«Public Disclosure Authorized Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD1666 INTERNATIONAL DEVELOPMENT ASSOCIATION Public ...»
Public Disclosure Authorized
The World Bank
FOR OFFICIAL USE ONLY
Report No: PAD1666
INTERNATIONAL DEVELOPMENT ASSOCIATION
Public Disclosure Authorized
PROJECT APPRAISAL DOCUMENT
PROPOSED CREDITIN 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 FACILITYIN THE AMOUNT OF US$27 MILLION TO THE
REPUBLIC OF CAMEROONFOR A
HEALTH SYSTEM PERFORMANCE REINFORCEMENT PROJECTApril 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
I. STRATEGIC CONTEXT
A. Country Context
B. Sectoral and Institutional Context
C. Higher Level Objectives to which the Project Contributes
II. PROJECT DEVELOPMENT OBJECTIVES
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
A. Institutional and Implementation Arrangements
B. Results Monitoring and Evaluation
V. KEY RISKS
VI. APPRAISAL SUMMARY
A. Economic and Financial Analysis
C. Financial Management
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 TABLESTable 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 FIGURESFigure 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 SHEETCameroon 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.