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«Public Disclosure Authorized Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD1666 INTERNATIONAL DEVELOPMENT ASSOCIATION Public ...»

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Public Disclosure Authorized

Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No: PAD1666

INTERNATIONAL DEVELOPMENT ASSOCIATION

Public Disclosure Authorized

PROJECT APPRAISAL DOCUMENT

ON A

PROPOSED CREDIT

IN THE AMOUNT OF SDR72.40 MILLION (US$100 MILLION EQUIVALENT) AND Public Disclosure Authorized

A PROPOSED GRANT FROM THE MULTI DONOR TRUST FUND FOR THE GLOBAL

FINANCING FACILITY

IN THE AMOUNT OF US$27 MILLION TO THE

REPUBLIC OF CAMEROON

FOR A

HEALTH SYSTEM PERFORMANCE REINFORCEMENT PROJECT

April 12, 2016 Public Disclosure Authorized Health, Nutrition and Population Global Practice 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 February 29, 2016) Currency Unit = XAF XAF 604 = US$1 US$1 = SDR 0.72395045 FISCAL YEAR January 1 – December 31

ABBREVIATIONS AND ACRONYMS

AEDES European Agency for Development and Health AIDS Acquired Immunodeficiency Syndrome AF Additional Financing ANC Antenatal Care CAD Canadian Dollar CAS Country Assistance Strategy CDVA Contract Development and Verification Agencies Centrale d’Achat et d’Approvisionnement en Médicaments Essentiels CENAME (National Supply Center for Essential Medicines and Medical Supplies) CHAI Clinton Health Access Initiative CHW Community Health Worker CORDAID Catholic Organization for Relief and Development Aid CPA Complementary Package of Activities CPF Country Partnership Framework CRVS National Civil Registration and Vital Statistics DA Designated account DALYs Disability Adjusted Life Years DHS Demographic and Health Survey DIB Development Impact Bond DLIs Disbursement Linked Indicators DP Development Partners DRC Democratic Republic of Congo Document de Stratégie pour la Croissance et l’Emploi (Growth and DSCE Employment Strategy) EA Environmental Assessment ECAM Enquête Camerounaise Auprès des Ménages (Cameroon Household Survey) EEA External Evaluation Agency EPI Expanded Program on Immunization FBO Faith Based Organization FM Financial Management GAVI Global Alliance for Vaccines and Immunization GCC Grand Challenges Canada GDP Gross Domestic Product GF Global Fund GFF Global Financing Facility GRS Grievance Redress Service HCWMP Health Care Waste Management Plan HD Human Development HIPC Heavily Indebted Poor Countries Initiative HIV Human Immunodeficiency Virus HRH Human Resources for Health HRITF Health Results Innovation Trust Fund HSS Health Sector Strategy (Stratégie Sectorielle de la Santé) HSSIP Health Sector Support Investment Project IB Investment Budget IC Investment Case IDA International Development Association IBRD International Bank for Reconstruction and Development IE Impact Evaluation IFR Interim Financial Report IMCI Integrated Management of Childhood Illnesses IMR Infant Mortality Rate IPP Indigenous Peoples Plan IPF Investment Project Financing IPPF Indigenous Peoples Planning Framework JICA Japan International Cooperation Agency KMC Kangaroo Mother Care LBW Low Birth Weight M&E Monitoring and Evaluation MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MINMAP Ministry of Public Procurement MMR Maternal Mortality Ratio MoPH Ministry of Public Health MPA Minimum Package of Activities MWMP Medical Waste Management Plan NGO Non-Governmental Organization NHA National Health Accounts PBF Performance Based Financing PDO Project Development Objective PFM Procurement and Financial Management PHCPI Primary Health Care Performance Initiative PIM Program Implementation Manual PIM Public Investment Management PIU Project Implementation Unit PNDS Programme National de Développement de la Santé (National Health Development Plan) PPA Performance Purchasing Agency PPP Purchasing Power Parity RFHP Regional Funds for Health Promotion RMNCAH Reproductive, Maternal, Neonatal, Child and Adolescent Health ROC Republic of Congo SCD Systematic Country Diagnostic SDG Sustainable Development Goals SDI Service Delivery Indicators SORT Systematic Operations Risk Rating Tool TFR Total Fertility Rate TOR Terms of Reference UHC Universal Health Coverage UNFPA United Nations Fund for Population Activities United Nations Children’s Fund UNICEF WB World Bank WBG World Bank Group WHO World Health Organization

–  –  –

I. STRATEGIC CONTEXT

A. Country Context

B. Sectoral and Institutional Context

C. Higher Level Objectives to which the Project Contributes

II. PROJECT DEVELOPMENT OBJECTIVES

A. PDO

B. Project Beneficiaries

C. PDO Level Results Indicators

III. PROJECT DESCRIPTION

A. Project Components

B. Project Financing

C. Project Cost and Financing

D. Lessons Learned and Reflected in the Project Design

IV. IMPLEMENTATION

A. Institutional and Implementation Arrangements

B. Results Monitoring and Evaluation





C. Sustainability

V. KEY RISKS

VI. APPRAISAL SUMMARY

A. Economic and Financial Analysis

B. Technical

C. Financial Management

D. Procurement

E. Social (including Safeguards)

F. Environment (including Safeguards)

G. World Bank Grievance Redress

Annex 1: Results Framework and Monitoring

Annex 2: Detailed Project Description

Annex 3: Implementation Arrangements

Annex 4: Implementation Support Plan

Annex 5: Economic and Financial Analysis

Annex 6: District mapping of PBF scale-up in northern regions of Cameroon

Annex 7: Health Services Incentivized through the PBF program

Annex 8: What is Performance Based Financing

Annex 9: Map of Cameroon

LIST OF TABLES

Table 1: Summary of health indicators

Table 2: Proposed budget breakdown

Table 3: Indicators for the Community Health Worker

Table 4: Proposed extension plan for national scale-up of PBF in Cameroon, 2016-2020.......... 50 Table 5: Estimated resource requirements for a phased national scale-up of PBF in Cameroon, 2017-2020

Table 6: Financial Management action plan

Table 7: Financial Management implementation support plan

Table 8: Procurement action plan

Table 9: Procurement plan for works, goods and non-consulting services

Table 10: Procurement plan for consulting services

Table 11: Implementation Support Plan

Table 12: Skills mix required

Table 13: Repartition of Project cost

Table 14: Summary of the cost-effectiveness analysis

Table 15: Average costs of health intervention per benefit

Table 16: Impact of the Project’s investments on fiscal sustainability

Table 17: District mapping of PBF scale-up in northern regions of Cameroon

Table 18: Services included in the PBF program, primary care level

Table 19: Services included in the PBF program, secondary care level

Table 20: Simplified example of how PBF works in a health facility

LIST OF FIGURES

Figure 1: Changes in consumption and poverty, 2001-2014

Figure 2: Inequalities in health outcomes

Figure 3: Average quality of care scores for PBF primary health care centers, 2012-2015......... 42 Figure 4: Provision of key maternal and child health services in PBF facilities, 2012-2015....... 43 Figure 5: Health facilities with PBF contracts in Littoral region, by sector, 2011-2013.............. 43 Figure 6: PBF and Community PBF service delivery model

Figure 7: Illustrative Structure of a KMC DIB for Cameroon

Figure 8: Implementation arrangements of the Cameroon PBF program

Figure 9: Cameroon GFF coordination platform

Figure 10: Verification and payment procedures for PBF subsidies

Figure 11: Fund flows for IDA & GFF

Figure 12: Performance Based Financing (PBF) in the Cameroon’s health sector 2012-15........ 86 Figure 13: Rapid expansion of PBF projects in Sub-Saharan Africa between 2006 and 2013.... 96 Figure 14: The Separation of Functions and its Governance Issues

PAD DATA SHEET

Cameroon Health System Performance Reinforcement Project (P156679)

PROJECT APPRAISAL DOCUMENT

.

–  –  –

Proposed Development Objective(s) The proposed Project Development Objective (PDO) is to increase utilization and improve the quality of health services with a particular focus on reproductive, maternal, child and adolescent health and nutrition services.

.

–  –  –

Legal Covenants Name Recurrent Due Date Frequency Recruitment of Fiduciary Personnel 05-Nov-2016 Description of Covenant SCHEDULE 2. Section I.A.2.(b)(i)(B). The recipient will recruit not later than two (2) months after the Effective Date, an accountant, an assistant accountant, and an internal auditor all in accordance with Section III of Schedule 2.

Name Recurrent Due Date Frequency Implementation of External Verification 05-Jun-2017 Description of Covenant SCHEDULE 2. Section I.G.4.(a). The Recipient shall maintain or, as needed, in accordance with Section III of this Schedule 2, recruit not later that nine (9) months after the Effective Date and thereafter maintain, throughout Project implementation, external verification agents, with qualifications, experience, and terms of reference satisfactory to the Association, for purposes of the third-party verification of the Basic Health Services Package to be carried out under Part A.1 of the Project.

Name Recurrent Due Date Frequency Upgrading of Financial and Accounting 05-Nov-2016 System Description of Covenant SCHEDULE 2. Section II.B.4. The Recipient shall upgrade, not later than two (2) month after the Effective Date, the Project’s computerized financial and accounting system to be fit for Project purpose, in a manner satisfactory to the Association.

Name Recurrent Due Date Frequency Recruitment of External Auditors 05-Feb-2017 Description of Covenant SCHEDULE 2. Section II.B.5. The Recipient shall engage external auditors for the purpose, not later than five (5) months after the Effective Date, in accordance with the provisions of Section III of this Schedule 2.

.

–  –  –

1. Cameroon has an estimated population of 22.8 million (2014) and the annual population growth rate is 2.7, with 41 percent of the population under 15 years old.

Cameroon’s average Growth Domestic Product (GDP) growth in real terms has stood between 3.3 (2010) and 5.9 percent (2014) over the last five years, with GDP per capita per year (Purchasing Power Parity (PPP)) estimated at US$2,400 in 2013. Cameroon is a lower middle income country, but poverty levels are high and social indicators remain low. It was ranked 153rd out of the 188 countries tracked in the 2014 Human Development Index (HDI) and is one of a group of countries whose HDI scores have deteriorated in the past two decades.

2. Despite great development potential (significant natural resources, a relatively educated work force and a capable bureaucracy), Cameroon’s economic growth is lagging behind its potential and has not had a lasting impact on poverty. Cameroon is endowed with significant natural resources, including oil, high value timber species and agricultural products (coffee, cotton, cocoa). Poor infrastructure, an unfavorable business environment, and weak governance hamper economic activity and make it difficult to reach the growth rates needed to reduce poverty in a sustainable manner. After a significant decrease in poverty rates in the 1990s, the poverty rate has barely shifted between 2000 and 2007. Since 2001, it is estimated that around 40 percent of the population lives below the poverty line and chronic poverty stands at about 26 percent. In 2014, poverty incidence was 38 percent (using the national poverty line). These averages are high compared to other countries in the region with similar economic characteristics.

3. Moreover, there are significant regional disparities in poverty and depths of poverty in Cameroon; poverty is predominant in rural areas and in the northern regions of the country. 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 2014 finds that 56.8 percent of rural families are poor, compared to

8.9 percent of urban families. Approximately 87 percent of the poor live in rural areas; the

poor – in terms of numbers and level of poverty - are concentrated in the three northern regions:

Far North, North, and Adamawa. Fifty six percent of all poor are found in the Far North and North regions, this reflects a rapid increase (in 2001, it was 34 percent). Changes in poverty between 2001 and 2014 show an unambiguous regional pattern, with northern Cameroon becoming poorer and southern Cameroon becoming better-off. Poverty declined continuously in the center-west of the country, in the Littoral, Center, West and South-West regions, as well as in Douala and Yaoundé. By contrast, poverty continuously rose in the North and Far North regions. The regions of Adamawa, North-West and South are characterized by stagnation while the East region initially experienced an increase in poverty followed by a sharp decline.



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