qualified workers in remote parts of the north. Per capita spending on health is also lower in the north than in other regions. 34. The project will address these challenges through both the demand- and supply-side of health service delivery in the additional regions targeted by the project. At the health facility level, Performance Based Financing will be applied in the same manner it has been implemented in the ongoing project. Health services will be provided through contracting health facilities at regional, district, and local levels. In the selected departments, a Performance Purchasing Agencies (PPAs) will contract out with rural public, Faith-based organization (FBO) and Non- governmental organization (NGO) health care facilities. Result-based grants will be paid to these health facilities for achieved results. Facility payments will be based on (i) the volume of predefined technical support services delivered to health care centers (by supervising entities) and mother and child health (MCH) and communicable diseases services delivered to the targeted population (by health centers) and (ii) the technical quality of these services. While geographical PBF equity bonuses can incentivize health workers to accept remote and difficult posts, additional initiatives such as managerial training courses for facility management may be introduced. The team will also work closely with the Direction of Human Resources in the Ministry of Public Health to identify ways that the PBF operation can support rural retention strategies developed by the Government of Cameroon. 35. The project will introduce a “Community PBF” component in the northern regions designed to improve health-seeking behavior and geographical access to preventative and curative health services. Community health workers (CHW) will be trained in the management of diseases such as malaria, acute respiratory infection and diarrheal illnesses among children and will be contracted to provide basic curative services at the community level, refer patients for complicated cases, and support sensitization and outreach campaigns organized by associated health facilities. At the community level, trained and certified community health workers will receive performance contracts to mobilize the population, particularly the most vulnerable households in their communities to demand the services they need at the community or health facility level. CHWs will keep a log book of persons they referred to health facilities as well as for basic curative services (for common illnesses such as malaria, acute respiratory infections and diarrheal illnesses) they provided to community members. Referrals and services provided by CHWs will be verified by the PPA and externally counter-verified by contracted community organizations (as is the case for the quarterly quality evaluation at facility-based services). The approach will build upon existing models already in place by UNICEF, World Food Program and Plan International. 23 36. The project will also introduce mechanisms to improve financial access to essential health services at the community and health facility level among poor and vulnerable households. The mechanism used to identify the poor that will be applied will build on both experiences from the Health Sector Support Investment Project in other regions of Cameroon and the Cameroon Social Safety Nets project. Exemption mechanisms for the poor will be put in place that will cover health care provided at the community and health facility levels. The project will also introduce fee-waivers for certain essential services for systematically identified vulnerable households as a further demand-side mechanism to boost households’ use of health services. In order to fill the financial gap caused by this loss in facility revenue through the absence of direct payments, facilities will be reimbursed for services provided free to the vulnerable. 37. The supply-side/demand-side effort in improving health outcomes is further strengthened by the links to the parallel Safety Net Project (P128534) that is providing cash transfer payments and accompanying measures to poor households in selected villages in the same regions. The cash transfer program will provide a small regular payment that will help beneficiary households to stabilize their basic consumption and avoid having to resort to negative coping mechanisms when shocks occur. Bi-monthly cash transfers will help poor and vulnerable groups by increasing household income for a period of 24 months. The total annual transfer per household is FCFA 180,000. While the health operation will be implementing PBF at the district level, the safety net project is only targeting communities in these departments based on pre-established poverty identification criteria adopted by the project. The safety net project will use several methods to identify households for the unconditional cash transfers (including geographical targeting, community participation, proxy means testing, and self-targeting). 24 Figure 1: PBF service delivery arrangements 38. The target population in the three regions will be approximately 2.15 million inhabitants, increasing the size of the population covered by the project from 2.5 million to 4.65 million. The additional targeted beneficiaries will be the women of reproductive age, teenage girls and children (under 5) in the selected three regions: Adamaoua, North and Far-North. Within the three regions, administrative departments and health districts have been identified for the project due to their high levels of chronic poverty and poor health outcomes (as per results from the 2007 Household Survey, ECAM3). The departments and districts are presented in Table 2. Table 2: Target population, Northern Regions, Cameroon Chronic Health Population Poverty Public Private Region Department District 2012 Rate facilities Facilities Mayo Kar hay 120,371 60.7 16 1 Danay Yagoua 233,345 47.8 13 1 Guidiguis 142,740 61 14 0 Mayo Kaele 121,875 50.1 16 0 Kanay Moulvoudaye 146,968 63 9 0 Far North Mayo Sava Mora 170,985 48.7 16 1 Bourha 71,682 64.7 13 0 Mayo- Koza 172,838 60.8 15 0 Tsanaga Mogode 105,094 63.1 10 0 Sub-total 1,285,898 122 3 25 Benoue Lagdo 145,446 54.7 15 0 Golombe 71,290 53.9 7 0 Mayo Louti Guider 230,343 58.4 18 2 North Mayo oulo 131,770 56.7 10 0 Mayo Rey Rey bouba 100,328 65.5 13 0 Sub-total 679,177 63 2 Ngaoundéré Adamaoua Vina 183,519 41.4 27 8 Rural Sub-total 183,519 27 8 Total 2,148,594 212 13 39. Enhanced Program Assessment (EPA) (US$400,000): An Enhanced Program Assessment will be conducted in the three northern regions. Cameroon is already conducting a large-scale and operationally challenging experimental impact evaluation (and qualitative study) in three out of four regions where PBF is been implemented. Given that specific communities have already been identified and targeted by the safety net project, a full impact evaluation is not an option for rolling out the new operation in the northern regions. Thus a mixed-methods Enhanced Program Assessment will be developed within the operational framework of the project to (i) evaluate the process of implementing the combined demand- and supply-side interventions in the targeted areas, and (ii) assess the relationship between the interventions and health outcomes of interest. Table 3: Project outcome indicators Indicators Original Changes Revised target with AF target PDO Indicators 1. People with access to a basic package of health, 750,000 Increase by 1,500,000 nutrition, or reproductive health services 100% 2. Number of children immunized in targeted areas 100,000 Increase by 200,000 100% 3. Number of births attended by skilled professional in 30,000 Increase by 60,000 targeted areas 100% 4. New cases of tuberculosis detected and treated in 5,000 Increase by 10,000 targeted areas 100% 5.1 Direct Project Beneficiaries (number) 885,000 Increase by 1,770,000 100% 5.2 Direct Project Beneficiaries (number) of which female 443,000 Increase by 885,000 100% Intermediate Outcome Indicators 6. Pregnant women receiving antenatal care during a visit 100,000 Increase by 200,000 to a health provider 100% 7. New acceptors of modern contraceptive methods in 20,000 Increase by 40,000 targeted areas 100% 8. Children by the first anniversary who have received one 100,000 Increase by 200,000 dose of Vit. A in the last six months in targeted areas 100% 9. Patients treated for Tuberculosis (TB) in targeted areas 80% No change 80% 10. Tracer drugs available in targeted health facilities on 75% No change 75% the day of the visit 26 Indicators Original Changes Revised target with AF target 11. Percentage of health facilities achieving an average 60% No change 60% score of 75% of the quality index of services as measured in PBF in the targeted areas 12. Percentage of health facilities reporting monthly 75% No change 75% activities using standard report form in targeted areas. 13. Number of consultations provided to people from the 75,000 No change 75,000 poorest quintile as measured by asset index in targeted Table 4: Costs by component Component Original project Changes with AF Revised cost cost 1: District Service Delivery 20 35 55 2: Institutional 5 5 10 Strengthening Total 25 40 65 IV. Appraisal Summary Economic and Financial Analysis 40. Investing in mother and child health services will be critical to ensure access to quality services for direct beneficiaries. The economic justification relies on the disproportionate burden of maternal and neonatal morbidity and deaths in Cameroon and the fact that affordable and cost- effective interventions to prevent these avoidable deaths are well-established. Evidence for low- income countries suggests that improved coverage with a package of interventions directed to mother and child is extremely cost-effective (US$82-142 per DALY averted). The interventions proposed under this project are all considered global “best buys”. The RBF approach has demonstrated its effectiveness and efficiency in addressing health system bottlenecks in the context of Cameroon. Technical Appraisal 41. The HRITF supported trust fund will finance the scale up of implementation of Performance Based Financing in the current 26 districts until December 31, 2017. The current implementation arrangements, which have worked well, will be maintained for the proposed Additional Financing. Project implementation will continue to be coordinated by the Project Implementation Unit (PIU) and supported where appropriate by consultants recruited under the project. Early on in implementation the international NGOs (AEDES and Cordaid) contracted to play the role of PPAs will transfer capacity and ownership of the PPA role to the Regional Funds for Health Promotion in the North-West, South-West and East regions, as is the case in the Littoral region, where the PPA responsibilities have been implemented by the Regional Fund for Health Promotion since January 2011. 27 42. During the project preparation stage, the project team worked with the main actors in the field to fine-tune the project objectives, approach and institutional framework that will enable effective implementation of the project in the north of Cameroon. The team also (i) collected additional information on the health situation in the three regions, including a mapping of health facilities, (ii) assessed the potential population and geographical coverage that could be attained given the financial envelope and length of the project, and (iii) held technical working group sessions to further develop the PBF, community health worker and targeting of the poor components of the intervention. 43. For the extension to the northern regions of the country through the IDA Additional Financing, the projet will recruit locally-based NGOs that have the organizational capacity and strong experience in the health sector in the Northern Regions to serve as Performance Purchasing Agencies (PPA). The project will then build the capacity of the recruited NGOs to play the role of PPAs through training and field trips to visit and learn from the Regions where the project is already operating succesfully. Figure 2: Institutional Arrangements for implementation 44. The community component of the project, which aims to support geographical and socio- cultural barriers of the population, has been futher developed and aligned with the PBF approach. Community health workers will be trained in community case management for common diseases such as malaria, acute respiratory infections and diarrhea, particularly among children. Various models are currently being implemented by UNICEF, WFP and Plan International in the three regions. The above-mentioned NGOs will also be tasked to train and contract community health workers for these activities. 28 45. The districts that will implement PBF will be chosen from the departments that have the highest poverty levels, namely the Far North and North. One or two districts in the Adamaoua region will also be targeted. The choice of districts was finalized with regional delegations during the stage of project preparation leading up to appraisal based on data from the 2007 Household Survey (ECAM3). The target population is approximately two million people, with two-thirds targeted in the Far North, and one-third for the North and Adamaoua. 46. The project will conduct baseline survey to better understand the challenges of the health system in the northern regions and to support the Enhanced Program Assess of the project in the Northern regions, which will measure the performance of health facilities in the targeted districts as well as in a group of selected control districts. Close to 400 health facilities in total (200 intervention and 200 control) will be involved in the baseline survey. The mission has developped ToRs for the baseline survey to be supported by a client-executed grant under HRITF. 47. The procurement method that will be used to recruit the PPAs is “quality-based selection.” The NGOs will submit a project management manual outlining the details of implementation, organization, administration, monitoring and evaluation, environmental and social monitoring and mitigation, financial management, disbursement and procurement. Unit costs of each service to be purchased should be specified in the PBF manual. Based on best practices of results-based financing and adapting them to local conditions, each health service will be priced using a model that ensures that health centers are motivated to produce the optimal quantity and quality of the target indicators. 48. The identified risks and the corresponding risk mitigating measures are summarized in the ORAF below (Annex 2). Financial Managements Arrangements 49. The financial management (FM) assessment for the Cameroon Health Sector Support Investment Project was conducted to determine whether the project has adequate financial management systems and related capacity for project implementation. The FM assessment was carried out in accordance with the Financial Management Manual for World Bank-Financed Investment Operations issued by the Financial Management Sector Board that became effective on March 1, 2010 and the requirements of OP/BP 10.02. 50. The assessment concludes that the financial management arrangements meet the minimum requirements of OP/BP 10.02 and project’s risk is substantial. 51. The Additional Financing will be managed under the existing financial management arrangements for the main project. The Project Unit comprises one Finance and Administrative Officer, one accountant and one internal auditor. The latters are well qualified and experienced in World Bank financed project and have been managing adequately ongoing Health Project (P104525). The additional financing will imply a workload that will be mitigated by the recruitment of one additional accountant according to terms of reference acceptable to the Bank. 29 52. The additional financing will comply with the existing manual of procedures and funds received and expenses will be included in Quarterly financial reports according to the same format. 53. All project funds will be subject to a financial audit following existing audit arrangements. The terms of reference of existing independent external auditor will be amended to take into account this additional financing. 54. The PPA contract will distinguish between fees for the PPA’s services and those pertaining to health centers and community health workers for payment of services rendered based on performances. The NGOs/PPAs financial management capacity will be assessed as part of the procurement due diligence, whereas the minimum financial capacity will be specified as part of contracting to ensure contracting of NGOs is based on (i) their financial capacity and (ii) their RBF technical proposal. 55. For Component 1 (District Service Delivery), after verification of reported results, PPAs will address a request to the PIU with relevant documents and the PIU will transfer funds to the PPA for services rendered in the health sector. Each PPA will open and operate two operational accounts in commercial banks, acceptable to IDA, one for the PPA’s operating costs and one for results-based payments. Funds will flow to these operational accounts from new Designated Accounts to be opened in acceptable commercial bank to IDA. Furthermore, as per existing arrangements, Component 1 will be IFR based disbursement and component 2 transactions based disbursement. 56. The funds flows arrangements are described below. 30 Figure 3: Fund flows for IDA IDA PIU - Yaounde Designated Account for Component 1 PPA: Special Operational Operational Fund/ Account for Results Account NGO Based Payments For Operations Designated Account for component 2 Districts Health Center Suppliers, Consultants Figure 4: Fund Flows for Trust Funds TF PIU - Yaounde Designated Account for component 1 PPA: Special Operational Operational Fund/ Account for Results Account NGO Based Payments For Operations Designated Account for Districts component 2 Health Centers Suppliers, Consultants 31 Disbursement Arrangements 57. As under the original credit, two designated accounts will be opened in a financial institution acceptable to the association. For Component 1, disbursements will be made to DA- A from which transfers will be made to operational accounts. For Component 2, disbursements will continue to be made to DA-B from which transfers will be made to operational accounts. 58. Retroactive financing. In order to ensure the prompt execution of the extension of PBF to the northern regions of Cameroon, retroactive financing from the IDA Credit for a maximum of 20% of the credit ($4 million) will be allowed for payments prior to the date of the signing of the Financial Agreement of the IDA Credit that are made on or after May 1, 2014. Procurement Arrangements 59. The project procurement arrangements remain unchanged, and disbursement conditions will continue to be against performance with the same legal and disbursement conditions as the existing ones but are extended to include NGOs as described in the institutional arrangements. The dedicated Project Procurement Specialist will continue managing the procurement function under the project. The team managed the original Project with efficiency and integrity and is proficient with IDA procurement requirements. Procurement for the project during the Additional Financing period would be carried out in accordance with the World Bank’s "Guidelines: Procurement of Goods, Works and Non-consulting Services under IBRD Loans and IDA Credits and Grants by World Bank Borrowers " dated January 2011; and "Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits and Grants by World Bank Borrowers " dated January 2011; 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 the provisions stipulated in the Legal Agreement. 60. Requirements for the National Competitive Bidding. The following additional procedures shall apply to National Competitive Bidding: The procedures to be followed for National Competitive Bidding shall be those set forth in the Recipient’s Procurement Code of September 24, 2004, as revised from time to time in a manner deemed acceptable to the Association, subject, however, to the modifications described in the following paragraphs required for compliance with the Procurement Guidelines. (i) In accordance with paragraph 1.16 (e) of the Procurement Guidelines, each bidding document and contract financed out of the proceeds of the Financing shall provide that (a) the bidders, suppliers, contractors and their subcontractors, agents, personnel, consultants, service providers, or suppliers shall permit the Association, at its request, to inspect all accounts, records and other documents relating to the submission of bids and contract performance, and to have said accounts and records audited by auditors appointed by the Association and (b) the deliberate and material violation of such provision may amount to an obstructive practice as defined in paragraph 1.16 (a)(v) of the Procurement Guidelines; (ii) The invitation to bid shall be advertised in, at least, one national newspaper with wide circulation; 32 (iii) The bid evaluation, qualification of bidders and contract award criteria shall be clearly indicated in the bidding documents; (iv) The bidders shall be given adequate response time (at least four weeks) from the date of the invitation to bid or the date of availability of a bidding documents, whichever is later, to prepare and submit their bids; (v) Eligible bidders, including foreign bidders, shall be allowed to participate; (vi) No domestic preference shall be given to domestic contractors and to domestically manufactured goods and association with national firm shall not be a condition for participation in a bidding process; (vii) Bids are awarded to the lowest evaluated bidder provided that such bidder is qualified; No scoring system shall be allowed for the evaluation of bids, and no “blanket” limitation to the number of lots which can be awarded to a bidder shall apply; (viii) Qualification criteria shall only concern the bidder’s capability and resources to perform the contract taking into account objective and measurable factors; and (ix) Fees charged for bidding documents shall be reasonable and reflect only the cost of printing and delivery to the prospective bidders. Safeguards 61. The Additional Financing will not change the environmental category of the project, which remains Category B as it is not anticipated that the project activities will have large scale negative impacts. The AF triggers the same two safeguards policies triggered the parent project: OP/BP. 4.01 - Environmental Assessment and OP/BP 4.10 - Indigenous peoples. The Government has prepared and disclosed the Medical Waste Management Plan (MWMP) in 2008 with an action plan. The assessment of the MWMP’s implementation was satisfactory as most of the actions proposed were implemented including follow-up workshops. It was therefore agreed that the same document will be maintained and its implementation consolidated. It was also agreed that the Medical Waste management Plan prepared in 2008 will need an update early on during project implementation to define more concretely what will be implemented in the new project areas sites. During the update process, all relevant stakeholders will be consulted. 62. The Government also prepared and disclosed an Indigenous Peoples Planning Framework (IPPF) in 2008 to ensure that the Indigenous People located in the East region would benefit from the project. Consultations with beneficiaries, the Government, the Performance Purchasing Agency in the East region, and local community-based organizations hired to conduct client satisfaction surveys have all confirmed that Indigenous Peoples in the East region have been benefitting from the intervention in several ways: (i) improved availability and quality of health services, community outreach campaigns by local health agents and community leaders for improved health knowledge and health-seeking behavior, with a focus on vulnerable populations, (ii) inclusion of specific components of the intervention to push for increased access to and utilization of health services among vulnerable groups through targeted subsidies at the point of 33 service delivery, and (iii) supervision and implementation support activities to monitor and assess if the health intervention was benefitting vulnerable groups and indigenous peoples. The PPA in the East region has maintained a continuous dialogue with indigenous groups in the region to assess their perception of the intervention and incorporate their recommendations into their PBF approach tailored for the East region. 63. The IPPF which was prepared, consulted upon, and disclosed in April 2008 under the original project remains valid for this AF. During implementation of the parent project, the borrower implemented measures to ensure that IPs in the project area were informed about project activities, consulted about their preferences as project beneficiaries, and able to benefit from the health services provided by the project (through pre-paid enrollment in health care mutual or direct assumption of health care costs). A social audit will be conducted during implementation of the Additional Financing to assess in-depth perceived and real benefits of the project among the indigenous populations in the targeted regions. In addition, an Indigenous Peoples Plans (IPPs) will be prepared to ensure that: free, prior and informed consultations leading to broad community support are held; the IPs are not adversely affected by the project; they receive culturally appropriate benefits from the project; there is a grievance redress mechanism; and, there is monitoring and evaluation of the projects impacts on and benefits for IPs. 64. Institutional arrangement: The Ministry of Public Health has a unit that is responsible for environmental issues which works in close collaboration with the Ministry of Environment, Nature Protection and Sustainable Development (MINEPDED). The Unit has well trained staff and when necessary seeks support from MINEPDED or external consultants. It was agreed that the same arrangement will be maintained during the implementation of the Additional Financing period. 65. The project is expected to have a positive social impact by improving access to health care services for poor and vulnerable households. Component 1 (through the payment for performance) will provide incentives for health facilities to target vulnerable groups in their catchment areas and provided subsidized care to these groups, leading to improved financial access for the poor and vulnerable. PBF subsidies will also aim to reduce staff absenteeism and to improve staff responsiveness with patients. As a result, health facilities with PBF contracts will in turn provide more and better care for marginalized populations and also improve medical waste management. The improved management of Medical waste will be a PBF indicator. 66. The project will have a positive impact on gender in Cameroon. Given that the project’s objectives are to improve maternal and child health in target areas, improving women’s health is an essential component of the intervention. Particular attention will also be given to ensuring active participation of women in project areas through the use of Community-based organizations (CBO) (local NGOs, women’s groups, agricultural groups, etc.). The project is expected to have a positive impact not only on pregnant women but on all women, as PBF subsidies will improve the quality of care for the identified package of health services essential for the general population. 34 67. Consultation and disclosure: The IPPF and Medical Waste Management Plan (MWMP) were originally discussed at in-country workshops with key stakeholders and local media covered the dissemination prior to the launch of the parent project. The documents were disclosed in-country on April 4th, 2008 and at the Infoshop on April 3rd, 2008. During the project re-launch, the IPPF and the MWMP will be shared by the main stakeholders. During the project implementation the PIU and Performance Purchasing Agency managers will do a social audit to assess the implication of the action plan of the IPPF during the previous phase and to draw an action plan from the lessons learned to improve the project’s actions in favor to IP. The PIU will consult and organize knowledge sharing sessions on the waste management best practices. During implementation support missions, the World Bank environmental and Social safeguards team will ensure that the main stakeholders are consulted and also that the environmental and social indicator are integrated in the PBF payments criteria. 35 Annex 1: Results Framework and Monitoring CAMEROON: Health Sector Support Investment Project Additional Financing Results Framework Revisions to the Results Framework Comments/ Rationale for Change End of project target (number) PDO Current Proposed To increase utilization and improve the quality of health services with a particular No change focus on child and maternal health and communicable diseases PDO indicators Current Proposed change* 1. People with access to a basic package of Revised Revised end of project target: 1,500,000 health, nutrition, or reproductive health Increase target number by 100% services (Number) - Core Indicator 2. Number of children immunized in Revised Revised end of project target: 200,000 targeted areas (Number) - Core Indicator Increase target number by 100% 3. Number of births attended by skilled Revised Revised end of project target: 60,000 professional in targeted areas (Text Increase target number by 100% Description) – Custom Indicator 4. New cases of TB detected and treated in Revised Revised end of project target: 10,000 target areas (Number) – Custom Indicator Increase target number by 100% 5.1 Direct project beneficiaries (Number) – Revised Revised end of project target: 1,770,000 Core Indicator Increase target number by 100% 5.2 Female beneficiaries (Text Revised Revised end of project target: 885,000 Description) – Core Indicator Increase target number by 100% Revisions to the Results Framework Comments/ Rationale for Change Intermediate Results indicators Current Proposed change* 1. Pregnant women receiving antenatal Revised End of project target: 200,000 care during a visit to a health provider Increase target number by 100% (Number) - Core Indicator 2. New acceptors of modern contraceptive Revised End of project target: 40,000 methods in targeted areas (Number) – Increase target number by 100% Custom Indicator 3. Children by the first anniversary who Revised End of project target: 200,000 have received one dose of Vit. A in the last Increase target number by 100% six months in targeted areas 4. Patients treated for TB (Text No change End of project target: 80% Description) 5. Tracer drugs available in No change targeted health facilities on 36 Revisions to the Results Framework Comments/ Rationale for Change the day of the visit (Text Description) – End of project target: 75% Custom Indicator 6. Health facilities achieving an average No change End of project target: 60% score of 75% of the quality index of services as measured in RBF in the targeted areas (Text Description) – Custom Indicator 7. Percentage of health facilities reporting No change End of project target: 75% monthly activities using standard report form in targeted areas (Number) – Custom Indicator 8. Number of consultations provided to No change End of project target: 75,000 people from the poorest quintile as measured by asset index in targeted areas (Text Description) – Custom Indicator * Note that four indicators in the Results Framework were revised in a Level-2 restructuring completed in March 2014. Three were revised to be presented as absolute numbers instead of proportions (PDO indicators 2 and 3, intermediate result indicator 8), and one was changed from an absolute number to a percentage (7). This table presents the updated Results Framework. 37 REVISED PROJECT RESULTS FRAMEWORK Project Development Objective (PDO): To increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases. Cumulative Target Values Responsi Data Baseline Progress bility for Dec Nov Dec Dec 2017 Source/ PDO Level Results Indicators UOM Original Project To Date Frequency Data Comments Core 2011 2012 2013 Methodolog Start (2009) (Dec 2013) Collectio y n 1. People with access to a basic package of number of Report from health, nutrition, or reproductive health services consultations/ca Number - 1,085,778 202,997 1,500,000 Annually PBF MoH pita/year in statistics targeted areas children under 1 2. Number of children immunized in targeted 72% Health center Number 90,595 22,164 200,000 Annually MoH year who areas (MICS 2006) reports received DPT3 3. Number of births attended by skilled professional in targeted areas 63% Health center Number 57,139 13,173 60,000 Annually MoH (MICS-2006) reports Littoral: 613 4. New cases of tuberculosis detected and N-West: 1094 Health center treated in targeted areas Number S-West: 1089 3,148 814 10,000 Annually MoH reports East: 944 (entire regions) Beneficiaries ADDING UP 1,770,000 Ministry Project 5.1. Direct Project beneficiaries, Number 0 1,231,304 - 238,334 Quarterly INDICATORS reports Unit 1-3ABOVE. Estimate based 124,961 885,000 Ministry Project on the fact that 5.2. Of which female (beneficiaries) Number 0 622,031 - Quarterly reports Unit there is no gender bias. 38 Intermediate Results and Indicators Target Values Responsi Progress Data Unit of Baseline bility for To Date Dec Nov Dec Dec Source/ Intermediate Results Indicators Measu Original Project Frequency Data Comments Core (May 2011 2012 2013 2017 Methodolog rement Start (2009) Collectio 2013) y n Intermediate Results 1 and 2: District health services and institutional strengthening Littoral: 94% N-West: 79% S- MICS and 1. Pregnant women receiving antenatal care Numbe West: 80% 195,654 37,701 200,000 Quarterly Health center MoH during a visit to a health provider r East: 62% reports (MICS 2006) 2. New acceptors of modern contraceptive Numbe Health center MoH - 19,432 3,074 40,000 Quarterly methods in targeted areas r reports 57,7% 3. Children by the first anniversary who have Numbe (0-59 months old Health center received one dose of Vit. A in the last six 148,132 24,895 200,000 Quarterly r children - reports MoH months in targeted areas MICS-2006 4. Patients treated for TB in targeted areas Littoral: Littoral: 77.5% MoH 51% N-West: N-West: 52% 66% S-West: S-West: 66.2% Health center % - 80% Annually 50% East: not reports East: 38% yet ( % for available each ( % for region) each region) 5. Tracer drugs available in targeted health Supervision facilities on the day of the visit % - 29.90% 30.0% 75% Quarterly report from MoH PBF 6. Percentage of health facilities achieving an Littoral: average score of 75% of the quality index of 9.5% MoH services as measured in PBF in the targeted N-West: areas 12% S-West: Supervision 4.3% % - 24.60% 60% Quarterly report from East: not PBF yet available ( % for each region) 39 7. Health facilities reporting monthly activities Littoral: using standard report form in targeted areas. 9.5% N-West: MoH 12% S-West: Supervision 4.3% % 0 29.00% 75% Quarterly report from East: not PBF yet available ( % for each region) 8. Number of consultations provided to people Report from from the poorest quintile as measured by asset Numbe MoH 22,578 7 75,000 Annually PBF impact index in targeted areas r evaluation 40 Annex 2 Operational Risk Assessment Framework (ORAF) Cameroon: Additional Financing for Health Sector Support Investment Project (P146795) . . Project Stakeholder Risks Stakeholder Risk Rating Moderate Risk Description: Risk Management: The project benefits from strong support from both the To respond to these weaknesses, the Ministry of Public Health (MoH) will create a PBF Minister of Public Health and the head of the Project technical unit at the central level with the mandate to (i) promote PBF approach within Steering Committee and is popular among health and outside the MoH; and (ii) prepare the technical, institutional, and financial professionals at operational and regional levels. framework for the possible expansion nationwide of the PBF approach. Nevertheless, ownership of the PBF approach is still weak Resp: Status: Stage: Recurrent: Due Date: Frequency: among many senior staff at the central level of the Ministry of Public Health. Client In Progress Both 01-Jul-2014 Implementing Agency (IA) Risks (including Fiduciary Risks) Capacity Rating Moderate Risk Description: Risk Management: Capacity building: Specific measures are not yet The MoH needs to provide instruction to the Regional Funds in the 3 regions to plan to implemented to ensure the development and the replace the international NGOs in the implementation of PBF at the regional level. In strengthening of the technical capacity of the Regional addition, the MoH should carefully include the PBF approach in the design of the new Funds for Health Promotion to take over the management Regional Funds and their instillation in the other seven regions. The project will use of PBF in the three regions of North-West, South-West existing non-governmental organizations active in the health sector in the three northern and East from the international NGOs contracted to regions to build Performance Purchasing Agencies (PPA) in the regions. The PPAs will implement PBF. These international NGOs have been be primarily responsible for contracting with health centers and other types of providers, contracted to (i) develop and implement PBF during the verification of the quantity and quality of services provided, and the payment of pilot phase, and (ii) to build the capacity of Regional subsidies to contracted providers and regulatory bodies. The PPA contracts in the Funds to take over the implementation of PBF. northern regions will be designed so that the project will contribute to the development of technical capacities of these organizations so that they are apt to temporarily assume Management capacity at the institutional and service the role of purchasing agencies. These organizations will contribute to the establishment delivery level: Weak management capacity, particularly in of PPAs within the Regional Funds for Health Promotion, who are expected to take over peripheral zones, in the context of a centralized system the role of PPAs in the region in the medium-term. 41 could threaten effective PBF implementation and be a The Ministry of Health is currently finalizing its organizational arrangements and critical constraint to the success of PBF. A key assumption depending on the identified need, external consultancy firms and technical assistance of PBF is that facilities have the management capacity to will be provided to enhance the capacity within the Ministry and within the program respond to incentives, provided they are given the with a particular focus on extension of the project to the 3 regions in the north of the autonomy to do so. PBF also emphasizes the oversight country. role of the PPA, who is responsible for purchasing services, monitoring quality, and overseeing To mitigate workload generated by the additional financing, one additional accountant implementation of PBF in general. In the Northern will be recruited on competitive basis according terms of reference acceptable to IDA. regions, management capacity appears to be weak both in public sector health facilities and at the administrative The Ministry of Public Health has agreed to take special measures to grant to health level in peripheral zones. At this piloting stage of the facilities the autonomy of management of financial resources as required by the PBF project, there is a need to implement the PBF approach approach in the other three regions. according to “best practice” principles, including the full autonomy of health facilities in the management of all Additional recruitment of staff for he PIU will take place to respond to the increased financial resources generated by facilities. So far, only the workload and responsibility generated by the doubling of the target population covered Littoral region has been implementing this principle to the by the operation. Coordination mechanisms for the two implementation agencies (health fullest extent. and safety net) will be developed early on during project preparation. Resp: Status: Stage: Recurrent: Due Date: Frequency: Implementation capacity: Extension of project areas with current PIU will substantially increase workload for Client Not Yet Due Implementation 01-Jan-2015 implementing agency. Strong coordination and communication is needed between the Health and Safety Net project implementation agencies. Governance Rating Moderate Risk Description: Risk Management: In the health sector, supply and use of financial and non-financial resources to the Despite recent improvements in promoting transparency regional, district and health facility levels has become more transparent and and engagement on citizens more needs to be done to accountability has improved in project areas through implementation of PBF. These strengthen overall governance. risks will also be mitigated in the new project zones through implementation of PBF best practices (transparency of funds management). Establishment of the PBF Technical Fiduciary and accountability arrangements. Due to the Unit at the central level of the MoH will foster and facilitate improved governance and capacity challenges explained above, there could be risks accountability in the health sector through stewardship of PBF reform in Cameroon. associated with fiduciary (financial management in particular) and accountability mechanisms, given that Resp: Status: Stage: Recurrent: Due Date: Frequency: Cameroon does not have a strong record of satisfactory Both Not Yet Due Implementation 01-Jan-2015 42 performance in these specific areas. Risk Management: Key and standard fiduciary controls have been built into the project design to mitigate fiduciary risks. Strong fiduciary controls and checks and balances following Bank and government procedures as appropriate will be used as much as possible to reduce fiduciary risks. Regular audits, FMR, and controls will be strictly implemented. PBF mechanism includes verification of services before any payment is made and above all, a counter-verification by an independent party is carried at each level. Options for promoting demand-side governance to strengthen accountability are also part of the project monitoring and evaluation framework: community based organizations are involved in verification at community levels; and the Bank and Government teams will work closely to ensure the agreed demand side governance interventions are implemented on time and in a credible way. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both Not Yet Due Implementation 01-Jan-2015 Risk Management: - PIU staff has satisfactory record in handling fiduciary responsibilities and resources to support implementation at the central and local government levels. - Engagement of an independent qualified private external auditor acceptable to the Bank to audit the project’s accounts periodically as will be stipulated in the Credit Agreement. International standards on fraud and corruption will be included in the terms of reference for the external financial auditor. - PIU staff and other stakeholders have been trained in procurement and FM. -New PIU staff will be trained in procurement and FM. - Emphasize fiduciary action plans during implementation support missions to address administrative and implementation issues and pre-empt fraud and corruption. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both Not Yet Due Both 01-Jan-2015 Risk Management: Through scaling-up PBF and use of its mechanisms to improve accountability and transparency, opportunities for mismanagement of resources will be reduced at all levels of the health system. 43 Resp: Status: Stage: Recurrent: Due Date: Frequency: Both Not Yet Due Implementation 01-Jan-2015 Project Risks Design Rating Moderate Risk Description: Risk Management: The bottlenecks inherent in the health system could The outline for scale-up of the HSSIP has been discussed at the national level. Further constrain the effective delivery of services. dialogue will be held to ensure buy-in by government and stakeholders at the regional and periphery levels, ensuring full accountability to funds released and results. The External Evaluation Agency spot checks, complaints and grievance mechanism and use of the national PBF cloud computing system will provide management information for strengthening the program. These compliance measures will be complemented by facilitating measures such as incentives linked to performance through the PBF and scaling-up ongoing social accountability initiatives that include increased participation of the communities in decision making for funds received at facilities and enhancing transparency in sharing information about services and funds received with community. Resp: Status: Stage: Recurrent: Due Date: Frequency: Not Yet Due Both 01-Jan-2015 Social and Environmental Rating Low Risk Description: Risk Management: The National Medical Waste Management Plan may not While this risk has been mitigated in the current project areas as implementation of the be respected in the target regions where PBF will be waste management plan is a requirement to receive PBF subsidies, measures to ensure scaled up. compliance in the new target region must be and will be ensured. Resp: Status: Stage: Recurrent: Due Date: Frequency: Client In Progress Both CONTINUO US Program and Donor Rating Moderate Risk Description: Risk Management: Donors and development partners are not fully on-board The team has spent substantial time working with donors to align health sector with the PBF approach in the country. Many partners are intervention strategies and gain buy-in for PBF. Progress has been made despite the lack active in the North of Cameroon (UNICEF, UNFPA, of any formal engagement. Dialogue will be intensified during preparation of the 44 AFD, etc.) and interventions may not be necessarily project. The impact evaluation results will be disseminated in early 2015, providing a complementary to the PBF approach. platform of scientific evidence for dialogue on PBF in Cameroon. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Both CONTINUO US Delivery Monitoring and Sustainability Rating Moderate Risk Description: Risk Management: There will be need for some interim arrangements as PBF The team and Government counterparts are currently assessing various models for capacities are built in the new targeted regions. establishing a Performance Purchasing Agency (PPA) will be built in the North of the country through (i) the recruitment of national (Cameroonian) expertise (there is a substantial pool of Cameroonian PBF experts currently in-country) and (ii) the technical support of international PBF experts (as has been done in the case of Littoral region) for development and implementation of the PPA. There are also many opportunities for South-South collaborations. The option to hire local and international NGOs to perform the job of the PPA for the three regions (the model applied in the North-West, South- West and East) will also be considered. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Implementation 01-Jan-2015 Overall Risk Overall Implementation Risk: Rating Moderate Risk Description: The introduction of PBF in the 26 districts currently targeted by the operation has led to enhanced accountability and brought providers closer to the communities they service. However contextual factors in the newly targeted areas (health-seeking behaviors, financial and geographic barriers, low health workforce density, unfamiliar with PBF approach) may have some impact on the implementation of the project at start-up. A number of mitigating measures are already in place or in the process of being implemented to improve operational and governance systems, including: (i) extensive knowledge and lessons learned from several years of experience with PBF in Cameroon (ii) linking with the safety net program to improve financial access and healthy lifestyle behaviors, (iii) use of the substantial and growing community of Cameroonian PBF experts to quickly transfer capacity to newly targeted stakeholders ; and (iv) use of strong advocates and technical experts of PBF within the Ministry of Health to facilitate smooth scaling-up. 45 IBRD 33382R 12º E 14º E 16º E Lake C A MER O O N This map was produced by 1963 Level the Map Design Unit of The Chad World Bank. The boundaries, 1973 Level colors, denominations and any other information shown CITIES AND TOWNS 2001 Level on this map do not imply, on the part of The World Bank To Group, any judgment on the PROVINCE CAPITALS Fotokol Massaguet legal status of any territory, or any endorsement or NATIONAL CAPITAL Maltam acceptance of such To boundaries. RIVERS Maiduguri 12º N To Mandélia MAIN ROADS 0 40 80 120 160 Kilometers To RAILROADS Maiduguri 0 40 80 120 Miles ts. PROVINCE BOUNDARIES INTERNATIONAL BOUNDARIES Mora M Lake a Maga r da To Maroua an Guelengdeng E X T R E M E Yagoua NIGERIA M NORD Kaélé 10º N 10º N To Figuil Kim To Pala To Leré CAMEROON Garoua Lake Touroua Lagdo CHA D NORD Fa ué ro no Bé 8º N 8º N bang. Mbé Mts M na Vi Ngai Ngaoundéré ts. M ADAMAOUA ua Banyo ao m m ére Dj Wum da Ngaoundal A Tibati To NORD- Lake 6º N Ikom OUEST Kumbo Mbakaou To 6º N Bamenda Bankim Sangbé Bouar Mamfe Mb Garoua Boulai u Foumban Bafoussam Dschang OUEST Yoko Lo m CENT RA L A F R I CAN SUD- Bafang CENTRE REPUBL I C OUEST Nkongsamba Mb am Bélabo Kadei Kumba Bertoua i Yabassi Yabassi Nanga ur Eboko Batouri Mt. Cameroon o LITTORAL W (4,095 m) Buea Ntui Tiko 4º N Limbe Douala Akonolinga Abong Mbang Yola 4º N Edea YAOUNDÉ EQUATORIAL Eséka Nyong EST Bou GUINEA Mbalmayo mb a Echambot Kribi Ebolowa Sangmélima Lokomo SUD Ambam Dja Kom Mouloundou 2º N 2º N To Oyem G ul f o f EQUATORIAL GA BO N G ui n e a GUINEA CO NGO 10º E 12º E 14º E 16º E APRIL 2013