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Document of
The World Bank
FOR OFFICIAL USE ONLY
Report No: 81976-ZM
INTERNATIONAL DEVELOPMENT ASSOCIATION
PROJECT APPRAISAL DOCUMENT
ON
A PROPOSED CREDIT
IN THE AMOUNT OF SDR33.9 MILLION
(US$52.0 MILLION EQUIVALENT)
AND
A GRANT
IN THE AMOUNT OF US$15 MILLION
FROM THE MULTI DONOR TRUST FUND FOR HEALTH RESULTS INNOVATION
TO THE
THE REPUBLIC OF ZAMBIA
FOR A
HEALTH SERVICES IMPROVEMENT PROJECT
February 28, 2014
Health, Nutrition and Population – Eastern and Southern Africa
Country Department AFCS3
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.
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i
CURRENCY EQUIVALENTS
(Exchange Rate Effective January 31, 2014})
Currency Unit = Zambian Kwacha
ZMW 5.57499992 = US$1
US$ 1.53420000 = SDR 1
FISCAL YEAR
January 1 – December 31
ABBREVIATIONS AND ACRONYMS
AFTFM Africa Region Financial Management
AFTHE Africa Health, Nutrition & Population Unit, Eastern & Southern Africa
AFTHW Africa Health, Nutrition & Population Unit, Western & Central Africa
AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal Care
ARI Acute Respiratory Infection
AWP Annual Work Plan
BCC Behavioral Change Communication
BOZ Bank of Zambia
BP Bank Policy
CHA Community Health Assistant
CHW Community Health Worker
CP Cooperating Partner
CPD Continuing Professional Development
CPR Contraceptive Prevalence Rate
CPS Country Partnership Strategy
DA Designated Account
DALY Disability Adjusted Life Year
DfID UK Department for International Development
DHIS-2 District Health Information System
DLI Disbursement Linked Indicator
DLR Disbursement Linked Result
DMO District Medical Office
EEP Eligible Expenditure Program
EmONC Emergency Obstetric and Newborn Care
eZICS Electronic Zambia Inventory Control System
FM Financial Management
GAC Governance and Corruption
GMCSP Governance and Management Capacity Strengthening Plan
GMP Growth Monitoring and Promotion
GNC General Nursing Council
GRZ Government of the Republic of Zambia
HIV Human Immunodeficiency Virus
HMIS Health Management Information Systems
HRH Human Resources for Health
HRITF Health Results Innovation Trust Fund
ii
IBRD International Bank for Reconstruction and Development
ICT Information and Communication Technology
IDA International Development Association
IFMIS Integrated Financial Management System
IFR Interim Financial Report
IHP+ International Health Partnership plus
IMCI Integrated Management of Childhood Illnesses
ITN Insecticide Treated Nets
IYCF Infant Young Child Feeding
JMT Joint Management Team
KPI Key Performance Indicators
LCMS Living Conditions Monitoring Survey
LY Life Year
M&E Monitoring and Evaluation
MCDMCH Ministry of Community Development, Mother and Child Health
MDG Millennium Development Goal
MNCH Maternal, Newborn, and Child Health
MOF Ministry of Finance
MOH Ministry of Health
MSL Medical Stores Limited
NCHWP National Community Health Worker Program
NFNC National Food and Nutrition Commission
NHA National Health Accounts
NHC Neighborhood Health Committee
NHSP National Health Strategic Plan
NICC Nutrition Inter-Agency Coordinating Committee
OAG Office of Auditor General
OP Operation Policy
ORAF Operational Risk Assessment Framework
ORT Oral Rehydration Treatment
PAD Project Appraisal Document
PDO Project Development Objective
PER Public Expenditure Review
PHC Primary Health Care
PIM Project Implementation Manual
PNC Postnatal Care
QALY Quality Adjusted Life Year
RBF Results Based Financing
SAG Sector Advisory Group
SBA Skilled Birth Attendant
SOE Statement of Expenditure
SUN Scaling Up Nutrition
SWAp Sector Wide Approach
TFR Total Fertility Rate
UHC Universal Health Coverage
UNICEF United Nations Children’s Fund
WB The World Bank
WHO World Health Organization
ZDHS Zambia Demographic and Health Survey
ZMW Zambian Kwacha
iii
Regional Vice President: Makhtar Diop
Country Director: Kundhavi Kadiresan
Acting Sector Director: Tawhid Nawaz
Sector Manager: Olusoji O. Adeyi
Task Team Leader: Netsanet W. Workie
iv
ZAMBIA
Health Services Improvement Project
TABLE OF CONTENTS
Page
I. STRATEGIC CONTEXT .................................................................................................1
A. Country Context ............................................................................................................ 1
B. Sectoral and Institutional Context ................................................................................. 1
C. Higher Level Objectives to which the Project Contributes .......................................... 6
II. PROJECT DEVELOPMENT OBJECTIVE (PDO) ......................................................7
A. PDO............................................................................................................................... 7
Project Beneficiaries ........................................................................................................... 7
PDO Level Results Indicators ............................................................................................. 8
III. PROJECT DESCRIPTION ..............................................................................................8
A. Project Components ....................................................................................................... 8
B. Project Financing ........................................................................................................ 15
C. Lessons Learned and Reflected in the Project Design ................................................ 16
IV. IMPLEMENTATION .....................................................................................................18
A. Institutional and Implementation Arrangements ........................................................ 18
B. Results Monitoring and Evaluation ............................................................................ 19
C. Sustainability............................................................................................................... 19
V. KEY RISKS AND MITIGATION MEASURES ..........................................................20
A. Risk Ratings Summary Table ..................................................................................... 20
B. Overall Risk Rating Explanation ................................................................................ 20
VI. APPRAISAL SUMMARY ..............................................................................................21
A. Economic and Financial Analysis ............................................................................... 21
B. Technical ..................................................................................................................... 24
C. Financial Management ................................................................................................ 25
D. Procurement ................................................................................................................ 27
E. Social (including Safeguards) ..................................................................................... 28
F. Environment (including Safeguards) .......................................................................... 28
G. Governance and Corruption (GAC) ............................................................................ 28
v
Annex 1: Results Framework and Monitoring .........................................................................30
Annex 2: Detailed Project Description .......................................................................................35
Annex 3: Implementation Arrangements ..................................................................................57
Annex 4: Operational Risk Assessment Framework (ORAF) .................................................75
Annex 5: Implementation Support Plan (ISP) ..........................................................................81
Annex 6: Economic and Financial Analysis ..............................................................................84
Annex 7: Country map ................................................................................................................93
LIST OF FIGURES
Figure A.2: Distribution network of drug supply ......................................................................... 40
Figure A.3: High impact MNCH and nutrition interventions ....................................................... 43 Figure A.4: RBF model and flow of funds ................................................................................... 52 Figure A.5: Project Implementation mechanisms ......................................................................... 58
Figure A.6: Flow of funds ............................................................................................................. 63 Figure A.7: Presence of the private health sector – Zambia by province ..................................... 90
Figure A.8. Economic growth in Zambia and SSA countries....................................................... 91
LIST OF TABLES
Table 1: Selected health status and utilization indicators ............................................................... 2 Table 2: Estimated number of project beneficiaries (rounded) ...................................................... 7 Table 3: Project costs and financing by component ..................................................................... 15
Table A.1: Summary – Definition and Interpretation of PDO and Intermediate Indicators ......... 33 Table A.2: Schools and number of graduates ............................................................................... 37
Table A.3: Disbursement linked indicators .................................................................................. 45 Table A.4: Detailed Distribution of project components by implementing agencies ................... 59
Table A.5: Financial management action plan ............................................................................. 61 Table A.6: Summary assessment of procurement capacity, risks and mitigation measures......... 65 Table A.7: Prior review and procurement method thresholds – Zambia ...................................... 67 Table A.8: Timeline of main focus of implementation................................................................. 83
Table A.9: Skill mix required ....................................................................................................... 83 Table A.10. Number of beneficiaries in project provinces ........................................................... 87 Table A.11. Expected impact on child maternal mortality and maternal mortality ...................... 87
Table A.12. Cost-benefit analysis results ..................................................................................... 88 Table A.13. Historical trend of government budget for health sector .......................................... 92
vi
.
PAD DATA SHEET
Zambia
Health Services Improvement Project (P145335)
PROJECT APPRAISAL DOCUMENT .
AFRICA
AFTHE
Report No.: PAD812 .
Basic Information
Project ID EA Category Team Leader
P145335 B - Partial Assessment Netsanet Walelign Workie
Lending Instrument Fragile and/or Capacity Constraints [ ]
Investment Project Financing Financial Intermediaries [ ]
Series of Projects [ ]
Project Implementation Start Date Project Implementation End Date
25-Mar-2014 30-Jun-2019
Expected Effectiveness Date Expected Closing Date
01-Jul-2014 30-Jun-2019
Joint IFC
No
Sector Manager Sector Director Country Director Regional Vice President
Olusoji O. Adeyi Tawhid Nawaz Kundhavi Kadiresan Makhtar Diop .
Borrower: Ministry of Finance
Responsible Agency: Ministry of Health
Contact: Dr. Davy Chikamata Title: PS, Ministry of Health
Telephone
No.:
260-211-252989 Email: [email protected]
Responsible Agency: Ministry of Community Development, Mother and Child Health
Contact: Prof. Elwyn Chomba Title: PS, Ministry of Community
Development Mother & Child Health
Telephone
No.:
260-211-235327 Email: [email protected]
.
vii
Project Financing Data(in USD Million)
[ ] Loan [ X ] Grant [ ] Guarantee
[ X ] Credit [ ] IDA Grant [ ] Other
Total Project Cost: 67.00 Total Bank Financing: 52.00
Financing Gap: 0.00 .
Financing Source Amount
BORROWER/RECIPIENT 0.00
International Development Association (IDA) 46.91
Health Results-based Financing 15.00
IDA recommitted as a credit 5.09
Total 67.00 .
Expected Disbursements (in USD Million)
Fiscal Year 2015 2016 2017 2018 2019 0000 0000 0000 0000
Annual 12.10 13.58 13.67 13.28 14.37 0.00 0.00 0.00 0.00
Cumulative 12.10 25.68 39.35 52.63 67.00 0.00 0.00 0.00 0.00 .
Proposed Development Objective(s)
The project development objective is "to improve health delivery systems and utilization of maternal,
newborn and child health and nutrition services in project areas." .
Components
Component Name Cost (USD Millions)
Component 1: Strengthening capacity for primary and
community level MNCH and nutrition services
27.50
Component 2: Strengthening utilization of primary and
community level MNCH and nutrition services through
results based financing approaches
24.00
Component 3: Strengthening project management and policy
analysis
15.50
.
Institutional Data
Sector Board
Health, Nutrition and Population .
Sectors / Climate Change
Sector (Maximum 5 and total % must equal 100)
Major Sector Sector % Adaptation
Co-benefits %
Mitigation
Co-benefits %
Health and other social services Health 100
viii
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)
Major theme Theme %
Human development Health system performance 30
Human development Nutrition and food security 20
Human development Child health 20
Human development Population and reproductive health 20
Human development Malaria 10
Total 100 .
Compliance
Policy
Does the project depart from the CAS in content or in other significant
respects?
Yes [ ] No [ X ]
.
Does the project require any waivers of Bank policies? Yes [ ] No [ X ]
Have these been approved by Bank management? Yes [ ] No [ X ]
Is approval for any policy waiver sought from the Board? Yes [ ] No [ X ]
Does the project meet the Regional criteria for readiness for implementation? Yes [ X ] No [ ] .
Safeguard Policies Triggered by the Project Yes No
Environmental Assessment OP/BP 4.01 X
Natural Habitats OP/BP 4.04 X
Forests OP/BP 4.36 X
Pest Management OP 4.09 X
Physical Cultural Resources OP/BP 4.11 X
Indigenous Peoples OP/BP 4.10 X
Involuntary Resettlement OP/BP 4.12 X
Safety of Dams OP/BP 4.37 X
Projects on International Waterways OP/BP 7.50 X
Projects in Disputed Areas OP/BP 7.60 X .
ix
Legal Covenants
Name Recurrent Due Date Frequency
Engagement of independent verification
agent. FA Schedule 2. Section I. C 1.(e) 30-Dec-2014
Description of Covenant
For purposes of carrying out each such verification, engage not later than December 30, 2014, in
accordance with the provisions of Section III of this Schedule 2, the independent verification agent
referred to under Part C (7) of the Project, under terms of reference, qualifications and experience
satisfactory to the Association.
Name Recurrent Due Date Frequency
Health Care Waste Management Plan.
Financing Agreement Schedule 2.
Section I. F.5
30-Dec-2014
Description of Covenant
Not later than December 30, 2014, the Recipient shall; (i) in accordance with terms of reference
acceptable to the Association, update the said HCWMP and furnish said updated HCWMP to the
Association for its approval; (ii) thereafter disclose the updated HCWMP in country and at the
Infoshop; (iii) thereafter ensure that the Project is carried out in accordance with the provisions of the
update
Name Recurrent Due Date Frequency
Audit committee in MCDMCH.
Financing Agreement Ref. Schedule 2
Section II. B .4
30-Dec-2014
Description of Covenant
The Recipient shall: (a) not later than December 30, 2014, set up and operationalize the audit committee
in MCDMCH, with composition and terms of reference acceptable to the Association; and (b) thereafter
maintain the said audit committee through-out the implementation of the Project. .
Conditions
Name Type
HRITF Grant Agreement cross-effectiveness: Financing Agreement Section
4.01 (a)
Effectiveness
Description of Condition
The MDTF for Health Results Innovation Grant Agreement has been executed and delivered and all
conditions precedent to its effectiveness or to the right of the Recipient to make withdrawals under it
(other than the effectiveness of this Agreement) have been fulfilled.
Name Type
Project Implementation Manual: Financing Agreement 4.01 (b) Effectiveness
Description of Condition
The Recipient has adopted the Project Implementation Manual in accordance with the provisions of
Section I.B of the Schedule 2 to this Agreement.
x
Team Composition
Bank Staff
Name Title Specialization Unit
Liba C. Strengerowski-
Feldblyum
Operations Analyst Enviornmental Specialist AFTN2
Yvette M. Atkins Senior Program
Assistant
Senior Program
Assistant
AFTHE
Luis M. Schwarz Senior Finance Officer Senior Finance Officer CTRLA
Richard M. Seifman Consultant Consultant AFTHE
Hocine Chalal Lead Environmental
Specialist
Lead Environmental
Specialist
AFTN1
Gandham N.V. Ramana Lead Health Specialist Lead Health Specialist AFTHE
Wedex Ilunga Senior Procurement
Specialist
Procurement AFTPE
Carolyn J. Shelton Senior Operations
Officer
Senior Operations
Officer
AFTHE
Jumana N. Qamruddin Senior Health Specialist Operations Officer AFTHE
Edit V. Velenyi Economist Economist AFTHE
Ziauddin Hyder Sr Nutrition Spec. Nutrition AFTHE
Musonda Rosemary
Sunkutu
Senior PHN Specialist Senior PHN Specialist AFTHE
Christopher H. Herbst Health Specialist Human Resources for
Health
AFTHW
Netsanet Walelign
Workie
Sr Economist (Health) Team Lead AFTHE
Dinesh M. Nair Senior Health Specialist Senior Health Specialist HDNHE
Stephen Mugendi
Mukaindo
Counsel Counsel LEGAM
Collins Chansa E T Consultant Health Systems
Specialist
AFTHE
John Bosco Makumba Operations Officer Operations Officer AFTHE
Huihui Wang Economist (Health) Economist (Health) AFTHE
Paivi Koskinen-Lewis Social Development
Specialist
Social Development
Specialist
AFTCS
Lingson Chikoti E T Consultant Financial Management AFTME
Charity Inonge
Mbangweta
Temporary Program Assistant AFCS3
.
xi
Locations
Country First
Administrative
Division
Location Planned Actual Comments
Zambia Western Western Province X
Zambia North-Western North-Western
Province X
Zambia Northern Northern Province X
Zambia Northern Northern Province X Muchinga is identified
as Northern Province
since it is a new
province and is not yet
appearing in the portal.
We have requested this
to be updated by ISGIS-
OPS by email exchange
on Feb. 4, 2014.
Zambia Luapula Luapula Province X
1
I. STRATEGIC CONTEXT
A. Country Context
1. Zambia is a lower-middle income country (per capita gross national income (GNI)
US$1,350 in 2012), with a population estimated at 14.08 million in 2012. Sixty percent of the
population lives in rural areas. Zambia has a vast land area of 752,612 square kilometers and the
population is sparsely distributed (average density of 18 people per square kilometer). This
density is particularly low in rural areas, making service delivery a challenge. Annual economic
growth has been sustained at about six percent in recent years. The country has had a long period
of political stability and experienced five successful multiparty elections since 1991.
2. Despite political stability and robust annual economic growth in the last decade,
poverty, particularly in rural areas, remains stubbornly high. The effect of economic growth
on overall poverty reduction has been small and urban centered growth has not generated higher
incomes and better basic services for Zambians living in rural areas. Rural poverty at 78 percent
is more than double compared to urban poverty of 28 percent.1 Over the past decade, the Gini
coefficient worsened from 0.47 to 0.52, especially in rural areas.
3. Zambia has defined its development agenda through its Vision 2030 and the revised
Sixth National Development Plan (2013-2016). Specific development goals include fostering a
competitive and outward-oriented economy, significantly reducing hunger and poverty, and
reaching high middle income status. Recognizing that there are benefits in bringing decision
making and implementation closer to the people, the Government of Zambia (GRZ) is moving
towards greater transfer of authority and resources to local government. In this regard, the
national decentralization policy has been revised and approved in early 2013. Primary health care
(PHC) is among those activities prioritized for decentralization.
B. Sectoral and Institutional Context
4. In the last decade, Zambia has made notable progress in improving selected health
outcomes. Incidence and death rates from HIV/AIDS and malaria have dropped for all age
groups2
. However, progress is insufficient to achieve health and nutrition Millennium
Development Goals (MDGs) by 2015. There has been a very remarkable decrease in under-five
mortality, from 192 to 89 deaths per 1,000 live births between 1990 and 2012.3 However, it is
still high compared to the average for lower middle income countries (61 deaths per 1,000 live
births), and insufficient to achieve MDG 4 target of 64. The maternal mortality ratio also fell
from 470 to 440 deaths per 100,000 live births between 1990 and 2010, but this seven percent
reduction is insufficient to achieve the MDG 5 target4. Zambia has one of the highest total
fertility rates (TFR) in the world (5.9 births in 2010), contributing to both under-five and
1 Central Statistics Office, 2010. Living Conditions Monitoring Survey, Lusaka.
2 Zambia Country Report: monitoring the declaration of commitment on HIV and AIDS and the universal access,
Biennial Report, submitted to the United Nations General Assembly Special Session on HIV and AIDS, March 31,
2012 3 Levels &Trends in Child Mortality, 2013. Estimates Developed by the UN Inter-Agency Group for Child Mortality
Estimation, Geneva. 4 Trends in Maternal Mortality: 1990-2010, 2012, Estimates by WHO, UNICEF, UNFPA and the World Bank.
2
maternal mortality, and to increased malnutrition. Although stunting in under-five children has
decreased from 53 percent in 2002 to 45 percent in 2007, it remains high compared to regional
averages (35 percent) and is far from the MDG 1c target of 23 percent. An estimated one-third of
under-five mortality and almost a quarter of maternal mortality are associated with malnutrition,
which affects immune status, physical and cognitive development, learning performance and
productivity in adult life.
5. Zambia’s coverage and utilization of high impact maternal, newborn and child health
(MNCH) and nutrition interventions present a number of challenges, particularly high
urban-rural disparities. Rural areas are worse off for many indicators (Table 1). For example,
TFR is 7.0 per woman in rural and 4.6 in urban areas; and deliveries assisted by a skilled birth
attendant are 31.3 percent in rural and 83.0 percent in urban areas. The only exception where
rural areas are performing better than urban areas is in the Insecticide Treated Nets (ITN)
indicators – children who slept under an ITN is 60.1 percent in rural areas and 50.9 percent in
urban areas. Although measles immunization coverage is 83 percent (versus 75 percent
regionally), full immunization coverage for children aged 12-23 months has been stagnant during
the past decade at around 70 percent. While overall ITN coverage has increased substantially in
recent years, 43 percent of under-five children still do not sleep under an ITN. Sixty percent of
under-five children with suspected malaria do not receive antimalarial drugs, and only 36 percent
receive deworming tablets. Whereas 60 percent of women receive four antenatal care (ANC)
visits (better than the regional average of 43 percent5), the quality of ANC is doubtful. With HIV
prevalence at 14.3 percent among adults aged 15-49 years, the figure is higher in women (16.1
percent) than men (12.3 percent). Contraceptive prevalence rate (CPR) is low (32.7 percent),
contributing to poor reproductive health outcomes, such as high fertility, high teen pregnancy
and low birth spacing.
Table 1: Selected health status and utilization indicators Urban Rural National
Outcome indicators
Total fertility rate (births per woman)* 4.6 7.0 5.9
Contraceptive prevalence (% of women ages 15-49) ** 42.0 27.6 32.7
Chronic malnutrition prevalence (% of under-5 children) ** 39.0 47.9 45.4
HIV prevalence (% of adults aged 15-49 years who are HIV positive) ** 19.7 10.3 14.3
Service coverage indicators
Delivered by skilled providers (% of pregnant women) ** 83.0 31.3 46.5
Full immunization coverage (% of children aged 12-23 months) ** 71.2 66.2 67.6
ARI treatment coverage (% of under-5 children) ** 63.4 38.9 46.6
Children with diarrhoea who received ORT or increased fluid (% of under-5
children) ** 75.7 73.6 74.3
Children with fever who sought treatment from a facility/provider same day/next
day (% of under-5 children) *** 25.2 24.3 24.5
Children who slept under an ITN last night (% of under-5 children) *** 50.9 60.1 57.0
Women who slept under an ITN last night (% of pregnant women) *** 52.3 60.9 58.2
Sources: *** 2012 Zambia National Malaria Indicator Survey; ** 2007 Zambia Demographic and Health Survey, and * 2010
Zambia Census of Population and Housing.
5 Average for lower middle income, WDI 2012
3
6. Low coverage and utilization of MNCH and nutrition services are attributed to demand
as well as supply side constraints. On the demand side, communities often lack information on
preventive practices, including early detection of health and nutrition complications. In addition,
long distances to health facilities and lack of transportation often limit access to services and
delay in seeking care. On the supply side, despite the increase in the number of health facilities,
including primary care, service utilization remains low due to bottlenecks such as: (i) stock-outs
of essential health and nutrition supplies and consumables due largely to supply chain issues; (ii)
insufficient and inequitable distribution of skilled health workers to carry out facility-based and
outreach activities especially in the management of childhood illnesses and severe malnutrition,
midwifery, and obstetric complications; and (iii) compromised efficiency of health workers due
to tardiness, low morale, and absenteeism. The for-profit private sector owns about 14 percent of
the total number of health facilities, reflecting Zambia’s limited experience with public - private
partnerships in the health sector.
7. Fiscal constraints and allocative inefficiencies in health financing, exacerbate the
challenges in the health sector. According to the 2010 National Health Accounts (NHA),
Zambia’s total health expenditure per capita was US$59 (50 percent from Government, 39
percent from donor funding, and 7 percent from out-of-pocket payments). An analysis of
changes over time in Zambia and other Africa comparators in health outcomes (e.g. under five
mortality, maternal mortality and life expectancy), and system capacity (e.g. beds, physicians)
shows poor health returns despite relatively high health sector expenditures.
8. There are proven, cost effective high impact interventions and life-saving
technologies to reduce morbidity and mortality in Zambia.6 The challenge is to improve
access, quality and utilization of basic MNCH and nutrition services. Some of the constraints can
be relieved by: (i) enhancing productivity of the health work force by linking rewards to results;
(ii) skill enhancement of existing health workers; (ii) ensuring better availability of life-saving
technologies; (iii) targeting resources to selected diseases with high burden and impact; (iv)
promoting family planning by choice; and (v) promoting nutrition in women and children.
9. The Government is committed to improving maternal and child health as reflected
in policy documentation and wide ranging institutional reforms. The Vision 2030, the
revised Sixth National Development Plan (2013-2016), the National Health Policy, the National
Health Strategic Plan (NHSP, 2011-2015), and the Roadmap for Accelerating Reduction of
Maternal, Newborn and Child Mortality (2013-2016), all specifically identify maternal and child
health as a priority. The National Food and Nutrition Strategic Plan (2011-2015) emphasizes the
importance of reducing all forms of malnutrition and is operationalized through the “Scaling-Up
Nutrition (SUN)” First 1000 Most Critical Days Implementation Plan. Commitment to
strengthening service delivery at the community and primary levels of care is reflected in wide
ranging institutional reforms including the Human Resources for Health (HRH) Strategic Plan
(2011-2015) and the national decentralization policy that aims to devolve responsibility of
service delivery from central and provincial levels to districts and communities. These policies
reflect the importance of ensuring skilled care: (i) across the continuum of care (pre-pregnancy,
pregnancy, childbirth, postnatal, and childhood), and (ii) at all levels of the health care delivery
6 Close to two-thirds (64.2 percent) of all deaths in Zambia are caused by communicable diseases, poor maternal and
child health and nutrition conditions. Source: World Development Indicators.
4
system, including at individual, family and community levels to improve MNCH and nutrition
outcomes. The country is in the process of formulating health and social insurance schemes
which amplifies their commitment to move to universal health care and shared benefits.
10. Furthermore, consistent with its focus on broadening social and health services to the
poor and under-served, the GRZ supports its renewed health sector vision of “equity of
access to assured quality, cost-effective and affordable health services as close to the family
as possible” by taking a more strategic approach to community-based health care and
strengthening the National Community Health Worker Program (NCHWP).7 The aim is to
reduce the workload of scarce clinicians in the provision of basic preventive, promotive and
curative MNCH and nutrition services primarily in underserved rural areas. Created based on a
national situation analysis and lessons learned from other countries in the region (notably,
Malawi and Ethiopia), the major guiding principle of the NCHWP is to empower Neighborhood
Health Committees (NHC) and maximize skills and potentials of the existing cadre of
Community Health Workers (CHWs) in Zambia. The NCHWP specifies CHW’s role which
includes community empowerment, demand generation, and provision of basic MNCH and
nutrition services during pregnancy, childbirth and post-natal period and infancy and childhood,
assisted by the NHC.
11. Health services are delivered through the MOH and MCDMCH, and are organized into
three levels: (i) the PHC level (promotive, preventive, curative, and rehabilitative health services
based on a basic health care package at health posts, health centers, and district/first level referral
hospitals); (ii) the secondary level that consists of more than twenty (20) general/second level
referral hospitals providing curative care in internal medicine, pediatrics, obstetrics and
gynecology, and general surgery; and (iii) the tertiary level that consists of six (6) central
hospitals (including the University Teaching Hospital) providing specialized and sub-specialized
care.
12. GRZ has shifted the responsibility for MNCH and nutrition at PHC and community
level to the MCDMCH, reflecting commitment to scale up community access to these
services. Recognizing that the formal health sector confronts a formidable range of
communicable and non-communicable disease priorities, and that community development and
social welfare have strong links to maternal, newborn, and child well-being, GRZ decided that
the ministry best positioned to provide access to preventive and basic care would be MCDMCH,
given its community-focused mandate. This shift provides a great opportunity to embark on a
more integrated approach at the community level, as the same Ministry is responsible for
Community Development, Social Welfare and Primary Health Care.
13. The Government, in collaboration with Cooperating Partners (CPs), is forging a
concerted effort to remove systemic bottlenecks hampering the delivery and scaling up of
MNCH and nutrition services. The GRZ has been committed to the Sector-Wide Approach
(SWAp) since the health reforms of 1991. Health reforms helped catalyze donor harmonization
and alignment through initially pooled financing (basket funding) of district health plans whose
7 Ministry of Health, Republic of Zambia. National Community Health Worker Strategy in Zambia, August 2010.
5
focus was on primary health care, recognition that 80 percent of diseases could be dealt with at
PHC level. More recently, a National Aid Policy and an overall national development policy
framework (Vision 2030) are in place. Through the health SWAp, the CPs have generously
responded with financial, technical and in-kind material resources to improve health service
delivery in Zambia.
14. Through the Joint Assistance Strategy for Zambia (JASZ), and the Health Sector
Memorandum of Understanding (MOU), the Zambian Government has provided
leadership and ownership to improved coordination and collaboration. In line with the
JASZ and MOU, Cooperating Partners are committed to a coordinated approach to support: (i) a
package of high impact MNCH and nutrition interventions; (ii) health systems strengthening
including HRH, health financing, supply chain management, monitoring and evaluation systems,
and health information systems; (iii) strengthening fiduciary capacity at national and down to
district levels; (iv) strengthening community health, namely demand generation and service
provision at community level, including social accountability mechanisms; and (v) strengthening
evidence generation and policy analysis and formulation. The major CPs providing support or
planning future support to MNCH and nutrition include: the World Bank, Ireland, the European
Union, Sweden, the United Kingdom, United Nations agencies (UNFPA, UNICEF, WFP,
WHO), and the United States. 8
15. While improved coordination and collaboration is essential, there is an urgent need for
enhanced results-oriented service delivery, geared towards enhancing both quantity and
quality of services, coupled with means to accelerate attainment of Universal Health
Coverage and equity in utilization. Increasingly, and partly as a lesson from the Zambia health
sector experiences on results-based financing, the need to refocus policy dialogue on results is
imperative. This is a timely opportunity to utilize relatively recent demand, supply and combined
side approaches, ones which have been applied in multiple country settings to obtain better
results, and to some degree already piloted in Zambia (such as Results Based Financing), and
Disbursement Linked Indicator financing, to accelerate health service delivery and utilization by
the under-served and less responsive populations.
8 U. S. Government through USAID, PEPFAR, CDC, and other implementing partners support which inter alia, has
projects for MNCH and nutrition services including health systems strengthening program, family program and
reproductive health, Saving Mother Giving Life program, water and sanitation, HIV/AIDS, malaria and TB from
2014-2016 and new heath support program under preparation; The Global Fund is supporting HIV/AIDS, Malaria,
TB through 2016; The UN support to MNCH led by UNICEF through the H4+ Canada Grant; The European Union
is implementing two projects focusing on MNCH, pharmaceutical services, and health policy development during
the period 2013-2017; The United Kingdom has committed financing for HRH, family planning, nutrition and HIV
prevention through 2016 and preparing additional support to MNCH, HRH, and nutrition; Sweden support for health
system strengthening and HRH, also in the process of launching additional support to MNCH, HRH, and nutrition;
WHO support to reproductive health and safe motherhood; UNFPA support through family planning; WFP –
nutritional support; and Irish AID support to nutrition.
6
C. Higher Level Objectives to which the Project Contributes
16. The proposed project will support the first strategic objective of the Country
Partnership Strategy (CPS) for the period FY2013-16, “reducing poverty and the
vulnerability of the poor,” by targeting areas where income poverty is higher, a significantly
larger proportion of under-5 children suffer from chronic malnutrition, and the coverage of high
impact health and nutrition interventions is lower. Furthermore, the Project will make direct
contributions to the reduction of maternal and child mortality by scaling up high impact MNCH
and nutrition interventions, all key elements in a healthier and more productive society. The
CPS, under Outcome 1.2 “Improved access to resources for strengthening household resilience
and health in targeted areas,” indicates continued support from the Bank on health system
strengthening to accelerate improvement in maternal and child health outcomes, and building on
lessons from the Malaria Booster and Health Results Based Financing (RBF) projects. In
addition, the CPS recognizes chronic malnutrition as an urgent human development challenge
and calls for strengthening institutional capacity in support to scaling up nutrition interventions.
The proposed project fits well within these objectives. The Project is particularly responsive to
service delivery to needy populations and will contribute towards the UHC aspirations of
Zambia. In addition, the Africa Strategy– Africa’s Future and the World Bank’s Support to it, is
founded on strengthening governance and public sector capacity, including through enhancement
of incentives within the civil service. In particular, the Africa Strategy recognizes that critical
services are too often either not delivered or delivered poorly due to weak management of public
funds. Importantly, the Strategy supports initiatives to empower citizens to get information on
their entitlements, as well as voice their grievances when services are not properly delivered.
This is fully consistent with the Bank’s twin goals to end extreme poverty and promote shared
prosperity
17. The Bank has long been engaged with the GRZ in macroeconomic management and
sectoral support, including agriculture and transportation. It has been a leading participant
in the Zambia Health SWAp, providing financial, material, and technical support to the sector,
with major contributions to HIV/AIDS and malaria programs. Engagement with other CPs in the
JASZ has resulted in significant progress in addressing priority communicable and non-
communicable diseases, including nutrition.
7
II. PROJECT DEVELOPMENT OBJECTIVE (PDO)
A. PDO
18. “To improve health delivery systems and utilization of maternal, newborn and child
health and nutrition services in project areas”. This will be achieved by addressing immediate
as well as systemic and medium term bottlenecks to service delivery for pregnant women,
lactating mothers, newborns and young children especially at primary care and community
levels. The PDO is well aligned to GRZ’s key national and health sector policies and strategies
that emphasize the importance of improving MNCH and nutrition services.
Project Beneficiaries
19. The project beneficiaries are pregnant and lactating women, and under-5 children who
are located in five of the country’s ten provinces: Luapula, Muchinga, Northern, North-
Western, and Western provinces. These provinces are identified based on: (i) high poverty
levels, (ii) low human opportunity index – immunization, (iii) high under-five mortality, (iv) low
coverage of skilled birth attendance, (v) high prevalence of stunting in under-5 children, and (vi)
complementarity with both geographic and program-based initiatives supported by other CPs.
Complementarity will be emphasized to the greatest extent possible to optimize benefits from
other initiatives by GRZ and CPs in the health sector.
20. Individuals will benefit from a package of MNCH and nutrition services provided at district
hospitals, health centers, health posts, outreach posts and communities (through community and
public health initiatives carried out by CHWs). In total, the proposed project will directly benefit
about 1.2 million women of reproductive age including pregnant and lactating women and about
1.1 million under-5 children.
Table 2: Estimated number of project beneficiaries (rounded) Province Population Children
0 –11
months*
Children
< 5 yrs*
Women in
child bearing
age*
Expected
pregnancies*
Expected
deliveries*
Expected
live
births*
Luapula 992,000 40,000 198,000 218,000 54,000 52,000 49,000
Muchinga 712,000 29,000 142,000 157,000 38,000 37,000 35,000
Northern 1,106,000 44,000 221,000 243,000 60,000 58,000 55,000
North-Western 727,000 29,000 145,000 160,000 39,000 38,000 36,000
Western 903,000 36,000 181,000 199,000 49,000 47,000 45,000
TOTAL 4,440,000 178,000 887,000 977,000 240,000 232,000 220,000
Source: 2010 Census of Population and Housing * Calculated based on proportions provided under Zambia HMIS
8
PDO Level Results Indicators
21. Progress towards achieving the PDO will be monitored by the following key performance
indicators (KPIs):
i. Deliveries attended by skilled health providers (percent);
ii. Under-2 children received monthly growth monitoring and promotion (percent)9;
iii. Health Centers offering Integrated Management of Childhood Illnesses (percent);
iv. Health Centers with essential medicines and commodities in stock10
(percent); and
v. Children 0-11 months fully immunized (percent)
III. PROJECT DESCRIPTION
A. Project Components
22. The proposed project will support GRZ’s efforts to accelerate progress towards maternal and
child health MDGs and for it to be better prepared to tackle emerging challenges. The Project
will support strengthening service delivery, while focusing on results and reducing inequities,
particularly in five low performing and poorer provinces selected by the GRZ, but of potential
benefit and replication throughout the country. Activities will be targeted to provinces that are
poorer and underserved, with a combination of innovations to scale-up coverage of high impact
MNCH and nutrition interventions. Specifically, the Project will support supply side
interventions such as improving the availability of skilled care, increasing the availability of
health and nutrition commodities, and strengthening referral linkages, including quality
enhancement of existing mother waiting homes. This will be complemented by community-
based demand side approaches to enhance utilization of services. Institutional capacities of MOH
and MCDMCH will be supported to enhance evidence-based policy analysis, health systems
performance, and management of adjustments to changing roles and responsibilities in light of
the decentralization process. The Project will also support the management and implementation
of competencies, particularly in targeted provinces, as well as an independent mechanism to
verify results. The Project will be structured under three components, and implemented over five
years. (See Annex 2 for detailed Component descriptions).
Component 1: Strengthening capacity for primary and community level MNCH and
nutrition services (US$27.5 million IDA)
23. The objective of this component is to strengthen health systems in project areas through: (i)
Enhanced training capacity and standards for nursing and midwifery; (ii) Improved supply chain
systems for essential commodities; and (iii) Improved referral system and linkages across levels
of care. The Project will accomplish these objectives using a Disbursement Linked Indicator
(DLI) approach which pays for achievement of results, and is responsive to KPI achievements. A
DLI approach shifts the focus of payments from inputs to results. DLIs are a series of output and
9 Baseline will be established through a survey immediately after project effectiveness and targets will be set based
on baseline coverage. 10
The tracer drugs will include Oxytocin, Iron Folic Acid tablets, Sulfadoxine-Pyrimethamine (for IPT), Vitamin A,
Oral Rehydration Salt, Pentavalent vaccine and Depo-Provera/Norplant
9
process indicators against which funds will be disbursed to GRZ on an annual basis upon the
achievement of indicators and targets listed in the DLI matrix (presented in Annex 2).
24. A DLI approach is aimed at supporting government programs using the program’s
institutions and systems, thereby building their capacity, and linking disbursements to
achievement of results. The approach aims to enhance the effectiveness of total public spending
for such programs and strengthen their results orientation. Three key elements to define DLIs
include: (i) agreeing on DLI indicators including defining success measures, means for
verification and delivery schedules; (ii) defining the price of each indicator and payment
modalities; and (iii) defining the eligible expenditures that will be verified for payment. DLIs are
not 'tranched', meaning that if one is missed it does not affect the payment of others that were
met. Each DLI is individually priced at the capped amount of the maximum payment available.
The following box describes the DLI approach. For this project, the Project Implementation
Manual will provide more details on the means of verification.
Global lessons from DLI approaches The Disbursement Linked Indicators (DLIs) approach has been used as a mode of financing by the World
Bank in over 50 countries during the last decade, starting with Brazil, Argentina, Pakistan, and Nigeria.
Operating within a sector investment lending mode, DLIs are linked to key results and indicators
established for measuring those results. The necessary data collection systems for those indicators are
strengthened or put in place to facilitate timely and accurate reporting. Each DLI has a credible
verification protocol that is acceptable to the Bank. Verification mechanisms depend on the nature of the
indicator at hand and can include program data if that is deemed acceptable, data provided through audits
or by other parts of GRZ (e.g. Central Bureau of Statistics), or by other bodies independent of the health
sector. The DLIs and their verification, as well as updates on their progress, are often made available in
the public domain.
The achievement of DLIs is the basis for disbursements. The indicators need to be tangible, transparent,
and verifiable, and will have been generated by expenditures supported by the project. An agreement is
reached between the Bank team and the implementing Ministries on choice of indicators, timeline and
amounts to be linked to each DLI. While DLIs could vary in nature, they will be driven by results. While
desirable for DLIs to be primarily results, they can also be complemented by intermediate outputs or
process indicators.
Major criteria for a DLI approach include: (i) clearly defined and measurable indicators; (ii) under the
control of implementing entities; (iii) data sources credible and independently verified; and (iv) timely
availability of data is ensured.
Sub-component 1.1: Enhance training capacity and standards for nursing and midwifery
(US$10 million IDA)
25. This sub-component supports GRZ's effort to address the shortage of health workers with
sufficient MNCH and nutrition skills at first level district hospitals and health centers in the five
target provinces. The lack of adequately trained health workers is negatively impacting the
delivery of critical health services to the poor and is contributing to unsatisfactory MNCH and
nutrition outcomes. A key concern is the limited capacity of nursing schools to deliver a
comprehensive package of training in MNCH and nutrition [in particular Emergency Obstetric
10
and Newborn Care (EmONC), midwifery skills, nutrition and Integrated Management of
Childhood Illnesses (IMCI)]. Registered and enrolled nursing schools often lack sufficiently
trained faculty, teaching equipment and supplies, particularly in remote parts of the country.
Lack of on-site clinical supervision capacity means that teaching is primarily theoretical and
classroom based, with little practical training provided in nearby health facilities. As a result,
nursing graduates are often inadequately prepared to address MNCH and nutrition service
delivery challenges presented to them. Once posted to these facilities, limited opportunity for
Continuing Professional Development (CPD) training in MNCH and nutrition further negatively
impacts their competence, motivation and ultimately their retention.
26. To address these challenges, this sub-component will support GRZ’s human resources for
health strategy and national training operational plan (NTOP), and the plans of the General
Nursing Council (GNC), to strengthen pre-service, in-service as well as professional
development opportunities for nurses and midwives. Specifically, the Project will finance results
aimed at GRZ efforts to: (i) strengthen the capacity of eight training institutions in the five target
provinces (institutional listing in Annex 2) to deliver an integrated and comprehensive pre-
service education package on MNCH and nutrition to nursing students; (ii) deliver a three-month
practical in-service training to nurse and midwifery graduates (delivered at provincial hospitals)
who are posted to primary health facilities in the five target provinces as part of their induction
before they commence their posts; and (iii) support CPD training development and roll out to
nurses and midwives already working in primary level facilities in the five target provinces.
Funding will be disbursed against achievement of agreed results through the DLIs (See Annex 2
Table A.2 for the list of DLIs, DLI#1-3).
Sub-component 1.2: Improve supply chain systems and availability of essential commodities
(US$10 million IDA)
27. This sub-component will support and contribute to the implementation of the National
Supply Chain Strategy focusing on increasing availability of selected essential commodities,
supplies and equipment to support service delivery for high impact MNCH and nutrition
interventions in project areas. Medical Stores Limited (MSL) has been responsible for central
storage and primary distribution of essential medical supplies and equipment to all the districts in
the country. Whereas significant improvements have been noted in primary distribution, little
progress has been made in secondary distribution, resulting in significant shortages at service
delivery level. Recently, the GRZ has introduced the Regional Hubs concept and allowed MSL
to distribute products up to the health facility in an effort to improve secondary distribution.
Partly due to procurement challenges and the need to rationalize the provision of essential
medicines and medical supplies, the MOH uses a push system to distribute pre-packed Health
Centre Kits. Though the kit system has ensured some level of availability at service delivery
points, challenges still exist and the MOH has been making efforts to review the contents of the
Kit to improve its relevance to the prevailing disease burden.
28. This sub-component will support existing systems and pay for results that: (i) improve
availability of essential health and nutrition commodities, supplies and equipment; (ii) strengthen
storage and distribution capacity, particularly for the "last mile" with enhancement of regional
hubs and/or staging posts and to the service delivery points, and employing a hybrid distribution
system (combining Push and Pull systems); and (iii) improve stock visibility and accountability
11
through implementation of an electronic Zambia Inventory Control System (eZICS). A rapid
assessment of stock levels, storage and distribution capacities, and staff competencies at health
centers will be undertaken to provide baseline data. Funding will be disbursed against DLIs (See
Annex 2 Table A.3 for the list of DLIs, DLI #4-6).
Sub-component 1.3: Improve referral system and linkages across levels of care (US$7.5
million IDA)
29. This sub-component aims to strengthen the extent and quality of primary health care (district
hospital, heath center and health post) as well as community level service delivery platforms to
effectively scale-up a package of high impact MNCH and nutrition interventions, along the
continuum of care. By bringing services as close to the family as possible and reducing the
workload of scarce clinicians in the provision of basic preventive, promotive and curative
facilities, primarily in underserved rural areas, this sub-component will address the issue of
inequitable access to and poor utilization of quality, cost-effective and affordable basic MNCH
and nutrition services. While this sub-component focuses primarily on the supply of services, it
is linked to the incentive demand efforts to be developed under Component 2.
30. Specific results that this sub-component will contribute to include: (i) development of an
agreed package of evidence-based high impact MNCH and nutrition interventions, which will be
delivered through primary care and community levels; (ii) revitalization and harmonization of
community structures through strengthening linkages with community based service delivery
structures, specifically linkages between community development committees, social welfare
committees and NHC, and CHWs. This effort includes an agreed and defined framework,
protocols, norms and guidelines. (iii) quality checklists for supervision and mentorship across
service delivery levels including district hospitals, health centers, health posts and communities;
and (iv) enhanced referral systems across different levels of service delivery points through
increased provision of equipment (including transport and communications), refurbishment and
renovation of waiting homes and their timely maintenance.
31. Special emphasis will be provided to mobilize local Chiefs and engage them actively in
social mobilization and day-to-day activities at primary care and community levels. Given that
the populations in the selected provinces are sparsely distributed, community level service
delivery mechanisms will have high potential to bring services closer to the people mainly
through expansion of and strengthening service delivery at outreach posts. Eventually
community-based MNCH and nutrition service delivery will be incorporated in the formal health
system. Based on lessons learned from the five provinces, this model will be adapted and
extended to the rest of the country. Funding will be disbursed against DLIs (See Annex 2 Table
A.3 for the list of DLIs, DLI #7-9).
12
Component 2: Strengthening utilization of primary and community level MNCH and
nutrition services through results based financing approaches (US$12 million IDA; US$12
million HRITF).
32. Zambia has been implementing a Results Based Financing (RBF)11
project through a facility
based pilot initiated in 2008. Early findings from the HMIS and on-going process evaluation
have documented a number of positive results including more efficient allocation and use of
resources as a result of increased autonomy, strengthened supervision, higher utilization and
better quality of services, and improved data collection. An impact evaluation is scheduled for
July 201412
and will further inform Government’s decision in fine-tuning the RBF approach,
including scale-up. In the interim, the Government would like to ensure continuity until the
impact evaluation is completed and the results are available.
33. This component’s objective is to build on the on-going RBF pilot to strengthen MNCH and
nutrition service delivery, with a specific focus on increasing supply and demand side efficiency
and reaching the underserved population. Phased expansion of the facility-based RBF will allow
for the completion of the impact evaluation of the ongoing pilot and capacities to be built in new
targeted districts. In addition to geographical expansion to cover the five project provinces, the
next phase of the RBF will seek to stimulate demand for services by extending the results based
approach to community level and strengthen the referral system and the quality of care by the
inclusion of a district hospital RBF. The expansion phase will specifically aim to mainstream
RBF implementation arrangements into the Government structures. To enable this process,
MOH/MCDMCH will: (i) create a dedicated team with core skills and competencies in RBF
management, monitoring and evaluation, including financial management; (ii) expand the
platform for dialogue and joint financing of RBF expansion; and (iii) align RBF with other
health service purchasing arrangements in Zambia, particularly to the proposed National Social
Health Insurance and the forthcoming National Health Financing Strategy. Figure A4 in Annex 2
shows the proposed RBF model and funding flows. The Project Implementation Manual (PIM),
currently being developed by a joint MOH/MCDMCH team, will reflect the institutional
arrangements for this mainstreaming and coordination opportunities. The sub-components under
Component 2 are:
Sub component 2.1: Expand results based financing at primary facility level (US$10 million
IDA; US$10 million HRITF)
34. The project will expand RBF to targeted health facilities (health centers and district
hospitals), and District Medical Offices (DMOs) across the five provinces. Health Centers will
be rewarded for the quantity and quality of MNCH and nutrition services they provide. In order
to incentivize improvements in quality of care at district hospitals, including referral from health
centers, this component will also extend a similar RBF approach for quality of care for MNCH
and nutrition services at selected district hospitals in each of the five provinces. Performance will
11
The Zambia Results Based Financing is a Facility Based Performance Based Financing where: (i) incentives are
directed only to providers, not beneficiaries; (ii) awards are purely financial--payment is fee for service; and (iii)
payment depends explicitly on the degree to which services are of approved quality. 12
Results of the Facility based RBF impact evaluation are expected to be available in January 2015.
13
be verified using robust internal and external evaluation methods. The facilities will be given
considerable autonomy in how they use the funds they earn to cover: (i) health facility
operational costs (at least 50 percent); and (ii) performance bonuses for health workers (up to 50
percent).
35. DMOs will be responsible for supervising health centers. The quantity of services delivered
at each health center will be verified prior to making payments. Each RBF health center will
report quarterly on the delivery of agreed outputs through a standard invoice. The quantities
reported will be initially verified by the DMOs. The DMO will also contract the District Hospital
to verify quality of service delivery at health centers. The DMO will then compile data on the
quantity and quality performance for submission to the District RBF Steering Committee for
further verification. Based on performance data (both quantity and quality), the District RBF
Steering Committee will recommend the quarterly amounts to be paid to each RBF health center.
Counter verification will be carried out by an independent verification agency (see sub-
component 3.3). ICT solutions including on-line entry of information and cloud computing to
improve transparency will allow faster processing and facilitate continuous monitoring.
Government research / training institution or University (outside the Ministry of Health and
Ministry of Community Development Mother and Child Health) will be eligible to compete for
the external verification assignment.
36. DMOs and District Hospitals will also enter into performance contracts with the Provincial
Medical Office and will be paid based on results against a graded performance framework. For
DMOs, the performance framework will measure performance against availability of protocols
and guidelines, meeting supervision standards, provision of technical support, maintenance of
equipment, human resource management, implementation of medical waste management
guidelines, and other measures. For District Hospitals, the performance framework will include
indicators on referrals for MNCH and nutrition services, and quality improvement. Assessment
of quality at District Hospitals will be conducted by Provincial (General) Hospitals who will be
contracted by the Provincial Medical Office. Payments will be made on a quarterly basis
according to the quantity and quality of outputs delivered. Provincial RBF committees will be
the purchaser of health services at DMOs and District Hospitals and will recommend amounts to
be paid. The Project Implementation Manual will provide a detailed description of the
operational modalities and reporting arrangements.
Sub-component 2.2: Introduce results based approaches at community level (US$2 million
IDA; US$2 million HRITF)
37. This sub-component will support the design, piloting and evaluation of community based
RBF activities aimed at increasing utilization of MNCH and nutrition services at community
level. This is in line with government’s national decentralization policy, and the National
Community Health Worker Program Strategy and long standing practice of channeling funds to
community level structures. The sub-component will also complement and provide a more robust
delivery system for the social protection program, and the planned introduction of a National
Social Health Insurance Scheme. This will be achieved by supporting government’s effort to
improve the referral system by strengthening linkages between communities and health facilities,
boosting service delivery at community level, increasing accountability of CHWs, and
14
strengthening the role of Community-Based Organizations in monitoring and evaluation of
MNCH and nutrition services.
38. Specific activities will include: (i) early registration of women of reproductive age; (ii)
Provision of a complete antenatal care and delivery package (e.g. iron tablets supplementation,
malaria intermittent preventive treatment (IPT), distribution of bed nets, assisted deliveries,
referrals, etc.); (iii) counseling of women of reproductive age, follow up home visits, and
provision of commodities (e.g. nutrition and family planning); (iv) outreach activities to improve
management of childhood illnesses at household level; (v) mobilization of community members
for growth monitoring and promotion, immunization of children, and nutrition education, and
(vi) incentivizing Community-Based Organizations for submission of timely and quality data
reports on the stipulated MNCH and nutrition indicators. Health Centers will carry out
supervision in communities implementing RBF with the assistance of DMOs. Results will be
counter verified on an annual basis through independent organizations.
39. To support learning and inform the planned introduction of social health insurance, with an
additional World Bank-executed US$1.5 million HRITF grant, a three arm Impact Evaluation
testing three different approaches: (i) vouchers, (ii) conditional cash transfers linked to the
current social cash transfer program, and (iii) social health insurance will be piloted in nine
districts from January 2015.To allow proper design of the pilot and ensure it is rooted within the
Zambian context, a pre-pilot will be implemented in one district, with an additional recipient
executed US$0.85 million HRITF grant. Lessons from the community level impact evaluation
will be used to guide future expansions. The PIM will provide a detailed description of the
operational modalities and reporting arrangements.
Component 3: Strengthening project management and policy analysis (US$12.5 million
IDA; US$3 million HRITF)
40. The objectives of this Component are to strengthen project management, implementation,
monitoring and evaluation; provide technical assistance for evidence-based policy analysis and
health financing innovations, and appoint an independent verification agent to verify the Project
results.
Sub-component 3.1: Project management and implementation, monitoring and evaluation
(US$6.5 million IDA)
41. This sub-component will strengthen project implementation capacity of MOH and
MCDMCH with particular attention to the Province and District levels. Support will include: (i)
expert technical support for implementation of the DLI and the RBF approaches; (ii) building
capacity for day-to-day administration of Project activities (monitoring resource use,
procurement processing activities, administering withdrawal and disbursement procedures,
consolidating financial management aspects of implementation, reporting; as well as
coordinating with relevant sector ministries, departments, health professional training institutions
and associations, civil society organizations and the private sector); and (iii) strengthening the
HMIS, roll out and integration of community level MNCH and nutrition information into DHIS-
2.
15
Sub-component 3.2: Support evidence-based policy analysis and health financing innovations
(US$4 million IDA)
42. This sub-component will: (i) Support Government's efforts to produce evidence-based
analytical studies in health and nutrition, including health financing, planning and budgeting,
human resources for health, and drugs and medical supplies. The focus of these studies will be to
determine the performance of the health system in light of the intermediate performance
measures (access, efficiency, equity, and quality), and attainment of health systems goals (health
status, citizen satisfaction, and financial protection). A national rational drug use study is
identified as priority and subsequent analytical work will be identified by Government; and (ii)
Provide training and technical support to mid-level health managers to enhance their analytical
and operational knowledge in health financing, planning and budgeting.
Sub-component 3.3: Institute independent verification arrangements (US$2 million IDA;
US$3 million HRITF)
43. For results-based financing as well as disbursement-linked indicators, payments will be made
after an independent verification exercise is conducted. The verification process has to ensure the
accuracy and consistency of reporting on qualitative and quantitative performance indicators
before funding is released. This sub-component will support the design and setting up of the
verification mechanism for all results-based activities under the Project, including those
supported by Components 1 and 2, as well as costs to be incurred to support the selected
independent verification agent in carrying out this responsibility. This sub-component will also
finance the Project baseline, midline and endline surveys.
B. Project Financing
44. Lending Instrument: The proposed lending instrument is Investment Project Financing
(IPF). An IDA credit of US$52.5 million will finance the Project, and will be complemented by a
US$15 million grant from the HRITF. The Project implementation period is five years, from July
2014 to June 2019. An additional US$1.5 million HRITF grant will support the community level
RBF impact evaluation (sub-component 2.1).
Project Cost and Financing: Project costs and associated financing are outlined in Table 3
below.
Table 3: Project costs and financing by component
Project Components
Project
Cost (US$
million)
IDA Credit
Financing
(US$ million)
HRITF
Financing
(US$
million)
% IDA
Financin
g
Component 1: Strengthen capacity for
primary and community level MNCH and
nutrition services
27.5 27.5 100%
1.1 Enhance training capacity and standards
for nursing and midwifery
10.0 10.0 100%
1.2 Improve supply chain systems and
availability of essential commodities
10.0 10.0 100%
1.3 Improve referral system and linkages 7.5 7.5 100%
16
Project Components
Project
Cost (US$
million)
IDA Credit
Financing
(US$ million)
HRITF
Financing
(US$
million)
% IDA
Financin
g
across levels of care
Component 2: Strengthen utilization of
primary and community level MNCH and
nutrition services with results based
financing approaches
24.0 12.0 12.0 50%
2.1 Expand results based financing at primary
facility level
20.0 10.0 10.0 50%
2.2 Introduce results based approaches at
community level
4.0 2.0 2.0 50%
Component 3: Strengthen project
management and policy analysis
15.5 12.5 3.0 81%
3.1 Project management and implementation,
Monitoring and Evaluation
6.5 6.5 100%
3.2 Support evidence-based policy analysis and
health financing innovations
4.0 4.0 100%
3.3 Institute independent verification
arrangements
5.0 2.0 3.0 40%
Total Baseline Costs
Physical contingencies
Total Financing Required 67.0 52.0 15.0 77%
C. Lessons Learned and Reflected in the Project Design
45. Lessons from the Africa Region HRH Program. Implementing a rural pipeline
approach to train health workers is closely linked to rural job opportunities after
graduation. Lessons from the World Bank’s Africa Region HRH Program13
highlight that
training health workers from rural areas, in rural areas, and according to curricula adapted to
rural contexts, have the potential to increase the likelihood that they take on a rural job after
graduation. Combining such a strategy with sufficient available funding to absorb graduates, and
targeted deployment efforts by GRZ, providing career development opportunities, including skill
improvement through mentoring and supervision, are critical components of any longer term
comprehensive human resources retention strategy, which GRZ could develop and support over
time.14
Sub-component 1.1 will enhance training capacity and standards for nursing and
midwifery, and incorporates these specific lessons.
13
The WB Africa HRH Program began in 2008, and is partly funded by GRZ of Norway, and aims to assist
governments in the Africa Region develop and implement their strategies and policies on human resources for
health. A large part of this program has been to support governments to develop the necessary evidence on HRH on
which to base policy development 14
Lessons are captured in a book by Soucat, A. Scheffler, R (2013): “The Labor Market for Health Workers in
Africa: A New Look at the Crisis”, Directions in Development, World Bank)
17
46. Lessons on Community Health Workers (CHWs): A 2012 review of Global CHW
programs15
noted that services offered by CHWs have contributed to the decline of maternal and
child mortality rates and assisted in decreasing the burden and costs of TB and malaria. A 2012
review of CHW cadres in Ethiopia, Malawi and Rwanda, further demonstrates that CHWs can be
highly effective in providing basic MNCH and nutrition services, but supervision support is a
key factor in improving their efficacy.16
Other system requirements for successful CHW
programs would include a careful selection of CHWs and realistic and appropriate levels of
expected services, taking into account cultural context; high quality training, regular
remuneration, and a reliable supply chain.17
Sub-component 1.3 and Component 2 incorporate
these specific lessons.
47. Lessons from the Malaria Booster Project: GRZ and the World Bank have had a long and
successful collaboration in the health sector. Support to GRZ has evolved over time and has
responded to the needs and priorities of the country. Lessons learned from this operational
experience which have been integrated into the design of the proposed project include: (i)
sufficient institutional capacity to carry out the fiduciary elements of a Project ensures timely
implementation; (ii) maintaining support to and empowering decentralized levels of the health
system in delivering services is critical; (iii) communities play an important role in increasing
demand and utilization of services as well as bringing services closer to the people; (iv) a mix of
input- and results-based financing initiatives can maximize impact; (v) supporting GRZ in
implementing evidence-based decision making can lead to broader health sector reforms; (vi)
increased autonomy at decentralized levels is a critical element for more efficient use of
resources and brings a degree of transparency and accountability to the system; and (vii) the
need for an electronic Zambia Inventory Control System (eZICS), designed under the Malaria
Booster project (currently being piloted through UNICEF support), whose main focus is to
ensure availability of drugs and medical supplies through stock visualization, and initiation of
orders based on consumption and pipeline data.
48. Lessons from the RBF Project: Given Zambia’s poor health outcomes, and its population’s
low access to, and utilization of PHC services, the proposed Project’s strategic approach is
highly relevant. Findings from RBF programs in Cambodia, Haiti, and Afghanistan, as well as a
randomized controlled study in Rwanda have shown that RBF can be effectively deployed to: (i)
clearly signal health priorities to all levels of the health system; (ii) ensure that health facilities
focus on delivering basic health services to the population not yet reached; (iii) focus efforts on
producing tangible results on the ground, and to monitor them stringently; and (iv) empower
decision-makers closest to the communities they serve to set priorities according to local needs.
15
Zulfiqar A. Bhutta, Zohra S. Lassi, George Pariyo* and Luis Huicho (2012) Global Experience of Community
Health Workers for Delivery of Health Related Millennium Development Goals: a Systematic Review, Country
Case studies, and Recommendations for Scaling Up: A Systematic Review, Country Case Studies, and
Recommendations for Integration into National Health Systems. GHWA/WHO Publication 16
McGorman L. et al (2012) A Health Systems Approach to Integrated Community Case Management of Childhood
Illness: Methods and Tools. Journal of Tropical Medicine and Hygiene. Going to press in 2012. 17
WHO (2007) Community Health Workers: What do we know about them? The state of evidence on programmes,
activities, costs and impact on health outcomes of using community health workers, WHO 2007. Geneva,
Switzerland.
18
Early findings from the RBF pilot project in Zambia have shown improvements in health service
utilization.
IV. IMPLEMENTATION
A. Institutional and Implementation Arrangements
49. The Project will be implemented by two ministries - MOH and MCDMCH - under an
inter-ministerial framework for project management. Each Ministry will be given the
responsibility to execute specified activities in line with their gazetted portfolio functions,
recognizing that such assignments may be modified as GRZ reviews and revises how it
delegates, budgets, and integrates local government authorities in the provision of services. The
Permanent Secretaries from the two Ministries will each be responsible for the execution and
management of the Project activities assigned to their Ministries. The respective Directorates of
Policy and Planning in each Ministry, who will be responsible for overall coordination.
Designated Directorates and Units will be accountable for the implementation of Project
activities (see Annex 3).
50. To effectively coordinate implementation, a Joint Management Team (JMT), co-chaired by
the Permanent Secretaries of the MOH and MCDMCH, will be established under the Zambia
Health SWAp which has been in existence since 1993, to which the World Bank has been one of
the founding and key members, and to which the commitment was reaffirmed by signing the
2013 Memorandum of Understanding. Membership to the JMT will comprise Directors from the
two ministries. The JMT will meet monthly at a predetermined date and time. The role of the
JMT will be to oversee Project implementation by the two Ministries which will present and
discuss data and information related to activity level, review annual plans, identify challenges or
difficulties in implementing project responsibilities, follow up on previous decisions, and resolve
issues as they arise (The organogram for Project Administration Mechanisms is provided in
Annex 3).
51. The two Ministries will be selectively supported by the Project to enhance: (i) capacity to
provide leadership for MNCH and nutrition project efforts, particularly at decentralized levels;
(ii) capacity for the day-to-day administration of project activities (including RBF), monitoring
resource use, processing all central procurement activities, administering withdrawal and
disbursement procedures, consolidate the FM aspects of Project implementation and consolidate
reporting; and (iii) monitoring and evaluation of implementation activities. This includes
collection, analysis, reporting and dissemination of the data on inputs, outputs, outcomes and
impact from various sources; and (iv) support to strengthen the national and district level M&E
system based on the identified gaps and weaknesses.
52. The arrangements for the co-ministerial institutional structure, the principles for governing
project coordination, implementation and management, as well as technical advisors/specialists
to be provided under the Project are outlined in Annex 3 and will be elaborated in detail in the
PIM.
19
B. Results Monitoring and Evaluation
53. A comprehensive description of the Project’s results framework and the arrangements for
monitoring and evaluation (M&E) are described in Annexes 1 (Results Framework and
Monitoring) and 3 (Implementation Arrangements), respectively. The results framework will be
tracked and a mid-term review will provide the opportunity to assess progress and make
appropriate mid-course corrections. The Directorates of Policy and Planning of the MOH and/or
MCDMCH will be responsible for monitoring Project implementation and results. The agreed
PDO KPIs and a set of key intermediate outcome indicators, including DLIs, are to be monitored
during the life of the Project.
54. Sources of data and data collection mechanisms: The National Health Management
Information System (HMIS) will be primarily used to collect monitoring data, with additional
support provided by the Project to integrate community level information.18
During the Project
implementation period, two Demographic and Health Surveys (DHS) will be undertaken, with
one to be available in 2014, and the second expected in five years. Results from the DHS and
other population-based surveys will be used to recalibrate results of key services used and
outcome indicators. In addition, Project implementation agencies will also collect additional key
information specific to the Project, including annual facility surveys to be conducted by an
external entity for measuring and verifying agreed results for the DLIs and the RBF, Component
1 and 2.
55. Data Evaluation and verification: An independent survey at the beginning, mid and project
end will be planned to provide baseline information and measure the contribution of the Project
to the achievement of outcomes. The baseline survey will provide baseline information for all
DLIs. Further, independent, third party verification of activities under Components and 1 and 2,
will be financed by the Project under sub-component 3.3. For timely feedback and unbiased
monitoring, other process monitoring systems including operational research will be
incorporated.
C. Sustainability
56. GRZ has historically shown a willingness to finance health sector and social welfare efforts
from its own resources, and continues to do so, through partnership within the SWAp with
roughly 50 percent of per capita health expenditure from public sector resources. GRZ will
finance most recurrent costs such as salaries for health workers and health and nutrition supplies
from the regular budget envelops of both the MOH and MCDMCH. Furthermore, CPs are
committed to provide longer-term support to nutrition under the Scaling Up Nutrition (SUN)
1000-day program initiative.
57. The Project will mainstream a comprehensive package of MNCH and nutrition services
interventions in the health system by using existing institutional mechanisms, improve HRH
capacity, complemented with provision of critical inputs, and improve supply chain and logistics
management to reach the "last mile" and serve the intended beneficiaries. Enhancing the capacity
18
Data mechanisms for Component 1 are identified in Annex 2, Table A.3.
20
of community, district and provincial health workers, efficient provision of health consumables,
and strengthening supervision of CHWs are all fully consistent with GRZ's objectives to pursue a
decentralized policy. Community empowerment will be a major contribution to better basic
health and nutrition care, especially in under-served areas. GRZ recognizes that over the medium
to long term, as experience grows with the Project interventions, and as the evidence of
improvements in health and nutrition outcomes obtained in the Project areas become available, it
will integrate project interventions into programs, scale-up such efforts nationwide as
appropriate.
V. KEY RISKS AND MITIGATION MEASURES
A. Risk Ratings Summary Table
Risk Category Rating
Stakeholder Risk Substantial
Implementing Agency Risk -Capacity Substantial
-Governance Substantial
Project Risk
-Design Moderate
-Social and Environmental Low
-Program and Donor Moderate
-Delivery Monitoring and Sustainability Substantial
Overall Implementation Risk Substantial
B. Overall Risk Rating Explanation
58. Overall implementation risk is Substantial. The Project seeks to strengthen primary care and
community level health service delivery systems, introduction of training programs at central,
provincial and district levels, and incentive mechanisms. The two ministries are going through a
transition phase in dealing with significant changes in implementing MNCH and nutrition
interventions, including sorting out primary responsibilities and coordination between
themselves and across the entire sector. Additionally, GRZ is actively pursuing devolution of
responsibilities to local authorities and this will impact MOH and MCDMCH mandates and
responsibilities. The Project will introduce results based approaches: at a higher level paying for
results through the DLIs and at facility level through the RBF. The fiduciary management
capabilities of the MOH and MCDMCH are vulnerable to varying degrees, and depth. The
objective of bringing services closer to communities will depend on governance structures at
various levels, taking into account the decentralization process. Finally, prospects for public
sector recruitment and timely deployment of new nursing and midwife graduates pose a further
implementation risk element, given GRZ's announcement of a hiring freeze for 2014.
59. These implementation challenges will be mitigated by a number of factors: (i) there is a
history of delivering MNCH and nutrition services at community level supported by faith-based
organizations, non-governmental organizations, and external donors that can be strengthened; (ii)
where there are new activities that depend on strengthened capacity and the sequencing of
actions, the intention is to plan for gradual scale-up, training and technical assistance; (iii)
Government assurances were provided that new nursing graduates will be absorbed because
21
vacancies can be filled (and attrition annually represents a significant number of vacated posts),
additional MCH positions in 2013 were secured and will require new hires, and that the hiring
freeze is limited to 2014; (iv) there is significant and relevant CP technical and financial
assistance, inter-CP technical coordination mechanisms to exchange information and plans; (v)
the Project design provides for extensive investment in information systems from the district to
the community levels, and to monitor performance on a regular basis; (vi) a JMT will be put in
place to effectively coordinate the various activities under the Project. The intention is to hold
monthly joint project reviews to assess successes, challenges, and to implement mitigating
measures; and (vii) provision of technical support to the MOH and MCDMCH in fiduciary
management.
60. The Project will introduce additional RBF performance based financing in the health
sector. Experience suggests that risks associated with the RBF include: (i) an enhanced focus on
quantity of services over quality; (ii) gaming the system by inflating service delivery records or
inflating the results of the quality evaluation or establishing too easily achieved DLIs; (iii)
favoring service delivery to easier reach populations; and (iv) focusing on only targeted services
to the detriment of other equally important health interventions. In addition, community based
RBF is particularly challenging given the dispersed nature of activities, the difficulty in
verification and capacity challenges. The Project will mitigate these risks by: (i) incorporating
quality measures as an integral part of the process of determining payouts to facilities/health
workers; (ii) establishing strong internal and external verification systems to ensure that records
are authentic; (iii) involving communities in the verification process; and (iv) regularly
monitoring service delivery to the most disadvantaged, and making the necessary adjustments to
service tariffs to favor service delivery in remote areas.
VI. APPRAISAL SUMMARY
A. Economic and Financial Analysis
61. The proposed project was appraised from an economic and financial perspective.
Specifically, the appraisal assesses the development impact of the proposed project based on
global evidence and Zambia specific parameters, estimates the economic return of the investment
through a cost-benefit analysis, provides rationale for working with the public sector, and
analyzes the financial sustainability given the prevailing macroeconomic, and health financing
situation (See details for Annex 6). The analysis was informed by recent studies conducted in the
health sector in Zambia, and complemented by other international and regional studies.
Economic Analysis
62. Health is an important dimension of employability, and a key determinant of economic
growth and development. However, despite remarkable improvements in maternal and child
health outcomes between 2000 and 2012, the status of the health sector in Zambia is a major
constraint to productive employment for many Zambians, especially the poor.19
Human capital in
Zambia has not benefited much from the high economic growth and widespread poverty remains
19
Ianchovichina and Lundstrom (2009). Inclusive Growth Analytics: Framework and Application
22
a major economic challenge. 20,21
As such, poor-health is both a cause and effect of poverty.
Furthermore, Zambia is unlikely to achieve the health related Millennium Development Goals
(MDGs) by 2015, as the annual rates of reduction (2.1 percent for U5MR and 2.5 percent for
MMR) for the period 1990-2011 are significantly lower than the annual rates of reduction
required (4.4 percent for U5MR and 5.5 percent for MMR)22
necessary to achieve the MDGs.
63. One of the key issues in health service delivery in Zambia is low coverage of essential
services, coupled with poor quality of health service provision. For example, access to basic
MNCH and nutrition services depends substantially on the socioeconomic status of the
household and geographical location. Rural parts of the country are worse-off in both service
provision and health outcomes (Table 1). This can be attributed to both supply and demand side
factors. On the supply side, the numbers and skills of clinical health workers are insufficient, and
at the same time inequitably distributed to deliver quality MNCH and nutrition services. Against
the official staff establishment, there is a gap of 59 percent in the number of clinical health
workers countrywide (doctors, clinical officers, nurses, midwives, and paramedics).
Furthermore, low productivity of the available health workers, inequitable distribution of health
infrastructure, and erratic supply of essential drugs and nutrition supplies are the other major
challenges.
64. On the demand side, communities often lack information on preventive practices, including
early detection of health and nutrition complications. In addition, long distances to health
facilities and lack of transportation often limit access to health services in rural areas, leading to
delays in seeking care. For example, the percentage of households living within a radius of 5Km
to the nearest health facility is 54 percent and 99 percent for rural and urban households,
respectively.23
Strengthening the linkages between the primary and community levels would help
bridge long distances and bring services closer to the people. However, the use of communities
in Zambia has been challenging due to a plethora of community based organizations and CHWs
who work in a fragmented manner.
65. The project will contribute to Zambia’s development by promoting equity and shared
prosperity in five provinces with the highest concentration of the poor, and low human
development. These provinces are identified based on: (i) high poverty levels, (ii) low human
opportunity index – immunization, (iii) high under-five mortality, (iv) low coverage of skilled
birth attendance, (v) high prevalence of stunting in under-5 children, and (vi) complementarity
with both geographic and program-based initiatives supported by other CPs.
20
World Bank (2012). Zambia Economic Brief – Issue 1: Recent Economic Developments, and the State of Basic
Human Opportunities for Children 21
Despite recent economic growth averaging 6% since 2006, poverty levels in Zambia still remain high. Rural
poverty at 74% is more than double the urban poverty at 35%. In 2011, Zambia’s HDI was 0.430, a rank of 164 out
of 187 countries and below the average for Sub-Sahara Africa. Income inequality has also been growing. Over the
period 1990 to 2010, the Gini coefficient declined from 0.47 to 0.52. 22
Lozano et al 2011; Rajaratnam et al 2010; Hogan et al 2010 23
Living Conditions Monitoring Survey III of 2002/2003 (CSO, 2004)
23
66. The project will support scaling up of the coverage of a defined package of MNCH and
nutrition services that has been proven across many countries in Africa to be cost effective and of
high impact. MNCH and nutrition services can provide economic benefits in the form of averted
deaths, in particular maternal and child deaths, increased labor force and productive years, as
well as contribution to economic growth. Existing evidence shows that about 70 percent of
under-5 deaths are preventable through interventions such as vaccination, adequate nutrition and
proper management of childhood illnesses. Maternal mortality also has a negative effect on per
capita GDP in Africa, and studies suggest that an increase in MMR by one death decreases per
capita GDP by US$0.36 per year on average. This is critically important for Zambia given the
high MMR, high fertility, high unmet need for family planning, and high prevalence of
HIV/AIDS among women.
67. Results from a cost-benefit analysis shows that the proposed project will be a sound
investment for the country. The present value of benefits related to improved maternal and child
health is estimated to be US$152.7 million. The present value of costs based on the expected
disbursement is estimated to be US$63.1 million. As a result, the net present value of benefits is
estimated to be US$89.6 million, while the benefit-cost ratio is estimated to be US$2.42
(152.7/63.1 = 2.42). This implies that for every US$1 invested through this project, the benefit
will be US$2.42. Sensitivity analysis suggests that the benefit-cost ratio will be higher than 1.7
even if the project only achieves 70 percent of the expected impact (See Annex 6 for
assumptions, methods, data and results in details).
68. It is likely that the real benefit and efficiency have been underestimated by this analysis.
Conservative assumptions have been used for the expected impact of this project. Only economic
growth benefits related to increased productive years is considered in this analysis. This analysis
does not include the benefit of increased life-years of children saved before they become active
in the labor force. Many other benefits are also excluded because they cannot be measured or
easily translated to monetary value e.g., efficiency improvement.
69. The project will also contribute to improved efficiency and productivity at health facility and
community levels. Firstly, the project will support the use of primary and community-based
approaches which have been identified as among the key cost effective strategies of promoting
health, even under very poor economic conditions. The use of community level approaches
under Sub-components 1.3 and 2.2 is expected to generate additional benefits as it will help shift
the focus from the traditional facility level supply-side interventions towards the demand side,
with the objective of balancing incentives that target both the providers and the consumers.
Secondly, the project will support the country’s systems to be more results-focused and
productive through the supply chain, and MNCH and nutrition results-based approaches. Thirdly,
the project will enable managers at all levels to use evidence in policy analysis, planning, and
budgeting by supporting the country’s M&E system, analytics, and capacity building in
evidence-based decision making.
70. Working with the public sector through this project is economically justified based on a
necessity to correct market failures, and the scarcity of private providers. Firstly, public
intervention is necessary when there is market failure. The focus of this project is on high-impact
and cost-effective MNCH and nutrition interventions, which have positive externalities through
the consumption and/or production of goods. Without public intervention, these services would
24
otherwise not have been consumed or produced. Secondly, in Zambia, health services are
predominantly provided through the public sector. The Zambian Government owns 81 percent of
the total number of health facilities countrywide. In the five targeted provinces, there are only 9
private health facilities out of 811 in total, accounting for only one percent (Figure A.724
). As
such, it would be enormously inefficient and ineffective to expand coverage of high impact cost-
effective interventions through the private sector in the five provinces.
Financial Sustainability
71. Zambia spends 6.3 percent of its gross domestic product (GDP) on health. As a proportion of
the total government budget, the health budget has been on average 9.5 percent for the past five
years (2010-2014), which is lower than the Abuja target of 15 percent. In nominal terms, the
government health sector budget has been growing by an average of 30 percent per annum
between 2010 and 2014, and by 16 percent between 2013 and 2014. On the other hand, the flow
of financial resources from external sources has been on a decline since 2006. For example,
disbursement by CPs to the basket funding at MOH declined from 103 percent in 2006 to zero
percent in 2010. Nonetheless, CPs are still present in the health sector in Zambia and are funding
numerous vertical projects, particularly in HIV/AIDS, Malaria, MNCH, and Nutrition. Hence,
fiscal space for health in Zambia critically depends on the sustainability of external funding, the
extent to which the GRZ and other domestic resources can be used to finance health services,
harmonization of all funding sources, and efficient use of the money available.
72. It is, therefore, expected that this project will be financially sustainable. The proposed project
investment, US$13.4 million per year during a five-year period, accounts for a small portion of
the annual government budget on health. In 2014, the proposed annual investment of US$13.4
million is 1.7 percent of the 2014 government health budget (US$798 million). This estimate will
become smaller over time given that the government budget is expected to grow with economic
growth, and the proportion of total government budget on health has been increasing during the
past year. In addition, the Ministry of Health and Ministry of Community Development, Mother
and Child Health, have been actively engaged during project preparation, and have had strong
ownership of the project.
B. Technical
73. The Project supports MNCH and nutrition interventions, principally aimed at reducing
maternal and child mortality and morbidity including chronic malnutrition in selected provinces
in the country. In Zambia, inadequate health worker knowledge in MNCH and nutrition is a
serious constraint to deliver quality services, and more so outside the main urban settings.
Investing in these interventions is supported by a large body of evidence, including a series of
articles in The Lancet Maternal and Child Nutrition Series (2013), the SUN document, as well as
World Bank health and nutrition studies and policy documents, including the recent analysis of
benefits from connecting sectors and systems to achieve health results (World Bank Public
Health Policy Note "Connecting Sectors and Systems for Health Results", December 2012). In
sum, there is global consensus and solid longstanding evidence to support the premise that
24
Figure A.7 is found on page 90.
25
provision of competent service delivery to these cohorts can have a major positive effect on
health outcomes.
74. The continuum of care, from pre-pregnancy to childhood, from community to district
hospital, is the basic premise for this operation (The list of interventions across the continuum of
care is provided in Annex 2 under sub-component 1.3). The Project design draws on this
framework, building on best practices both in Zambia and in other countries. There is implicit
recognition that the mandates of MOH, which has national health responsibility, and MCDMCH,
with its community development, social welfare, and now MNCH activities, working in a
complementary and coordinated fashion, can better provide basic health services to beneficiary
in remote areas. This is an important feature of the Project. Further, reaching the community and
paying attention to the "last mile" of the supply chain, improving the theoretical and practical
knowledge base of health workers in areas such as skilled birth attendance, along with providing
incentives for both supportive supervision and community pro-activity, are well tried, tested, and
recognized techniques to increase health coverage and quality to mothers, newborns and young
children.
75. The technical design of the Project is also based on a growing global understanding that
transforming the input-based health systems to result-based systems can change the persistent
under-performance of countries' health services. In Zambia, poor health outcomes have persisted
despite substantial investments over several decades. RBF has emerged as a widely implemented
strategy to strengthen access to and supply of quality health services through the adoption of
financial or other rewards as an alternative to the traditional input-based approach.25
This design
benefitted specifically from the performance based financing and the disbursement linked
indicator approaches. The objectives, implementation institutions and levels of implementation
are well aligned.
C. Financial Management
76. With regard to Bank investment in the health sector, past project funds have been used to
strengthen fiduciary systems, an Independent Fiduciary Review Agent was contracted, and
assistance given to install and deploy an Independent Financial Management Information
System. For the proposed project, the World Bank team conducted FM assessments of both the
MOH and MCDMCH to determine whether the FM arrangements: (i) are capable of correctly
and completely recording all transactions and balances relating to the Project; (ii) will facilitate
the preparation of regular, accurate, reliable and timely financial statements; (iii) will safeguard
the Project’s entity assets; and (iv) will be subjected to auditing arrangements acceptable to the
World Bank. The assessment complied with the FM Manual for World Bank-Financed
Investment Operations that became effective on March 1, 2010, as well as with AFTFM
Financial Management Assessment and Risk Rating Principles.
77. With respect to funds flow and disbursement arrangements, both MOH and MCDMCH will
use a system under which funds will flow from the World Bank to a Designated Account (DA)
25
Final consensus definition of the PBF google groups forum; August 2010.
26
or a Holding Account, denominated in United States Dollars at the Bank of Zambia (BOZ), to be
operated by the Project. At the time of project execution, both ministries on behalf of the Project
will transfer funds from the DA to their respective ministerial Control Accounts. Once funds are
transferred to the ministerial control accounts, the funds will then be transferred to the Project’s
sub-accounts held at BOZ. From the sub-accounts, all payments would be made through the
mirror accounts (zero balance) held at a commercial bank.
78. MOH and MCDMCH will use both transaction-based method of disbursements (Statements
of Expenditure – SOEs) as well as disbursement linked indicators discussed in detail in Annexes
2 and 3 and to be addressed in the PIM. Other methods of disbursing to the Project will include
reimbursements, direct payment, and use of special commitments (e.g., letters of credit). The
details of the FM assessment and aspects of the financial arrangements are detailed in Annex 3
and will be included in the PIM.
79. The assessment concluded that the FM arrangements in place meet the World Bank’s
minimum requirements under OP/BP10.00, and therefore are adequate to provide, with
reasonable assurance, accurate and timely information on the status of the Project required by the
World Bank. The overall FM residual risk rating of the Project is Substantial for both MOH and
MCDMCH.
80. The main capacity constraints in the MOH are that the Project module Integrated Financial
Management and Information System (IFMIS) is not functioning well, the audit unit
concentrates on pre-audits instead of carrying out risk-based auditing, has weak control
environment and lacks or fails to follow-up on outstanding audit queries. In the case of
MCDMCH, the capacity constraints include inadequately qualified staff with little or no Bank
experience, IFMIS is not connected, no qualified staff in the audit unit, audit committee not
functional, weak internal control environment and lack of follow-up of audit queries. At the
national level, the following constraints were identified: inadequate supervision by government’s
controlling officers; poor accountability culture and inadequately funded watchdogs; internal
audit unit lacks adequate resources to carry out their work effectively; and weak audit committee
to follow up the recommendations of both internal and external audit reports.
81. As a result of the FM capacity constraints, this project will require: (i) agreement on the
format and content of the Interim Financial Report for the Project with the Bank, (ii) agreement
on the audit Terms of Reference (TORs); (iii) training of accountants in World Bank FM and
disbursement procedures; (iv) strengthening of internal audit functions through training including
risk-based internal auditing; (v) functionalizing the audit committee in MCDMCH; and (vi)
addition of FM section for the PIM. The Interim Financial Report format and the audit TORs
have been agreed during negotiations. Other activities will be pursued during implementation.
27
D. Procurement
82. Procurement of goods, works26
and non-consulting services under this Credit and Grant will
be carried out in accordance with the Bank’s “Guidelines: Procurement under IBRD Loans and
IDA Credits”, January 2011. Selection of consultants will be carried out in accordance with
Guidelines: Selection and Employment of Consultants by World Bank Borrowers, January 2011.
Procurement of goods, works and non-consultant services under NCB will follow Government of
Zambia Procurement Procedures as outlined in the Public Procurement Act number 12 of 2008
and the accompanying Public Procurement Regulations of 2011 subject to modifications detailed
in Annex 3 to make them acceptable to the World Bank. The Bank’s Anti-corruption
Guidelines: "Guidelines on Preventing and Combating Fraud and Corruption in Projects
Financed by IBRD Loan and IDA Credits and Grants" dated October 15, 2006, and updated
January 2011 shall apply to the project.
83. The MOH and MCDMCH Procurement Units will be responsible for carrying out their
Ministry's procurement tasks, with the JMT responsible for assuring proper reporting
coordination, and resolution of issues affecting project performance. Procurement capacity
assessments of the MOH and MCDMCH identified areas and needs for strengthening of
capacity. These have been shared with GRZ and are also provided in the Table A.727
“Summary
assessment for procurement capacity risks and mitigation measures.” The implementation of the
risk mitigation measures will be supported with Project financing.
84. Component 1: Strengthen capacity for primary and community level MNCH and nutrition
services (US$27.5 million IDA) will be implemented on the basis of DLIs. Their verification, as
well as updates on their progress, will be made based on pre agreed periods and will be reported
on and made available in the public domain. DLIs will be primarily based on outcomes or
outputs and will be complemented by intermediate outputs or process indicators. No
procurement is envisaged under this component as discreet goods, works or services are not
anticipated to be procured under this component. However, should any be identified procurement
will be carried out using the Bank’s Procurement and Consultants Guidelines referred to in
paragraph 83 above.
85. Component 2: Strengthen utilization of primary and community level MNCH and nutrition
services with results based financing approaches (US$12 million IDA; US$12 million HRITF).
From the procurement standpoint, it is observed that whilst the majority of the activities will be
implemented using results based approach, payments will be linked to attainment of results based
on pre-agreed targets or indicators which will be verified by an independent verification agent. It
is also expected that some input activities such as medical goods and equipment and minor
rehabilitation works will be procured. Such Procurement will be carried out using NCB
procurement procedures subject to modifications provided in Annex 3.. These modifications will
be further elaborated in the legal agreement particularly for the use of National Competitive
Bidding (NCB). Where needed, based on cost estimates and the limits for prior review
26
As described under Paragraph 25, the Project will finance only rehabilitation of existing infrastructure. 27
Table A.7 is found on page 67.
28
thresholds, use will be made of the provisions of the applicable Bank’s procurement and
consultant guidelines.
86. Component 3: Strengthen project management and policy analysis (US$13 million IDA;
US$3 million HRITF). Procurement under component 3 is expected to cover activities for
strengthening project management, implementation, monitoring and evaluation; provide
technical assistance for evidence-based policy analysis and health financing innovations, and
appoint an independent verification agent to verify the Project results. Bank’s procurement and
consultant guidelines will apply to the engagement of consultants.
E. Social (including Safeguards)
87. There will be no land acquisition under this project, and no losses of assets or restriction of
access to resources is anticipated. The MOH, MCDMCH and training institutions have
acceptable proof of ownership of the existing project activity sites and there are no disputes in
this regard. Thus, no involuntary resettlement issues are associated with this project, and OP 4.12
will not be triggered. The Project also seeks to mitigate RBF-specific risks. These risks include:
(i) favoring service delivery to easier to reach populations and not targeting those who are most
in need; (ii) focusing on delivering incentivized services to the detriment of other equally
important health programs; and (iii) involuntary participation in selected health services,
particularly in the context of the supply-side RBF proposed in the Project.
F. Environment (including Safeguards)
88. This is an environmental Category B project. GRZ developed the first Health Care Waste
Management Plan (HCWMP) in 2003 under the Zambia National Response to HIV/AIDS
Project (ZANARA). Due to capacity constraints in safeguards, finalization of the HCWMP took
longer than envisaged, and was only partially implemented by the end of the Project in 2008
(with procurement of incinerators that were distributed to hospitals and training of staff on
medical waste management). In 2006, under the Zambia Malaria Booster Project, the HCWMP
plan was updated and disclosed. Unfortunately, this plan was also not effectively implemented,
mainly due to the non-availability of qualified staff in safeguards in the MOH. In 2010, the plan
was further updated with support from other CPs. To ensure that the plan is implemented under
the new project, attention will be given during implementation to review and update the
HCWMP as necessary and ensure availability and adequacy of the capacity to implement under
the new project. The Project will support minor repair of existing infrastructure under
Component 2; therefore no negative environmental or social impacts in the areas of project
intervention are expected (For additional details see Annex 3).
G. Governance and Corruption (GAC)
89. The MOH and MCDMCH fiduciary environment is satisfactory and measures for
improvement have been completed while others are ongoing and will be monitored throughout
Project implementation, and include targeted health sector GAC training and mentorship.
90. The Office of the Auditor General (OAG), found that funding from several CPs was
misused, with GRZ subsequently reimbursing over US$3.2 million to the CPs. As a result, steps
29
were taken to strengthen health sector governance and accountability, initially with a
Governance Action Plan, and subsequently a Governance and Management Capacity
Strengthening Plan (GMCSP) designed to address financial management weaknesses over the
medium to long-term. The GMCSP has been incorporated into the operational plans for the
Medium Term Expenditure Framework and linked to the National Strategic Plan (2011-2015). In
2010, as a result of a Bank audit, Government repaid the Bank US$1.3 million for expenditures
adjudged to have been ineligible, pending a complete audit of the pooled funds by the OAG. The
OAG completed the additional audits and determined that out of the US$1.3 million,
US$813,489.89 was confirmed as eligible expenditure and was therefore refunded to GRZ in
November 2013.
30
Annex 1: Results Framework and Monitoring
.
Country: Zambia
Project Name: Health Services Improvement Project (P145335)
Results Framework
Project Development Objectives
PDO Statement
The project development objective is "to improve health delivery systems and utilization of maternal, newborn and child health
and nutrition services in project areas."
These results are at Project Level .
Project Development Objective Indicators
Cumulative Target Values Data
Source/
Responsibility
for
Indicator Name Core Unit of
Measure Baseline YR1 YR2 YR3 YR4 End Target Frequency
Methodol
ogy
Data
Collection
Deliveries attended
by skilled health
providers
Percentage 27.00 33.00 39.00 45.00 51.00 57.00 Annually HMIS MOH
Under-2 children
received monthly
growth monitoring
and promotion
Percentage Annually
MOH &
MCDMC
H
Facility and
community
survey.
Health Centers
offering integrated
Management of
Childhood Illnesses
Percentage 13.00 21.00 51.00 77.00 100.00 Annually
Facility
Survey MOH
Health Centers with
essential medicines Percentage Annually Health
Facility
Verification
Entity
31
and commodities in
stock (percent)
Survey
Children 0-11
months fully
immunized
Percentage 80.00 82.00 84.00 86.00 88.00 90.00 Annually HMIS MOH
.
Intermediate Results Indicators
Cumulative Target Values Data
Source/
Responsibility
for
Indicator Name Core Unit of
Measure Baseline YR1 YR2 YR3 YR4 End Target Frequency
Methodol
ogy
Data
Collection
Health workers
trained in MNCH
and nutrition
competencies
Number 400.00 800.00 1200.00 1600.00 2000.00 Annually
Project
data and
supervisio
n report.
Verification
Entity
Percentage of
trained health
workers deployed
to facilities in the
five provinces.
Percentage 70.00 75.00 80.00 85.00 85.00 Annually
Project
data and
supervisio
n report.
Verification
Entity
Health facilities
(health centers and
district hospitals)
using electronic
inventory control
and logistics
management
system
Number 0.00 94.00 151.00 376.00 565.00 734.00 Annually
Project
data and
supervisio
n report
MSL
Regional hubs and
staging posts
equipped in target
areas
Number 1.00 2.00 4.00 5.00 8.00 Annually
Project
data and
supervisio
n report
MSL
32
Protocols and
guidelines at
community and
primary care levels
updated and
disseminated
Number 1.00 2.00 3.00 4.00 4.00 Annually
Project
data and
Supervisio
n Reports
MOH,
MCDMCH
and NFNC
Districts with
community
information system
integrated DHIS-2
Number 0.00 10.00 20.00 30.00 39.00 Annually
Project
data and
supervisio
n reports
MOH and
MCDMCH
Health facilities
(health centers and
district hospitals)
implementing the
RBF approach
Number 70.00 92.00 149.00 275.00 365.00 545.00 Annually
Project
data and
supervisio
n report.
MOH and
MCDMCH
Health policy
analysis conducted
and results
disseminated
Number 3.00 3.00 Annually
Project
records
and
supervisio
n reports
MOH
Direct project
beneficiaries Number 3,300,000.00 Annually
HMIS and
Facility
Survey
MOH and
MCDMCH
Female
beneficiaries
Percentage
Sub-Type
Supplement
al
55.00
.
33
Table A.1: Summary – Definition and Interpretation of PDO and Intermediate Indicators .
Results Framework .
Project Development Objective Indicators
Indicator Name Description (indicator definition etc.)
Deliveries attended by skilled health providers Numerator: Number of deliveries conducted by skilled personnel (medical doctors and
registered midwife) in health facilities in project areas.
Denominator: Expected deliveries in project areas.
Under-2 children received monthly growth monitoring
and promotion
Numerator: Number of children under-2 who received monthly growth monitoring and
promotion in project areas.
Denominator: Population of children under -2 years in project areas.
Health Centers offering integrated Management of
Childhood Illnesses
Numerator: Number of Health Centers offering Integrated Management of Childhood
Illnesses in project areas.
Denominator: Total number of Health Centers in project areas.
Health Centers with essential medicines and commodities
in stock (percent)
Numerator: Number of Health Centers with essential medicines and commodities in
stock in project areas.
Denominator: Total number of Health Centers in project areas.
Children 0-11 months fully immunized Numerator: Number of children 0-11 months fully immunized (new) in project areas.
Denominator: Population of children 0-11 months in project areas. .
Intermediate Results Indicators
Indicator Name Description (indicator definition etc.)
Health workers trained in MNCH and nutrition
competencies
Number of health workers trained in MNCH and nutrition competencies in the targeted
provinces.
Percentage of trained health workers deployed to Numerator: Number of health workers trained in MNCH and nutrition competencies
34
facilities in the five provinces. deployed to facilities in the five provinces.
Denominator: Total number of Health workers trained in MNCH and nutrition
competencies under the project.
Health facilities (health centers and district hospitals)
using electronic inventory control and logistics
management system
Numerator: Number of health centers and district hospitals using electronic inventory
control and logistics management system in project areas.
Denominator: Total number of health centers and district hospitals in project areas.
Regional hubs and staging posts equipped in target areas Number regional hubs and staging posts equipped in target areas.
Protocols and guidelines at community and primary care
levels updated and disseminated
Number of protocols and guidelines at community and primary care levels updated and
disseminated.
Districts with community information system integrated
into DHIS-2
Number of districts in project areas with community information system integrated
into DHIS-2.
Health facilities (health centers and district hospitals)
implementing the RBF approach
Number of health centers and district hospitals implementing the RBF approach.
Health policy analysis conducted and results
disseminated
Number of health policy analysis conducted and results disseminated.
Direct project beneficiaries Direct beneficiaries are people or groups who directly derive benefits from an
intervention (i.e., children who benefit from an immunization program; families that
have a new piped water connection). Please note that this indicator requires
supplemental information. Supplemental Value: Female beneficiaries (percentage).
Based on the assessment and definition of direct project beneficiaries, specify what
proportion of the direct project beneficiaries are female. This indicator is calculated as
a percentage.
Female beneficiaries Based on the assessment and definition of direct project beneficiaries, specify what
percentage of the beneficiaries are female.
35
Annex 2: Detailed Project Description
1. The proposed project will support GRZ’s efforts to accelerate progress towards maternal and
child health MDGs and for it to be better prepared for emerging challenges, especially non-
communicable diseases. The Project will support strengthening service delivery, while focusing
on results and reducing inequities. Activities will be targeted to provinces that are poorer and
underserved to scale-up coverage of high impact MNCH and nutrition interventions.
Specifically, the Project will support supply side interventions such as improving availability of
skilled care, increasing availability of related health and nutrition commodities, and
strengthening referral linkages. This will be complemented by community-based demand side
approaches to enhance utilization of services. Institutional capacities of MOH and MCDMCH
will be supported to enhance evidence-based policy analysis, health systems performance, and
management of adjustments to changing roles and responsibilities in light of the decentralization
process. The Project will also support project management and implementation competencies,
particularly in the targeted provinces, as well as the establishment of an independent verification
mechanism. The Project will be structured under three components and implemented over five
years.
Component 1: Strengthening capacity for primary and community level MNCH and
nutrition services (US$27.5 million IDA)
2. The objective of this component is to strengthen health systems in project areas through: (i)
enhanced training capacity and standards for nursing and midwifery; (ii) improved supply chain
systems for essential commodities; and (iii) improved referral system and linkages across levels
of care. The Project will do this using a Disbursement Linked Indicators (DLIs) approach which
pays for achievement of results (see matrices below for each sub-component28
).
Sub-component 1.1: Enhance training capacity and standards for nursing and midwifery
(US$10 million IDA).
3. This sub-component supports Government’s effort to address the shortage of health workers
with sufficient MNCH and nutrition skills at first level district hospitals and health centers in the
five targeted provinces. The lack of adequately trained health workers is negatively impacting
28
Measurement is through the HMIS/DHIS information, surveys and reports provided by the MOH, MCDMCH,
General Nursing Council, which are verified by an independent entity. The Results Framework include the DLIs,
which are responsive to the KPIs, and will be tracked and reported. Eligible Expenditures can be paid for results
which exceed a given year's DLI output objective. On the other hand, if a DLI is missed, the amount is not paid but
does not affect payment for other DLIs that have been met (indicators are not "tranched'). A waiver is possible at the
Bank's discretion. The waiver will require GRZ to explain why the DLI was missed and present a work plan and
date for complying with the DLI. The decision regarding what will ultimately be paid--amount and timing--is at the
Bank's discretion. The Bank may, inter alia, withhold the amount or pay only partly depending on the progress
made, and complete the payment when the indicator is met. It may also withhold payment until the indicator is met
paying at that time or at the time of the next 12 month payment period. The purpose of the waiver is to maintain
incentives to meet indicators and reward conscientious efforts to meet a DLI. At the same time a program of Eligible
Expenditures (principally health sector salaries and operating costs) will be used to reconfirm funds were expended
to achieve the results.
36
the delivery of critical health services to the poor and is contributing to unsatisfactory maternal
and child health outcomes. Only 39 percent of posts for Skilled Birth Attendants (SBAs) for
example are filled29
, and of those many lack additional MNCH and nutrition competencies (Box
A.1). The more remote provinces in Zambia are worse off. Whilst Lusaka for example is home to
0.58 SBAs per 1000 population, Eastern province is home to 0.23, Luapula 0.21 and Northern
Province 0.21 (compared to the desired WHO benchmark of 2.23 per 1000 population).
Box A.1: Skilled birth Attendants with MNCH and nutrition skills in Zambia
Skilled birth attendants are health workers (usually doctors, nurses and midwives) who have been
trained to proficiency in the skills necessary to diagnose, manage or refer obstetric complications. These
same providers would also be expected to have good competencies related to broader MNCH and
nutrition skills, including IMCI, Family Planning, ANC and PNC skills to name but a few. In Zambia:
Doctors are very few in number (there are only two, urban based medical schools), and the cadre least
likely to take up rural employment (given the opportunity cost associated to rural job uptake). Clinical
officers (trained in Lusaka) , a cadre with competencies between a nurse and a doctor, trained for posting
at the district hospital level, are frequently not considered SBAs, due to their weak competencies
particularly in delivering EmONC services. Nurses (Registered and Enrolled), the single largest cadre in
Zambia (trained across the country, with the majority in Lusaka and Copperbelt Province), are currently
not considered SBAs due to insufficient training in EmONC and midwifery skills. Furthermore, many
nurses lack critical competencies related to MNCH and nutrition, including critical IMCI, Family
Planning, ANC and PNC related competencies. Registered midwives (RM) and enrolled midwives (EM)
(trained in select training institutions) are very few in number. Midwives are considered SBA’s however
the quality of some of their MNCH and nutrition skills (as with nurses) could benefit from improvement.
Midwifery training programs are one year in-service training programs for nurses (RN or EN) following
mandatory work experience. This is a lengthy requirement and makes the midwifery program unpopular.
4. A key problem that can help explain the deficiency in relevant competencies is the limited
capacity of nursing schools to deliver a comprehensive package of nurse/midwifery training in
MNCH and nutrition (in particular on EmONC, nutrition and IMCI related skills). Beyond a new
pilot (supported by the USAID Nurse Education Partnership Initiative (EPI), there are currently
no combined pre-service nurse/midwifery training programs. Registered and enrolled nursing
schools found in many provinces in Zambia, particularly in the more remote provinces, often
experience significant constraints in physical capacity (teaching aides, skill laboratories, and
other infrastructure), technical capacity (faculty and instructors) and organizational capacity
(leadership and management skills) to be able to beef up their training capacity.
5. Lack of on-site clinical supervision capacity moreover means that teaching is primarily
theoretical and classroom based, with little practical training provided in nearby health facilities.
As a result, nursing graduates are often inadequately prepared to address MNCH and nutrition
related service delivery challenges they face particularly in more remote or rural facilities. Once
nurses or midwives are posted into facilities moreover, provision of in-service training is
sporadic and non-transparent, often donor driven and focused on vertical instead of horizontal
skills building. Such training sessions are not linked to re-certification and they disrupt service
delivery: they are a major cause of staff absenteeism and/or discontent. To date, limited
opportunity for on-site continued professional development (CPD) training in MNCH and
29
2012 MOH Payroll data
37
nutrition related competencies exist. A streamlined mentorship and on-site skills building
program, one that is linked to re-certification requirements and keeps staff motivated and up to
date does currently not exist.
6. To address these challenges, this sub-component will support GRZ’s strategy to strengthen
pre-service, in-service as well as professional development opportunities for nurses and
midwives in Zambia. GRZ’s Human Resources for Health Strategy, the National Training
Operational Plan, and the General Nursing Council all emphasize the need for intervention to
strengthen quality of nursing/midwifery training and ultimate the quality of services delivered by
skilled providers at the facility level in Zambia.
Specifically, sub-component 1.1 will support GRZ to:
7. Strengthen the capacity of eight training institutions in the five target provinces (see table) to
deliver an integrated and comprehensive pre-service education package on MNCH and nutrition
to nursing students. GRZ’s National Training Operational Plan (2011) assessed the capacity
constraints of the health training institutions targeted by the Project. Using the DLI approach (see
Table A.330
), funding under this project can be used by the Ministry of Health (MOH) to fund
Eligible Expenditures for example those related to finalizing and certifying the comprehensive
pre-service education curricula for nurses/midwives (through the GNC) and to strengthen the
capacity of these schools to deliver the new curricula. This could include reimbursements for
costs related to strengthening teaching capacity of the nursing schools including faculty and
clinical instructor salaries and overheads, costs linked to training of trainers, upgrading of
equipment and supplies and other operational costs and administrative expenses. Whilst each
current cohort will already benefit from the strengthened capacity and improved curricula, the
first full cohort graduating from a combined nurse/midwifery program with particular emphasis
on MNCH and nutrition skills is expected to occur in 2019 (assuming they enroll by 2016).
Table A.2: Schools and number of graduates
Nursing schools to be supported by the Project 2015 2016 2017 2018 2019
Luapula
Mansa School of Registered Nursing 48 48 48 48 48
St Pauls Enrolled Nursing Training School (Nchelenge
District)
32 32 32 32 32
Muchinga
Chilonga: Our lady enrolled Midwifery and nursing school 70 70 70 70 70
North-Western
Kalene School of Nursing 26 26 26 26 26
Mukinge School of Nursing and Midwifery 55 55 55 55 55
Solwezi School of Nursing 50 50 50 50 50
Northern
Kasama School of Registered Nursing 66 66 66 66 66
Western
Lewanika Enrolled Nursing/midwifery School (Mongu) 85 85 85 85 85
Total 432 432 432 432 432
30
Table A.3 is found on page 45.
38
Note: These numbers are based on the current capacity of the schools to graduate students. These numbers will
change based on additional investments provided by partners on infrastructure (not funded under the Project).
8. Deliver a three month applied in-service training to nurse and midwifery graduates as part
of their induction before they commence their posts at primary facilities in the target provinces.
Funding under this project will support GRZ’s plan to provide a short yet intensive period of
practical training in MNCH and nutrition to nursing and midwifery graduates before they enter
into primary level posts in the five provinces. Such training, carried out for three months at the
(provincial) hospital in the target provinces will be provided to registered and enrolled nurses
and midwives as part of their induction requirement. Such applied training, primarily delivered
by clinical instructors, will also include significant outreach training at primary health facilities
to equip students with the skills necessary to succeed in particularly challenging environments
(to address health complications without the adequate medicine, supplies or equipment available,
or tackle more complex interventions in the absence of staff). Recent graduates, from training
institutions within the target provinces or other provinces, will commence their in-service
training only after they have been accredited and sent their letter of appointment for a posting in
a primary level facility in one of the five target provinces (approximately 3 months after their
graduation). The letter of appointment will specify the need for the 3 month applied in-service
training as part of their induction before their primary level posting/deployment. During their
training they are hence already absorbed onto MCDMCH payroll. Using the DLI approach,
funding under this project can be used by the MCDMCH to fund Eligible Expenditures related to
developing the in-service training modules, and obtain reimbursement for costs associated with
the provision of training in the provincial hospital, for example the operational costs and
expenses linked to the required clinical faculty and supervision. The Project will continue to
support this “temporary” in-service training requirement until the combined and comprehensive
nurse/midwifery pre-service training bears its first cohorts.
Box A.2: Example of the 3 month in-service training
1. Expanded applied program of Immunization (EPI) - 5 days
2. Applied Integrated Management of Childhood Illness (IMCI) - 6 days
3. Applied Emergency Obstetric care EmONC - 21 days
4. Applied Adolescent health - 10 days
5. Applied Family Planning (FP) - 12 days (reduced to 12 days)
6. Applied Reproductive Health cancers – 10 days
7. Applied Infant and Young Child Feeding (IYCF) – 5 days
8. Applied Sexual and Gender Based Violence - 7 days
9. Applied Prevention of Mother to Child Transmission (PMTCT) – 12 days
10. Interpersonal communication skills
9. Support the development and roll out of continued professional development training to
nurses and midwives already working in primary level facilities in the 5 target provinces. This
component will support the GNC and the MCDMCH in developing and implementing its
continuing professional development program for nurses and midwives already posted at primary
level facilities in the five target provinces. The Continuing Professional Development (CPD)
modules supported under this project will be those related to MNCH and nutrition. Using the
DLI approach, funding under this project can be used to fund Eligible Expenditures related to
developing and certifying the CPD training program (by the GNC), and obtain reimbursement
39
for costs associated with the provision of CPD to targeted primary health workers, including for
example salaries or operational costs linked to the funding of mentors, or the implementation of
innovative ICT-CPD training solutions. CPD will contribute towards strengthening the
motivation, skills building and retention of health workers at primary level in the target
provinces.
Sub-component 1.2: Improve supply chain systems and availability of essential commodities
(US$10 million IDA)
10. This component will support and contribute to the implementation of the Zambia Supply
Chain Strategy focusing on increasing availability of selected essential commodities, supplies
and equipment to support service delivery for high impact MNCH and nutrition interventions in
project areas. Relying on country systems and an independent verification mechanism, it will
finance results related to improved: (i) procurement of health commodities, supplies and
equipment; (ii) distribution capacity of MSL, particularly the “last mile” distribution of essential
medicines and supplies from the regional hubs and staging posts to health facilities; and (iii)
deployment of an electronic inventory control and logistics management information system to
improve stock visibility and accountability. The elements are discussed in more detail below:
11. Under this sub-component, the Project will support existing systems to: (i) improve
availability of essential health and nutrition commodities, supplies and equipment; (ii) strengthen
storage and distribution capacity, particularly for the "last mile" with enhancement of regional
hubs and/or staging posts and to the service delivery points and employing an hybrid distribution
system (combining a Push and Pull systems); and (iii) improve stock visibility and accountability
through implementation of an electronic Zambia Inventory Control System (eZICS). Resources
will be disbursed to MOH/MCDMCH on achieving agreed upon performance targets, verified by
an independent entity. A rapid assessment of stock levels, storage and distribution capacities, and
staff competencies at health centers will be undertaken to provide baseline data.
12. The activities to be considered for Disbursement Linked Indicators (DLI) approach include
the following:
Provision of essential health and nutrition commodities, supplies and equipment: The
Project will pay for eligible outputs/results for selected essential commodities to support
high impact MNCH and nutrition interventions at primary health care level. This will
cover prevention (nutrition supplementation, malaria prophylaxis, deworming tablets,
vaccines, and reproductive health commodities); treatment (selected essential tracer
drugs, ready to therapeutic food and specialized milk, diagnostic test kits and reagents);
and equipment (ambulances, EmONC equipment, GMP and cooking demonstration kits).
The Project will also support provision of incremental critical transportation for
supervision, logistics and supply management, and ambulances at the different levels of
primary health care and community level.
Strengthening storage and distribution capacity of MSL, particularly the “last mile”: The
Project will strengthen the storage and distribution systems from the central level to the
Regional Hubs and/or the staging posts and to the service delivery points (i.e., rural
health center) in the Project areas. Currently the MSL distributes up to the district level
40
and the district is responsible for the “last mile”. It is the secondary distribution, which
has largely been responsible for significant shortages at service delivery level. Recently,
GRZ introduced Regional Hubs and allowed MSL to distribute products up to the health
facility in an effort to improve secondary distribution. The new distribution network
structure has six regional hubs (in Chipata, Mongu, Kitwe, Kasama, Lusaka and Choma)
and seven staging posts as temporary holding points for facilities that are a long way
away from the main hubs (Livingstone, Solwezi, Chama, Zambezi, Kabompo, Mkushi
and Mansa). Two of the regional hubs (Kasama and Mongu) and five of the staging posts
(Chama, Mansa, Solwezi, Kapompo and Zambezi) will be hosted in the Project
provinces. The Staging Posts in North Western Province (Solwezi, Kapompo and
Zambezi) will be serviced by the Kitwe hub. In this respect, consideration will be made
to support the upgrading of the Kitwe hub although it is not in the target province. The
eligible expenditures to strengthen storage and distribution capacity will include: (i)
vehicles and warehouse mechanical handling equipment; (ii) racking of regional hubs,
some staging posts and where practicable, health facility stores in order to improve
storage capacity at this level; (iii) supply chain management staff who have been trained
to efficiently run a good supply chain system; and (iv) public/private partnership
contractual arrangements especially for the last mile distribution of drugs and medical
supplies.
Figure A.2: Distribution network of drug supply
Source: Medical Stores Limited
Support to the development and implementation of an ICT based logistics and inventory
control system to be able to: (i) take seasonal changes in demand and disease patterns
into consideration; (ii) determine optimal facility orders in a situation of rationing at
MSL; and (iii) maintain and transfer accurate inventory data as the system is paper based
and susceptible to errors. The implementation of the electronic Zambia Inventory Control
System (eZICS), developed under the previous WB project, will focus on improving
41
visibility of stock at each level of care as well as instituting rational optimization of
orders, taking into account consumption as well as pipeline data. The piloting of the
system is scheduled in three Districts, and a Cooperating Partner, DfID, has provided
funding to meet the costs. Specific Bank support will be directed towards necessary ICT
equipment, software licenses, and the relevant data transmission costs to the system as
well as system user training, the using the DLI approach.
13. Specific DLIs that progressively link to the achievement of the objectives in the three areas
discussed above, including the proposed payment value are detailed in Table A.3 (DLI #4 – DLI
#6) below.
Sub-component 1.3: Improve referral system and linkages across levels of care (US$7.5
million IDA)
14. This sub-component aims to strengthen the extent and quality of primary health care (district
hospital, heath center and health post) as well as community level service delivery platforms to
effectively scale up a package of high impact MNCH and nutrition interventions, along the
continuum of care. By bringing services as close to the family as possible and reducing the
workload of scarce clinicians in the provision of basic preventive, promotive and curative
facilities, primarily in underserved rural areas, this sub-component will address the issue of
inequitable access to and poor utilization of quality, cost-effective and affordable basic MNCH
and nutrition services.
15. Specific results that will be contributed by this sub-component include: (i) development of an
agreed package of evidence-based high impact MNCH and nutrition interventions, which will be
delivered through primary care and community levels; (ii) revitalization and harmonization of
community structure through strengthening of linkages with community based service delivery
structures, specifically linkages between the community development committees, social welfare
committees, and NHCs, and CHWs. This includes an agreed and defined framework, protocols,
norms and guidelines; (iii) quality checklists for the supervision and mentorship across different
service delivery levels including district hospitals, health centers, health posts and communities;
and (iv) enhanced referral systems across different levels of service delivery points through
increased provision of equipment and timely maintenance.
16. Special emphasis will be provided to mobilize local Chiefs and engage them actively in
social mobilization and day-to-day activities at primary care and community levels. Given that
the populations in the selected provinces are sparsely distributed, community level service
delivery mechanisms will have high potential to bring services closer to the people mainly
through expansion of and strengthening service delivery at outreach posts. Eventually
community-based MNCH and nutrition service delivery will be incorporated in the formal health
system, and based on lessons learned from the five target provinces; the model will be adapted
and extended to the rest of the country. DLIs which are linked to the sub-component 1.3 results
achievement are provided in Table A.3 (DLI #7 – DLI #9) below.
17. Figure A.3 below provides a list of evidence-based high impact MNCH and nutrition
interventions that will be delivered at primary care and community levels. However, this list will
42
be reviewed further by MCDMCH and MOH and a final list will be developed and disseminated
to scale up in the Project provinces and beyond.
18. The system for improved referral of patients would be strengthened by activating
Neighborhood Health Committees and establishing formal links with Health Centers, acquiring
ambulances, motorcycles/bicycles and communication equipment including radios and batteries.
Service at the Health Centers and residence of Health Center staff would also be improved by
providing better lighting. Efforts will be made to ensure energy at night at least, in delivery
rooms and in emergency outpatient rooms, and to provide water in delivery rooms, children's
wards and outpatient clinics, plus one water point for the general use of other patients. Districts
would be provided with Motor vehicle ambulances.
43
Figure A.3: High impact MNCH and nutrition interventions
Pre-pregnancy Pregnancy and child birth care Newborn and childcare
Dis
tric
t H
osp
ita
l
Promotion of
Adolescent
health Youth-
friendly services
(HIV and
prevention, STI
screening and
Treatment,
Essential
nutrition
actions).
Family Planning-
Long-term
permanent
methods.
Cancer screening
FANC plus All of the below
Essential Nutrition Actions
Identification of high risk
pregnancy and management of
complications of pregnancy
Monitoring progress during labor
Social support (companion)
during birth
Clinical management of obstetric
complications
Referral of complicated delivery
to higher levels
Prevention of mother-to-child
transmission of HIV Detection of
obstetric complications
Immediate newborn care (resuscitation if required,
thermal care, hygienic cord care, early initiation of
breastfeeding)
Exclusive breastfeeding Thermal care Hygienic
cord care Extra care of LBW infants Prevention of
mother-to-child transmission of HIV Management
of newborn illness Immunization
Management of severe newborn illness
Immunizations Vitamin A supplementation
Standard case management including: - ORT and
zinc for diarrhea - Antibiotics for dysentery -
Antibiotics for pneumonia - Antimalarial Care for
HIV-exposed and HIV-infected children - Co-
trimoxazole prophylaxis – ART
Management of severe infant and childhood illness
Hea
lth
C
ente
r
Weekly IFA
supplements
Bi-annual
deworming
BCC and
provision of
contraceptive
FANC Plus All of the below
Skilled birth attendance
Post-partum Vitamin A
supplement
Provision of treatment (to high
risk pregnant women)
Post-natal services for mothers
including infection management
of complicated delivery
(Emergency Obstetric Care)
Referral of complicated delivery
Neo-natal infection management
Management of complicated and uncomplicated
severe acute malnutrition
IMCI (Integrated Management of Childhood
illness)
ETAT (emergency triage assessment & treatment)
Referral
Ou
trea
ch/H
ealt
h P
ost
Weekly IFA
supplements
Bi-annual
deworming
BCC and
provision of
contraceptives
Early pregnancy screening
ANC services
IFA supplementation
Malaria prophylaxis
Deworming
Pregnancy weight gain monitoring
Sensitization for skilled birth
attendance
Post-natal services for mother
Referral
Growth Monitoring & Promotion
Vitamin A supplementation
ORS with zinc for diarrhea treatment
Cooking demonstration and use of Micronutrient
Powder (6-24 months)
Neo-natal infection management
Integrated Community Case Management
Immunization
Referral of severe acute malnutrition & children
with infections
Fa
mil
y &
Co
mm
un
ity
BCC for MNCH
and nutrition
services
Early pregnancy screening
Promotion of nutritious diet
Sensitization to access ANC and
skilled birth attendance
Male involvement in promotion
activities for MNCH and nutrition
services
Growth Monitoring & Promotion
Vitamin A supplementation
ORS with zinc for diarrhea treatment
Cooking demonstration and use of Micronutrient
Powder (6-24 months)
Referral of severe acute malnutrition and children
with infections Home-based newborn care
Promotion and support for Exclusive Breastfeeding
Community-based management of uncomplicated
acute malnutrition
Intersectoral: Water, sanitation, hygiene, iodized salt promotion, nutrition education, empowerment
Adolescence/Pre-
pregnancy
Pregnancy Birth Newborn /postnatal
Childhood
44
19. . District hospitals would receive technical support to improve planning and supervision.
Training will: (i) help improve the quality of supervision and service provision, particularly in
the areas of MNCH and nutrition with the strengthening of IMCI and safe motherhood; and (ii)
improve the skills of health personnel to ensure that cases in need are timely referred to the next
level of care (District and Provincial hospital). Key bottlenecks in the supply of MNCH and
nutrition services would be addressed, principally by increasing the number of trained nurses and
midwifes to ensure that the expected increase in demand for institutional deliveries can be
satisfied. The Project would help develop and expand a network of outreach teams by
broadening the staffing of existing outreach teams that are now limited and largely focused on
fewer number of service provision. New outreach teams would provide a continuum of services
from MNCH to nutrition as presented in Figure A.3. Outreach teams would also be responsible
to supervise CHWs. To ensure the proper functioning of outreach teams, Training Institutions
and District Hospitals would provide Continuing Professional Development (CPD) training to
existing nurses, and train additional ones. Teams would be provided with adequate vehicles, fuel
and per diem. Additional personnel would be recruited and trained to ensure that health centers
remain staffed when the outreach team is on the road. All districts in each project province will
be covered.
20. Teams of CHWs would be developed in each village, coordinated by Neighborhood Health
Committees. They will not replace the existing network of community volunteers; rather, they
are meant to supplement and enhance their efforts. CHWs will be accountable to the health
system and to their communities. They would be trained to undertake early pregnancy screening,
promotion of nutritious diets, sensitization to access ANC and skilled birth attendance,
encouragement of males to promote MNCH and nutrition services, Growth Monitoring &
Promotion, Vitamin A supplementation, ORS with zinc for diarrhea treatment, cooking
demonstrations and use of micronutrient powder (6-24 months), Referral of severe acute
malnutrition and children with infections home-based newborn care, Promotion and support for
Exclusive Breastfeeding, and Community-based management of uncomplicated acute
malnutrition, female education including the use of bed nets, family planning, good hygiene
such as washing hands, avoidance of risky sexual behavior, and increasing the capacity of
families to recognize the early danger signs of some common diseases so to as search for help
sooner. The complete list of services is presented in Figure A.3. Outreach teams would provide
technical support to CHWs when visiting their area. All CHWs would receive information,
education, and communication (IEC) materials. CHWs would report on technical matters to the
Health Posts (where available) and Health Centers and to the outreach team, and to
Neighborhood Health Committees on the quality of their interaction with the community.
21. As outlined in the National Community Health Worker Strategy in Zambia, Health Centers
will provide technical supervision and guidance to CHWs and neighborhood health committees
(NHCs). Specifically health centers will: (i) identify challenges and solutions for CHWs and
NHCs in implementing their day-to-day community activities; (ii) assist CHWs and NHCs in
identifying, prioritizing and solving health issues in their communities; (iii) identifying weakness
in the provision of community-based services as well as factors influencing services; (iv) ensure
the collation of relevant data for the DHIS; and (v) providing mentorship to CHWs.
45
Table A.3: Disbursement linked indicators
Disbursement Linked
Indicator
Action to be Completed Amount in
US$
Disbursement
Calculation
Formula
Means of
Verification
DLI #1: Capacity to
implement comprehensive
pre-service training program
on MNCH and nutrition for
nurses and midwives
strengthened
DLR#1.1: An updated pre-service training curriculum on
MNCH and nutrition for the training of nurses and midwives
has been adopted in FY 2014 and all Targeted Training
Institutions have prepared their capacity building plans
DLR#1.2: At least four (4) of the Targeted Training
Institutions have addressed the capacity gaps identified in their
respective Capacity Building Plans in FY 2015
DLR#1.3: All Targeted Training Institutions have addressed
the capacity gaps identified in their respective Capacity
Building Plans in FY 2016
3,000,000 DLR 1.1: 450,000
DLR 1.2:
1,350,000
DLR 1.3:
1,200,000
Annual report
provided by
MOH verified
by
independent
agency
DLI #2: The number of
vacancies for nurses and
midwifes in primary health
facilities in Targeted
Provinces filled by newly
recruited nurses and
midwifes who have
completed the three (3)
month induction in-service
training on MNCH and
nutrition increases
DLR#2.1: Consolidated staffing profiles for nurses and
midwifes in primary health facilities in Targeted Provinces
prepared in FY 2014 and training modules for the three (3)
months induction in-service training on MNCH and nutrition
for newly recruited nurses and midwifes developed
DLR#2.2: At least 10% of the number vacancies for nurses
and midwifes in primary health facilities in Targeted Provinces
filled by newly recruited nurses and midwifes who have
completed the three (3) month induction in-service training on
MNCH and nutrition in FY 2016
DLR#2.3: At least 20% of the number vacancies for nurses
and midwifes in primary health facilities in Targeted Provinces
filled by newly recruited nurses and midwifes who have
completed the three (3) month induction in-service training on
MNCH and nutrition in FY 2017
DLR#2.4: At least 30% of the number vacancies for nurses
and midwifes in primary health facilities in Targeted Provinces
4,000,000 DLR 2.1: 600,000
DLR 2.2: 800,000
DLR 2.3: 800,000
DLR 2.4: 800,000
DLR 2.5:
1,000,000
MCDMCH
and MOH data
verified by
independent
verification
agency
46
Disbursement Linked
Indicator
Action to be Completed Amount in
US$
Disbursement
Calculation
Formula
Means of
Verification
filled by newly recruited nurses and midwifes who have
completed the three (3) month induction in-service training on
MNCH and nutrition in FY 2018
DLR#2.5: At least 40% of the number vacancies for nurses
and midwifes in primary health facilities in Targeted Provinces
filled by newly recruited nurses and midwifes who have
completed the three (3) month induction in-service training on
MNCH and nutrition in FY 2019.
DLI # 3: The number of
nurses and midwives in
primary health facilities in
Targeted Provinces who
have completed the
continuing professional
development training in
MNCH and nutrition
increases
DLR# 3.1: Training modules for the continuing professional
development training in MNCH and nutrition developed in FY
2015
DLR# 3.2: At least 10% of the number of nurses and midwives
in primary health facilities in Targeted Provinces have
completed the continuing professional development training in
MNCH and nutrition in FY 2016
DLR# 3.3: At least 20% of the number of nurses and midwives
in primary health facilities in Targeted Provinces have
completed the continuing professional development training in
MNCH and nutrition in FY 2017
DLR# 3.4: At least 30% of the number of nurses and midwives
in primary health facilities in Targeted Provinces have
completed the continuing professional development training in
MNCH and nutrition in FY 2018
DLR# 3.5: At least 40% of the number of nurses and midwives
in primary health facilities in Targeted Provinces have
completed the continuing professional development training in
MNCH and nutrition in FY 2019
3,000,000 DLR 3.1: 350,000
DLR 3.2: 850,000
DLR 3.3: 600,000
DLR 3.4: 600,000
DLR 3.5: 600,000
Annual report
of GNC and
MCDMCH
verified by
independent
agency
47
Disbursement Linked
Indicator
Action to be Completed Amount in
US$
Disbursement
Calculation
Formula
Means of
Verification
DLI #4: The number of
primary health facilities in
Targeted Provinces stocked
with all tracer drugs
increases
DLR#4.1: A national supply chain strategy adopted in FY 2014
DLR#4.2: A baseline survey carried out to establish the
number of primary health facilities in the Targeted Provinces
with all tracer drugs in FY 2015
DLR#4.3: The number of primary health facilities in Targeted
Provinces project area stocked with all tracer drugs increases
by 5% from the Baseline in FY 2016
DLR#4.4: The number of primary health facilities in Targeted
Provinces project area stocked with all tracer drugs increases
by 10% from the Baseline in FY 2017
DLR#4.5: The number of primary health facilities in Targeted
Provinces project area stocked with all tracer drugs increases
by 15% from the Baseline in FY 2018
DLR#4.6: The number of primary health facilities in Targeted
Provinces project area stocked with all tracer drugs increases
by 20% from the Baseline in FY 2019
4,000,000 DLR 4.1: 400,000
DLR 4.2: 600,000
DLR 4.3: 600,000
DLR 4.4: 800,000
DLR 4.5: 800,000
DLR 4.6: 800,000
Health Facility
Survey
DLI #5: Regional essential
commodities storage and
distribution hubs established
in Targeted Provinces
DLR#5.1: The regional essential commodities storage and
distribution hub for Western Province established at Mongu in
FY 2014
DLR#5.2: The regional essential commodities storage and
distribution hub for the North-Western Province established at
Kitwe in FY 2015
DLR#5.3: The regional essential commodities storage and
distribution hub for the Northern Province established at
Kasama in FY 2016
3,000,000 DLR 5.1: 300,000
DLR 5.2:
1,350,000
DLR 5.3:
1,350,000
MOH /
MCDMCH
inspection
report
48
Disbursement Linked
Indicator
Action to be Completed Amount in
US$
Disbursement
Calculation
Formula
Means of
Verification
DLI #6: The electronic
Zambia Inventory Control
System (eZICS) is piloted
and implemented in
Targeted Provinces
DLR# 6.1: MOH adopts an implementation plan for the
national supply chain strategy in FY 2014
DLR# 6.2: The eZICS is piloted in selected Districts and
upgraded on the basis of the results of the pilots in FY 2015
DLR# 6.3: The eZICS is implemented in Western and North
Western Provinces in FY 2016
DLR# 6.4: The eZICS is implemented in Muchinga and
Northern Provinces in FY 2017
DLR# 6.5: The eZICS is implemented in Luapula Province in
FY 2018
3,000,000 DLR 6.1: 300,000
DLR 6.2: 450,000
DLR 6.3: 900,000
DLR 6.4: 900,000
DLR 6.5: 450,000
Annual report
provided by
MCDMCH
verified by
independent
agency
DLI #7: The number of
women registered during the
first trimester of their
pregnancy in targeted
Provinces increases
DLR#7.1: An updated community health workers strategy
adopted and disseminated in FY 2014
DLR#7.2: Guidelines for the delivery of community-based
MNCH and nutrition services adopted in FY 2015
DLR#7.3: The number of women registered during the first
trimester of their pregnancy in targeted Provinces increases by
5% in FY 2016
DLR#7.4: The number of women registered during the first
trimester of their pregnancy in targeted Provinces increases by
10% in FY 2017
DLR#7.5: The number of women registered during the first
trimester of their pregnancy in targeted Provinces increases by
15% in FY 2018
DLR#7.6: The number of women registered during the first
trimester of their pregnancy in targeted Provinces increases by
2,000,000 DLR 7.1: 200,000
DLR 7.2: 400,000
DLR 7.3: 500,000
DLR 7.4: 500,000
DLR 7.5: 300,000
DLR 7.6: 100,000
Health Center
and
MCDMCH
records
49
Disbursement Linked
Indicator
Action to be Completed Amount in
US$
Disbursement
Calculation
Formula
Means of
Verification
20% in FY 2019
DLI #8: The number of
mothers who delivered at
health facilities in Targeted
Provinces and who received
post-natal care increases
DLR#8.1: The list of CHWs, Neighborhood Health
Committees and Outreach Centers updated in FY 2014
DLR#8.2: The Recipient acquires adequate numbers of
ambulances and motorcycles for facilitating patient referrals in
targeted Provinces in FY 2015
DLR#8.3: The number of mothers who delivered at health
facilities in Targeted Provinces and who received post-natal
care increases by 5% in FY 2016
DLR#8.4: The number of mothers who delivered at health
facilities in Targeted Provinces and who received post-natal
care increases by 7% in FY 2017
DLR#8.5: The number of mothers who delivered at health
facilities in Targeted Provinces and who received post-natal
care increases by 10 % in FY 2018
DLR#8.6: The number of mothers who delivered at health
facilities in Targeted Provinces and who received post-natal
care increases by 15 % in FY 2019
3,000,0000 DLR 8.1: 300,000
DLR 8.2: 600,000
DLR 8.3: 750,000
DLR 8.4: 750,000
DLR 8.5: 450,000
DLR 8.6: 150,000
Health Center
and
MCDMCH
records
DLI #9: The number of
Outreach Centers in
Targeted Provinces
conducting GMP monitoring
following national standards
and guidelines increases
DLR# 9.1: Guidelines for conducting GMP monitoring
adopted in FY 2014
DLR# 9.2: Checklists and protocols for the supervision of
GMP monitoring at different service delivery levels adopted in
FY 2015
DLR# 9.3: The number of Outreach Centers in targeted
Provinces conducting GMP monitoring following national
standards and guidelines increases by 10% in FY 2016
2,500,000
DLR9.1: 250,000
DLR 9.2: 500,000
DLR 9.3: 625,000
DLR 9.4: 625,000
DLR 9.5: 375,000
DLR 9.6: 125,000
Health Center
and
MCDMCH
records
50
Disbursement Linked
Indicator
Action to be Completed Amount in
US$
Disbursement
Calculation
Formula
Means of
Verification
DLR# 9.4: The number of Outreach Centers in Targeted
Provinces conducting GMP monitoring following national
standards and guidelines increases by 20% in FY 2017
DLR# 9.5: The number of Outreach Centers in Targeted
Provinces conducting GMP monitoring following national
standards and guidelines increases by 30% in FY 2018
DLR# 9.6: The number of Outreach Centers in targeted
Provinces conducting GMP monitoring following national
standards and guidelines increases by 40% in FY 2019
51
Component 2: Strengthening utilization of primary and community level MNCH and
nutrition services through results based financing approaches (US$12 million IDA; US$12
million HRITF).
22. The RBF has traditionally been implemented within and through the different levels of the
Zambia public health care delivery system. Over the past few years, Zambia has gained valuable
experience from the on-going health facility RBF pilot, supported by the HRITF grant. An
impact evaluation, scheduled for July 2014, will inform Government’s decisions on fine-tuning
the RBF approach including scale-up. This will include refinement of the institutional
arrangements to increase sustainability and government ownership, integration of the national
decentralization process, consideration of institutional arrangements and provider payment
mechanisms under the Social Protection Programme and the proposed National Social Health
Insurance Scheme, and extension of the RBF to District Hospitals and community levels. This
Sub-component will therefore support the expansion of the ongoing RBF pilot to targeted health
facilities (health centers and district hospitals), District Medical Offices (DMOs), and the
community level across the five provinces.
23. The expansion of the facility-based and community RBF will be phased to allow for the
completion of the impact evaluation of the ongoing pilot and capacities to be built in new
targeted districts. The expansion phase will specifically aim to mainstream RBF implementation
arrangements into the Government structures. To enable this process, MOH will: (i) create a
dedicated team with core skills and competencies in RBF management, monitoring and
evaluation, including financial management; (ii) expand the platform for dialogue and joint
financing of RBF expansion; and (iii) align RBF with other health service purchasing
arrangements in Zambia, particularly the National Social Health Insurance. Figure A.4 shows the
proposed RBF model and funding flows. The Project Implementation Manual (PIM), currently
being developed by a joint MOH/MCDMCH team, will reflect the institutional arrangements for
this mainstreaming and coordination opportunities.
24. As highlighted in Figure A.4, the MOH at national level will be the fund holder, while the
Provincial RBF Steering Committees in the five provinces will be the verifier and purchaser of
services delivered by the DMOs and District Hospitals on a quarterly basis. On the other hand,
the District RBF Steering Committees in the respective districts will be the verifier and purchaser
of health services delivered at health centers and community levels. The health centers and
Community Based Organizations (CBOs) will be the providers of health services. Quantity
audits and quality assessments at health centers will be conducted by DMOs and district
hospitals, respectively. At district hospitals, quantity audits and quality assessments will be
conducted by Provincial Medical Offices, and Provincial (General) Hospitals, respectively.
Health Centers will carry out supervision in communities implementing RBF with the assistance
of DMOs.
52
Figure A.4: RBF model and flow of funds
* Government research / training institution or University (outside the Ministry of Health and Ministry of
Community Development Mother and Child Health) will be eligible to compete. for the external verification
assignment.
25. In addition to the internal verification process, an independent external verification agent will
be contracted to conduct periodic external verification at all levels (community, health centers,
district hospitals, DMOs, and provinces). See sub-component 3.3. The main role of the external
verification agent will be to independently verify the accuracy of reported data, patient tracing,
and quality of health services provided. ICT solutions including on-line entry of information and
cloud computing to improve transparency will allow faster processing and facilitate continuous
monitoring. Government research / training institution or University (outside the Ministry of
Health and Ministry of Community Development Mother and Child Health) will be eligible to
compete for the external verification assignment. The Project Implementation Manual will
provide more details on the means of verification.
53
26. Sub component 2.1 Expand results based financing at primary facility level (US$10
million IDA; US$10 million HRITF).
27. RBF will be implemented at health centers, District Hospitals, and DMOs in selected districts
in the five targeted provinces in January 2015 after completion of the impact evaluation. From
August to December 2014, the RBF will only be implemented in five districts31
currently on the
RBF pilot in the five targeted provinces. From January 2015, the revised model (Figure A.4) and
new Project Implementation Manual will take effect.
28. Performance-based payments at health centers and hospitals will be conditional upon the
attainment of pre-agreed MNCH and nutrition indicators on quantity and quality so that there are
improvements in both utilization and quality of health services provided. The idea is to embed
quantity with quality, and thus, the quality measure will add conditionality to the RBF payment.
The higher the quality attained, the more the health centers and hospitals will earn and vice
versa. In this manner, the quality checklist will have a system strengthening effect by
necessitating all health facilities on RBF to adhere to national norms and guidelines on both
structural and clinical quality improvement. Further bonuses for facility remoteness will also be
provided.
29. Health centers will be contracted by the DMOs to deliver a clearly articulated package of
MNCH and Nutrition services at agreed prices. The quantity of services delivered at each health
center will be verified prior to making payments. Each RBF health center will report quarterly on
the delivery of agreed outputs through a standard invoice. The quantities reported will be initially
verified by the DMOs. The DMO will also contract the District Hospital to verify quality of
service delivery at health centers. The DMO will then compile data on the quantity and quality
performance for submission to the District RBF Steering Committee for further verification.
Based on performance data (both quantity and quality), the District RBF Steering Committees
will recommend the quarterly amounts to be paid to each RBF health center.
30. In Zambia, district hospitals have an important role as apex institutions for referrals for
higher levels of MNCH and nutrition care from health centers. The district hospital RBF
initiative aims to strengthen the referral system and quality of care by incentivizing payments for
the delivery of a complementary package of MNCH and nutrition services such as assisted
deliveries, caesarean sections, severe malnutrition, cerebral malaria etc. District hospitals will be
contracted by Provincial Medical Offices (PMOs) to deliver the stipulated package of MNCH
and Nutrition services. Similar to the health center RBF, costs of services enumerated on
checklists would be reimbursed conditional on the quality of care. The basis for remuneration
will be informed by the costs estimated through the hospital records. Internal verification for
quantity and quality will be conducted by the Provincial Medical Offices and Provincial
(General) hospitals, respectively. Verified invoices will then be submitted to the Provincial RBF
Steering Committee for further verification and approval for payment.
31
The five districts currently on RBF in the five targeted provinces are Mwense, Mporokoso, Isoka, Mufumbwe,
and Senanga. The current RBF Model will be maintained in these districts from August to December 2014.
54
31. Once verification and purchasing are completed, money will be disbursed directly from the
MOH headquarters to the bank accounts of the health centers and district hospitals. All the health
facilities (health centers and hospitals) will be expected to use a maximum of 50% of the money
for staff motivation bonuses while at least 50% of the money will be used for recurrent
operational activities (maintenance and repair, drugs and consumables, outreach and other
quality enhancement measures, cleaning materials, stationery; transport, recruitment of retired
nurses and midwives on contract, etc.).
32. To enhance health systems performance at district management level, DMOs will be paid
based on results against a graded performance management framework. The performance
management framework will measure the DMO’s performance against: (i) undertaking quality
assessments, (ii) development and application of standard protocols, guidelines and quality
checklists, (iii) supervision and on-site mentorship, (iv) functioning of the referral system, (v)
maintenance of equipment, (vii) human resource management and optimal distribution, and (vi)
implementation of medical waste management guidelines. Provincial RBF Steering Committees
will recommend the amounts to be paid to each DMO on a quarterly basis according to the level
of achievement.
33. The Project Implementation Manual will provide a detailed description on the operational
modalities and reporting arrangements, including the performance assessment framework,
quality checklist, indicators on quantity and quality that will be used to trigger payments, internal
and external verification, and sanction process.
Sub-component 2.2 Introduce results based approaches at community level (US$2 million
IDA; US$2 million HRITF)
34. This is premised on the theory that demand exists for MNCH and nutrition at community
levels but the situation requires integrated support across the building blocks of the health
system. Also, given the Zambian country context, communities play an essential role in
demanding and delivering quality services. Trained CHWs and other health cadres at the
community level can play a great role in stimulating community level demand, and delivering
basic services. This sub-component will, therefore, introduce the results-based approach at the
community level aimed at improving the referral system by strengthening the linkage of the
communities to health facilities, boosting service delivery at community level, increasing
accountability of CHWs, and strengthening the role of Community-Based Organization in
monitoring and evaluation of MNCH services. This will be achieved by revitalizing and
strengthening the roles of community-based organizations32
in: (i) Early registration of women of
reproductive; (ii) Provision of a complete antenatal care and delivery package (e.g. iron tablets
supplementation, malaria IPT, distribution of bed nets, assisted deliveries, referrals etc.); (iii)
Counseling of women of reproductive age, follow up home visits, and provision of commodities
(e.g. nutrition and family planning); (iv) Conducting outreach activities to improve management
of childhood illnesses at household level; (v) Mobilization of community members for growth
monitoring, immunization of children, and nutrition education, and (vi) Submission of timely
32
Examples are Safe Motherhood Action Groups (SMAGs), Neighborhood Health Committees (NHCs), Health
Center Committees (HCCs), Community Welfare Assistance Schemes (CWACs) etc.
55
and quality data and reports on pre-agreed MNCH and nutrition indicators. The community level
RBF will also align the RBF with the national decentralization process, and other health service
purchasing arrangements in Zambia, particularly the Social Protection Programme, and the
proposed National Social Health Insurance scheme.
35. To be able to achieve the above, health centers will enter into performance contracts with
community-based organizations to deliver a defined package of community level MNCH and
nutrition services, and to conduct monitoring and evaluation activities. Health Centers will carry
out supervision in communities implementing RBF with the assistance of DMOs. Results will be
counter verified on an annual basis through independent organizations. The community approach
will be implemented in a phased manner in order to strengthen the design and learn lessons with
a potential for scaling-up. A pre-pilot will be implemented in one district to design the approach,
with an additional grant from HRITF. The first phase of implementation of the community RBF
pilot will be overlaid in the existing facility intervention districts
36. To support learning and inform the planned introduction of social health insurance, with an
additional World Bank-executed US$1.5 million HRITF grant, a three arm Impact Evaluation
testing three different approaches: (i) vouchers, (ii) conditional cash transfers linked to the
current social cash transfer program, and (iii) social health insurance will be piloted in nine
districts from January 2015.To allow proper design of the pilot and ensure it is rooted within the
Zambian context, a pre-pilot will be implemented in one district, with an additional recipient
executed US$0.45 million HRITF grant. Lessons from the community level impact evaluation
will be used to guide future expansions. The PIM will provide a detailed description of the
operational modalities and reporting arrangements.
Component 3: Strengthening project management and policy analysis (US$12.5 million
IDA; US$3 million HRITF)
37. The objectives of this Component are to strengthen project management, implementation,
monitoring and evaluation; provide technical assistance for evidence-based policy analysis and
health financing innovations, and appoint an independent verification agent to verify the Project
results
Sub-component 3.1: Project management and implementation, monitoring and evaluation
(US$6.5 million IDA).
38. This sub-component will strengthen project implementation capacity of MOH and
MCDMCH with particular attention to the Province and District levels. Support will include: (i)
addressing technical gaps and building capacity for the day-to-day administration of project
activities (monitoring resource use, procurement processing activities, administering withdrawal
and disbursement procedures, consolidating the financial management aspects of project
implementation, project reporting; as well as coordinating all relevant sector ministries,
Government departments, health professional training institutions and associations, civil society
organizations and the private sector); and (ii) strengthening the HMIS, roll out and integration of
community level MNCH and nutrition information into DHIS-2. This sub-component will
support: (a) Development and implementation of the community health and nutrition information
system and its integration into the District Health Information System Version 2 (DHIS-2); (b)
56
roll-out of the DHIS-2 through the provision of material (revision of HMIS tools, provision of
ICT equipment to health facilities and districts); and (c) capacity building in data management,
analysis, and use for decision making for improved service delivery at the various levels. This
will require training of trainers, service providers, and data management specialists; and support
to data audit exercises.
Sub-component 3.2: Support evidence-based policy analysis and health financing innovations
(US$4 million IDA)
39. This sub-component will support GRZ's efforts to produce evidence-based analytical studies
in health and nutrition, including health financing, planning and budgeting, human resources for
health, and drugs and medical supplies. The actual studies to be conducted will be decided by the
Zambian Government annually. The overall focus of these studies will be to determine the
performance of the health system in light of the intermediate performance measures such as
access, efficiency, equity, and quality, and to propose remedial actions towards the attainment of
the health systems goals (health status, citizen satisfaction, and financial protection). The
evidence and recommendations will be used to inform the development of policies, medium and
long term strategic plans, and annual plans and budgets. Secondly, training and technical support
will be provided to mid-level health managers aimed at enhancing their analytical and
operational knowledge in health financing, planning and budgeting. This will be achieved
through a combination of approaches including peer-to-peer learning through existing Technical
Working Groups, international discussion through face-to-face, video, web, and audio seminars;
and through short-term courses.
Sub-component 3.3: Institute independent verification arrangements (US$2 million IDA;
US$3 million HRITF.
40. For results-based financing as well as disbursement linked indicators, payments are made
based on an independent verification that the agreed-upon results have been attained. The
verification process has to ensure the accuracy and consistency of reporting on qualitative and
quantitative performance indicators before funding is released. This sub-component will support
the design, setting up of the verification mechanism for all results-based activities under the
Project as well as costs to be incurred by the selected independent verification entity in carrying
out this responsibility. Baseline, midline and endline surveys for the Project will also be financed
out of this sub-component.
57
Annex 3: Implementation Arrangements
A. Project Administration Mechanisms
1. The Project will be implemented by two ministries - the Ministry of Health (MOH), and the
Ministry of Community Development Mother and Child Health (MCDMCH). Within the
components and sub-components of the Project, each Ministry will be given the responsibility of
executing specified activities in line with the gazetted portfolio functions of each Ministry. The
Permanent Secretaries from the two ministries will both be responsible for the execution and
effective performance of the Project activities assigned to their Ministries including the budget.
In line with the Public Finance Act No. 15 of 2004, the two Permanent Secretaries will be the
“controlling officers” for the Project. As Controlling Officers, the Permanent Secretaries will be
the chief accounting officers in respect of all the monies received or disbursed, and all the goods
and services received under the Project. This implies that they will ensure that project resources
are used for the intended purposes and accounted for.
2. While the direct supervision of all Directorates and officials under the respective Ministries
will lie with the Permanent Secretaries, the overall coordination of the Project will be the
responsibility of the Directorates of Policy and Planning in the two Ministries. Each Ministry
will designate its Director of Planning to provide overall coordination during the implementation
process. Actual implementation of project activities will be the responsibility of a number of
designated Directorates and Units from the two Ministries. In light of this, all designated heads
of Directorates and Units will be responsible for project implementation. Each Directorate or
Unit may appoint focal point persons to manage specific activities in line with its mandate. See
the overall project administration arrangements in Figure A.5 below.
3. To effectively coordinate the various activities under the Project, a Joint Management Team
(JMT) will be established and will be co-chaired by the Permanent Secretaries of the MOH and
the MCDMCH. Membership to the JMT will comprise Directors from the two ministries. The
JMT will meet monthly at a predetermined date and time. The role of the JMT will be to oversee
the implementation of the Project by the two Ministries which will present and discuss data and
information related to activity level, review existing annual plans, identify challenges or
difficulties in implementing project responsibilities, follow up on previous decisions, and resolve
any issues as they arise. Given that the DLI approach is being introduced under this project, the
JMT will follow the DLI performances with the intention to identify early and then mitigate any
problems, and will participate in joint supervision missions.
4. The JMT will be organized under the Zambia Health SWAp which has been in existence
since 1993, and of which the World Bank is one of the founding and key members. The Zambia
Health SWAp is consistent with the principles of the Paris Declaration on Aid Effectiveness
(2005), the International Health Partnerships (IHP+), Accra Agenda for Action (2008), and the
2011 Bussan Partnership Agreement. Having re-affirmed its commitment to the Zambia Health
SWAp by signing the 2013 Memorandum of Understanding (MoU), the World Bank will ensure
that project implementation is consistent with the MoU. This includes the use of government
systems for making financial disbursements, accounting, procurement, implementation, and
reporting. Further, it will be the responsibility of the JMT to provide periodic reports to the
58
Senior Management of the MOH and MCDMCH as well as the MNCH and Nutrition Inter-
Agency Coordinating Committee (NICC). This arrangement will ensure coordination and
harmonization of policy proposals and decisions which affect the implementation of the Project
specifically and the health sector generally.
Figure A.5: Project Implementation mechanisms
5. The table A.4 below provides additional details on how each Component and Sub-component
will be implemented:
59
Table A.4: Detailed Distribution of project components by implementing agencies Project components and sub-components Targeted Province Responsible
Ministry (or
Entity)
Implementing
Directorate
Component 1: Strengthening capacity for primary and community level MNCH and nutrition services Sub-component 1.1: Enhance training capacity
and standards for nursing and midwifery
Western, North-
Western, Luapula,
Northern,
Muchinga
MOH, Nursing
& Midwifery
Schools, GNC,
MCDMCH
Directorates of Human
Resources &
Administration
Sub-component 1.2: Improve supply chain
systems and availability of essential commodities
Western, North-
Western, Luapula,
Northern,
Muchinga
MOH, MSL Directorate of Clinical
Care & Diagnostic
Services
Sub-component 1.3: Improve referral system and
linkages across levels of care
Western, North-
Western, Luapula,
Northern,
Muchinga
MCDMCH Directorate of Mother &
Child Health; Department
of Community
Development;
Department of Social
Welfare
Component 2: Strengthening utilization of primary and community level MNCH and nutrition services
through results based financing approaches Sub-component 2.1 Expand results based
financing at primary facility level
Western, North-
Western, Luapula,
Northern,
Muchinga
MOH Directorate of Policy &
Planning; Directorate of
Disease Control,
Surveillance & Research;
Directorate of Technical
Support Services
MCDMCH Directorate of Planning;
Directorate of Mother &
Child Health; Department
of Community
Development;
Department of Social
Welfare
Sub-component 2.2 Introduce results based
approaches at community level Western, North-
Western, Luapula,
Northern,
Muchinga
MOH Directorate of Policy &
Planning; Directorate of
Disease Control,
Surveillance & Research;
Directorate of Technical
Support Services
MCDMCH Directorate of Planning;
Directorate of Mother &
Child Health; Department
of Community
Development;
Department of Social
Welfare
Component 3: Strengthening project management and policy analysis
Sub-component 3.1: Project management and
implementation, monitoring and evaluation
Nation-wide MOH Directorate of Policy &
Planning
MCDMCH Directorate of Planning
Sub-component 3.2: Support evidence-based
policy analysis and health financing innovations
Nation-wide MOH Directorate of Policy &
Planning
MCDMCH Directorate of Planning
60
Project components and sub-components Targeted Province Responsible
Ministry (or
Entity)
Implementing
Directorate
Sub-component 3.3: Institute independent
verification arrangements 33
MOH Directorate of Policy &
Planning; Directorate of
Disease Control,
Surveillance & Research;
Directorate of Technical
Support Services
MCDMCH Directorate of Planning;
Directorate of Mother &
Child Health; Department
of Community
Development;
Department of Social
Welfare
B. Financial Management Assessment
6. The World Bank Financial Management (FM) team conducted FM assessments of MOH and
MCDMCH which will be implementing the Project. The objective of the FM assessments was to
determine whether the FM arrangements: (i) are capable of correctly and completely recording
all transactions and balances relating to the Project; (ii) will facilitate the preparation of regular,
accurate, reliable and timely financial statements; (iii) will safeguard the Project entity assets;
and (iv) will be subjected to auditing arrangements acceptable to the World Bank. The
assessment complied with the Financial Management Manual for the World Bank-Financed
Investment Operations that became effective on March 1, 2010, as well as with AFTFM
Financial Management Assessment and Risk Rating Principles.
7. The main MOH capacity constraints are that the Project module of IFMIS is not functioning,
the audit unit concentrates on pre-audits instead of carrying out risk-based auditing, has weak
control environment and lacks or fails to make follow-up on outstanding audit queries. In the
case of MCDMCH, the capacity constraints include inadequately qualified staff with little or no
Bank experience, the IFMIS is not connected, there are no qualified staffs in the audit unit, audit
committee not functional, weak internal control environment and lack of follow-up of audit
queries. At the national level, the following constraints were identified: inadequate supervision
by GRZ controlling officers; poor accountability culture and inadequately funded watchdogs;
internal audit unit lacks adequate resources to carry out their work effectively; and weak audit
committee to follow up the recommendations of both internal and external audit reports. As a
result of the FM capacity constraints, the Project will require from the MOH: (i) agreement on
the format, content, and timing of the Interim Financial Report for the Project with the Bank, and
(ii) agreement on the audit terms of reference. In the case of MCDMCH: (i) training of
accountants in World Bank FM and disbursement procedures, (ii) the internal audit function to
be strengthened through training including risk-based internal auditing, (iii) functionalization of
the audit committee, and (iv) a FM section in the PIM.
33
Selection of the independent verification agent will be coordinated by MOH, MCDMCH, MSL, and GNC, guided
by pre-determined Terms of References
61
8. The conclusion of the assessment is that the FM arrangements in place meet the World
Bank’s minimum requirements under OP/BP10.00, and therefore are adequate to provide, with
reasonable assurance, accurate and timely information on the status of the Project required by the
World Bank. The overall FM residual risk rating of the Project is Substantial for both MOH and
MCDMCH. FM supervision will be conducted based on the risk rating of each entity. Two on-
site supervisions per year will be carried out for MOH and quarterly on-site supervisions for
MCDMCH until capacity is built. Other forms of supervision will include desks reviews of IFRs
and audit reports.
Table A.5: Financial management action plan
Action Date due by Responsible
1 Agree on Interim Financial Report format
with the Word Bank
Agreed at negotiations MOH,
MCDMCH and
World Bank
2. Agree on audit Terms of Reference with
the World Bank
Agreed at negotiations MOH,
MCDMCH and
World Bank
3 Finalize with World Bank the FM
Chapter of the Project Implementation
Manual)
By effectiveness MOH,
MCDMCH
4 Train Accountants and planning officers
in World Bank Financial Management and
Disbursement Procedures
During project implementation MOH,
MCDMCH
5 MCDMCH internal audit function to be
strengthened through training in order to
effectively follow up internal and external
audit issues to ensure they are resolved.
During project implementation MCDMCH
6 Make MCDMCH audit committee
functional
December 30, 2014 MCDMCH
7 Provide training in risk-based internal
auditing to strengthen the internal audit
function.
During project implementation Ministry of
Finance
Financial Management
9. Budgeting arrangements: The budget preparation and monitoring will follow national
procedures. Both ministries will prepare Annual Work Plans (AWPs), which will be the basis
for budget preparation. GRZ’s current budget preparation process will be followed. The activity
budgets will be prepared by MOH and MCDMCH using existing national budget classifications
of programs and subprograms linked to the IFMIS Chart of Accounts, with the Ministry's Project
activities separately identified. The approval process will follow GRZ procedures and will be
expanded in the Project Financial Procedures Manuals (chapters in the PIM). Capacity within
MCDMCH to monitor project budgets in compliance with World Bank FM procedures is weak,
and therefore Project staff will receive training from the World Bank Financial Management
Specialist to strengthen their skills.
62
10. Accounting arrangements: (i) Staffing: MOH has two dedicated accountants within the
accounting department who are responsible for donor funding. The staffing arrangements are
adequate, and the Bank will train these accounting staff in World Bank Financial Management
and Disbursement Procedures, including the DLI procedures, before as part of negotiation. (ii)
Financial management manuals: MCDMCH will develop a project FM Procedures Manual as
part of the PIM that will document the accounting policies and procedures to be used for the
Project, and a substantially acceptable draft shall be ready before negotiation. MOH accounting
procedures are spelled out in the organization’s policies and procedures, which were approved by
the Board in May 2012. (iii) Information systems: Both MOH and MCDMCH will use
Government’s IFMIS to prepare Project accounts. (iv) Accounting basis: Both MOH and
MCDMCH will use cash basis accounting, in line with International Public Sector Accounting
Standards.
11. Internal control and internal auditing arrangements: (i) Internal auditing: MOH is
serviced by the Internal Audit Unit with positions filled up to provincial level only. Positions at
district level have not been filled as all the districts have been transferred to MCDMCH.
However, internal audit work is concentrated on pre-auditing payment transactions. The internal
auditing function is weak and will need to be strengthened through training of the Internal Audit
Unit and the Audit Committee to give them the capacity to follow up and resolve both internal
and external auditing issues. The training should be completed within six months after
effectiveness. Although MCDMCH has an internal audit unit; it is understaffed with three staff
only. The audit committee is also dormant. Therefore, both the internal audit unit and the audit
committee will need strengthening through staffing, training. (ii) Internal control systems: MOH
will process transactions using the rules and regulations specified under the existing Finance Act
2004 and Financial Regulations 2006. While the current accounting regulations are adequate to
assure a strong control environment, risks identified include lack of compliance and
enforcement; and to mitigate these risks, the FM procedure manual will have to be revised to
strengthen control measures. Although MCDMCH has adequate staffing, there are only two
qualified accountants (Principal Accountant and Accountant) with little World Bank project
accounting experience, therefore, mitigate these risks and ensure compliance with World Bank
procedures, a financial management procedures module acceptable to the World Bank will be
produced as part of the Project Implementation Manual to provide guidance to staff. The module
will document policies and procedures that are specific to the Project and will identify
expenditures that are ineligible for financing under the Project.
63
Funds flow, disbursement and reporting arrangements
12. Funds flow: Both MOH and MCDMCH will use a system under which funds will flow from
the World Bank to a Designated Account (DA) or a Holding Account, denominated in United
States Dollars at the BOZ, to be operated by the Project. The flow of funds is depicted below. At
the time of project execution, both ministries on behalf of the Project will transfer funds from the
DA through Control 99 (treasury account) to their respective ministerial Control Accounts held
at BOZ. The funding slips are then issued to the ministries showing the Kwacha equivalent that
has been transferred. Once funds are transferred to the ministerial control accounts, the funds
will then be transferred to the Project’s sub-accounts held at BOZ. From the sub-accounts, all
payments would be made through the mirror accounts (zero balance) held at a commercial bank.
All the bank accounts that will be involved in the flow of funds will be reconciled on a monthly
basis, and all non-reconciled items will be dealt with expeditiously.
Figure A.6: Flow of funds
World Bank
Bank of Zambia
MOH MCDMCH DA in USD DA in USD
Bank of Zambia Treasury Control 99 Account in ZMW
Bank of Zambia Bank of Zambia MOH sub control a/c in ZMW MCDMCH sub control a/c in ZMW
Bank of Zambia Bank of Zambia MOH project operational a/c MCDMCH project operational a/c
Commercial Bank Commercial Bank
MOH sub control mirror a/c in ZMW MCDMCH sub control mirror a/c in
ZMW
ZMW denominated payments ZMW denominated payments to various suppliers to various suppliers
13. Disbursement arrangements: Both MOH and MCDMCH will use two disbursement
methods: (i) Disbursement Linked Indicators (DLIs) under Component 1 and (ii) the transaction-
based method of disbursements (Statements of Expenditure – SOEs) under Component 2 and 3.
Other methods of disbursing to the Project will include reimbursements, direct payment, and use
of special commitments (e.g., letters of credit). Further disbursement details will be provided in
the disbursement letter. The possibility of retroactive financing disbursements will be considered
for project activities as long as the appropriate World Bank procurement and financial processes
and documentation are adhered to.
64
14. Disbursement linked indicators method under Component 1: In the first year, both MOH
and MCDMCH will receive DLI-zero grants as reflected in the DLI Matrices (Annex 2). At the
end of each year (year 2-5), both MOH and MCDMCH will prepare a report justifying the
correspondence value of each DLI as agreed with the Bank in the DLI matrices. This report will
be supported by a financial report on the Eligible Expenditure Programs (EEPs) from the
Ministry of Finance based on the Audited Financial Statement. The EEPs will be agreed with
both Ministries during negotiation. This financial report will be audited (audited financial
statements take up to 9 months to conclude). The JMT through an Independent Verifier will
verify the legitimacy of the report and whether the targets have been met by comparing the report
to actual results on the ground. Payments of DLIs will be in proportion to the targets met, and
the unutilized funds will be carried forward.
15. Financial reporting arrangements: Both MOH and MCDMCH will submit quarterly IFRs,
in a format agreed with the World Bank, within 45 days of the end of each calendar quarter
reported on. These quarterly reports will include: (i) statement of sources and uses of funds, and
(ii) detailed statement of uses of funds by project activity/component. All implementing entities
will prepare annual accounts within three months after the end of the financial year in
accordance with accounting standards acceptable to the World Bank. All implementing entities
will be responsible for ensuring their reports are audited and submitted to the World Bank within
six months after the end of the financial year.
16. Auditing arrangements: The Project audits will be audited by the Office of the Auditor
General (OAG), who is the Supreme Audit Institution in Zambia, who may contract acceptable
private audit firms to the World Bank to conduct the Project audits on their behalf. All audits
should be carried out in accordance with International Standards on Auditing. All Terms of
Reference for audits of the implementing entities should be agreed by negotiations. Audit
reports together with management letters should be submitted to the World Bank within six
months after effectiveness. Audit reports will be publically disclosed by the World Bank in
accordance with the World Bank disclosure policy.
C. Procurement Risk Assessment
17. Procurement risk assessments of MOH and MCDMCH were separately conducted in
September 2013 using the Bank’s Procurement Risk Assessment Management System (P-
RAMS) and the risks were found to be Substantial in both cases. Mitigation measures have been
identified and when implemented, could reduce the overall risk to Moderate.
18. Major risks identified as substantial include: (i) lack of accountability for procurement
decisions; (ii) staff with limited experience to carry out procurements under World Bank
procedures using competitive methods, (iii) inadequate bidder’s complaints mechanism, (iv)
absence/inadequate due diligence check on bidders; and (v) inadequate contract management
arrangements. Based on the Procurement Risk Assessment, the main risks and risk mitigation
measures are provided in the table below.
65
Table A.6: Summary assessment of procurement capacity, risks and mitigation measures
(a) MOH Issues Risks Mitigation Measures Date Due by
Accountability
for
procurement
decisions
Inadequate linkage between
technical and procurement staff
leading to inefficient
procurement system.
Procurement chapter of the
PIM which detail roles and
responsibilities of all players
in the procurement system
By effectiveness
Staffing Although staff levels are
adequate, there is lack of
mentorship and on the job
capacity building, lack of
assignment of staff to specific
procurements
Agree on, and implement a
training (Internal and
External) and mentorship
program based on identified
gaps and MOH needs
During project
implementation
Review of
Procurement
Decisions and
Resolution of
Complaints
No effective Bidder complaints
mechanism - could erode
bidders’ confidence and reduce
participation
Complaints handling
mechanism included in the
procurement manual and
publicized
By effectiveness
Evaluation and
Award of
Contract
Due diligence is not routinely
conducted on the winning bidder
to ensure that it a legitimate,
reputable, technically capable
company
Routinely carry out due
diligence on the winning
bidder to ensure that it is
legitimate, reputable,
technically capable
Immediate
(b) MCDMCH Issues Risks Mitigation Measures Date Due by
Accountability
for Procurement
Decisions
Relatively low experience and
capacity in implementing Bank
financed projects; No manual
in place outlining new
Institutional arrangements,
accountabilities and internal
governance
Develop a Procurement
chapter of the PIM to detail
roles and responsibilities of
all the players in the
procurement system
including internal governance
structures
By effectiveness
Staffing Inadequate staff with
inadequate experience in Bank
financed operations;
recruitment freeze – No
procurement experience in
competitive high value and
complex procurements
Increase key procurement
staff (consultant options) and
an aggressive training and
mentorship program
During project
implementation
Review of
Procurement
Decisions and
Resolution of
Complaints
No effective complaints
mechanism - could erode
bidder confidence and reduce
participation
Include complaints handling
mechanism in the
procurement manual and
widely disseminate
By effectiveness
Evaluation and
Award of
contract
Due diligence is not routinely
conducted on the winning
bidder to ensure that it a
legitimate, reputable,
technically capable company
Routinely carry out due
diligence on the winning
bidder to ensure that it is
legitimate, reputable,
technically capable
Immediate and throughout
the life of the Project
66
Issues Risks Mitigation Measures Date Due by
Contract
Management
and
Administration
Absence/inadequate procedures
to monitor deliverables –
quantity, quality, timeliness
and inventory control
Include in the Manual
receipt, inspection and
monitoring procedure to
ensure compliance with the
contract provisions
Immediately and
throughout the life of the
Project
19. Procurement manual (chapter of the PIM): Procurement arrangements will be both those
which are standard World Bank lending for goods and services and GRZ procurement systems
for the DLI approach. Appropriate clarity of accountability over procurement, record keeping,
and frequency and scope of prior and post review will be elaborated in the PIM procurement
module and in the procurement plans. The procurement modules will be prepared, reviewed
during negotiations and finalized within three (3) months of project effectiveness, to be ready for
project implementation. Other than for Component 1 which will disburse against Eligible
Expenditures drawn from annual GRZ audited statements, the procurement modules will address
the needs of the various implementation entities at national level MOH, MCDMCH, MSL), as
well as the needs and procedures for procurement at decentralized levels (Districts, Training
Institutions and Community levels). The procurement modules will outline the identified risks
and provide risk mitigation actions. It will cover the legal and regulatory framework, roles and
responsibilities of the institutions (including that of the Coordinating Committee) and staff
involved in procurement, internal and external controls (including but not limited to complaints
mechanism, due diligence checks) and quality assurance checks or systems, approval systems
and accountability, and contracts registration. It will spell out the roles and responsibilities of
various players in contract management, based on both Government regulations and as required
for prior review of IDA contracts.
20. Procurement decentralization: Since January 1, 2013, all procuring entities are carrying out
procurement in a decentralized environment. This means that the Zambia Public Procurement
Agency (ZPPA) is no longer involved in reviewing bidding documents and bid evaluation and
contract award recommendations except those procured under direct contracting (Goods and
Works) and Single Sourcing for consulting assignments. All procurement activities are being
carried out internally by the procuring entities using their own institutional arrangements,
controls and quality checks, without ZPPA participation. ZPPA is in the process of transforming
itself into a regulatory and oversight body for public procurement in Zambia.
21. Procurement Post Reviews (PPRs) and Independent Post Reviews (IPRs) by the World
Bank. Based on the assessed agency implementation risk for procurement, which is substantial,
the World Bank will carry out PPRs or IPRs for all contracts that will be based on the
procurement plan not having been subject of prior review by the World Bank using a sample of
15 percent. Based on continuing assessment of risk and the success of risk mitigation measures
implemented, the sample size will be reduced as risk mitigation measures are successfully
implemented. Moderate risk represents 10 percent and Low risk 5 percent. These changes will be
communicated to the respective Ministries as outcomes of the PPR / IPR exercise, which also
could result in the revisions of the prior review and National Competitive Bidding thresholds as
applicable. The review thresholds are shown in Table A.7 below.
67
Table A.7: Prior review and procurement method thresholds – Zambia
Expenditure
Category Procurement Method
Contract Value Threshold For
use of Method (US$)
Contracts Subject to
Prior Review (US$)
1. Works
ICB(Works/Supply & Installation) ≥ 10,000,000 All contracts
NCB ≥ 200,000 - <10,000,000 As in procurement plan
Shopping <200,000 None
Direct Contracting All values All contracts
Community Participation
Procedures
All values As in Procurement Plan
2. Goods ICB ≥ 2,000,000 All contracts
NCB ≥ 200,000 - <2,000,000 As in procurement plan
Shopping <200,000 (motor vehicles only) None
Shopping <100,000 (rest not motor vehicles) None
Direct Contracting All values All contracts
Procurement from UN Agencies All values None
Community Participation
Procedures
All values As in Procurement Plan
3. Consulting
Firms
QCBS, QBS
≥ 200,000
≥ 300,000 (Engineering &
Contract Management only)
All contracts
CQS, LCS, QBS, FBS <200,000 As in procurement plan
SSS All values All Contracts
4. Individual
Consultants
(IC)
Competitive selection
IC Single Source Selection
≥ 100,000
<100,000
All values
All contracts
? None?
All contracts
NOTE: Contracts selected on basis of CQS should not exceed US$200,000 equivalent. This same value will constitute the limit up
to which a short list may comprise entirely national firms.
22. Applicable legal and regulatory framework for National Competitive Bidding: The
procurement procedure to be followed for National Competitive Bidding (“NCB”) shall be the
open bidding procedure set forth in the Public Procurement Act, 2008, Act. No.12 of 2008, as
amended by the Public Procurement (Amendment) Act, 2011, Act No. 15 of 2011 (the “PPA”),
and the Public Procurement Regulations, 2011, Statutory Instrument No. 63 of 2011 (the
“Regulations”); provided, however, that such procedure shall be subject to the provisions of
Section I and Paragraphs 3.3 and 3.4 of Section III, and Appendix 1 of the “Guidelines for
Procurement of Goods, Works, and Non-Consulting Services under IBRD Loans and IDA
Credits & Grants by World Bank Borrowers” (January 2011) (the “Procurement Guidelines”),
and the additional provisions in the following paragraphs:
a) Eligibility: Eligibility to participate in a procurement process and to be awarded an IDA-
financed contract shall be as defined under Section I of the Procurement Guidelines; accordingly,
no bidder or potential bidder shall be declared ineligible for contracts financed by IDA for
reasons other than those provided in Section I of the Procurement Guidelines. No restriction
based on nationality of bidders and/or origin of goods shall apply, and foreign bidders shall be
allowed to participate in NCB without application of restrictive conditions, such as, but not
limited to, mandatory partnering or subcontracting with national entities.
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b) Domestic preference: No margins of preference of any sort shall be applied in the bid
evaluation.
c) Bidding documents: Procuring entities shall use bidding documents acceptable to IDA.
d) Bid validity: An extension of bid validity, if justified by exceptional circumstances, may
be requested in accordance with Appendix 1 of the Procurement Guidelines. A corresponding
extension of any bid guarantee shall be required in all cases of extension of bid validity. A bidder
may refuse a request for extension of bid validity without forfeiting its bid guarantee.
e) Qualification: Qualification criteria shall be clearly specified in the bidding documents.
All criteria so specified, and only such specified criteria, shall be used to determine whether a
bidder is qualified. Qualification shall be assessed on a “pass or fail” basis, and merit points shall
not be used. Such assessment shall be based entirely upon the bidder’s or prospective bidder’s
capability and resources to effectively perform the contract, taking into account objective and
measurable factors, including: (i) relevant general and specific experience, and satisfactory past
performance and successful completion of similar contracts over a given period; (ii) financial
position; and where relevant (ii) capability of construction and/or manufacturing facilities.
Prequalification procedures and documents acceptable to IDA shall be used for large, complex
and/or specialized works. Verification of the information upon which a bidder was prequalified,
including current commitments, shall be carried out at the time of contract award, along with the
bidder’s capability with respect to personnel and equipment. Where pre-qualification is not used,
the qualification of the bidder who is recommended for award of contract shall be assessed by
post-qualification, applying the qualification criteria stated in the bidding documents.
f) Bid evaluation: All bid evaluation criteria other than price shall be quantifiable in
monetary terms. Merit points shall not be used, and no minimum point or percentage value shall
be assigned to the evaluation criteria or significance of price in bid evaluation. No negotiations
shall be permitted.
g) Guarantees: Guarantees shall be in the format, shall have the period of validity and shall
be submitted when and as specified in the bidding documents.
h) Cost estimates: Detailed cost estimates shall be confidential and shall not be disclosed to
prospective bidders. No bids shall be rejected on the basis of comparison with the cost estimates
without IDA’s prior written concurrence.
i) Rejection of bids and re-bidding: No bid shall be rejected solely because it falls outside
of a predetermined price range or exceeds the estimated cost. All bids (or the sole bid if only one
bid is received) shall not be rejected, the procurement process shall not be cancelled, and new
bids shall not be solicited without IDA’s prior written concurrence.
j) Fraud and corruption: In accordance with the Procurement Guidelines, each bidding
document and contract shall include provisions stating IDA’s policy to sanction firms or
individuals found to have engaged in fraud and corruption as set forth in the Procurement
Guidelines.
k) Inspection and audit rights: In accordance with the Procurement Guidelines, each bidding
document and contract shall include provisions stating IDA’s policy with respect to inspection
and audit of accounts, records and other documents relating to the submission of bids and
contract performance.
69
23. Procurement plan: A draft Project Procurement Plan for the first 18 months was presented
at negotiations and agreed to be finalized before Board submission. The plan will be updated as
required at least once a year throughout the life of the Project or as required to reflect project
implementation needs and improvements in institutional capacity. Given the different facets of
the procurement for the Project, the Bank will provide intensive implementation support during
missions, annual reviews, including annual post-procurement reviews.
Procurement arrangements
24. Goods, Non-Consulting Services and Works: Particular methods of procurement of goods,
non-consulting services and works (other than for Component 1) are as follows: (a) International
Competitive Bidding: Except as otherwise provided in the next paragraph, goods and works shall
be procured under contracts awarded on the basis of International Competitive Bidding (ICB);
(b) Other methods of procurement of goods and works. The following list specifies the methods
of procurement, other than International Competitive Bidding, which may be used for goods and
works. The Procurement Plan shall specify the circumstances under which such methods may be
used. (i) National Competitive Bidding, (ii) Shopping, (iii) UN Agencies, (iv) Community
Participation, and (v) Direct Contracting.
25. Schedule for goods and works: Procurement of works: The Project will not finance civil
works. Under Components 2 and 3 only rehabilitation and fixtures to expand, inter alia health
waste management, mother waiting homes, or health supply storage capacity. It is unlikely there
will be any International Competitive Bidding (ICB) under works and National Competitive
Bidding (NCB) will follow Zambia Procurement Regulations and with the exceptions listed
above, may be used for contracts estimated to cost less than US$10,000,000 equivalent per
contract. Small value works estimated to cost less than US$200,000 per contract may be
procured under the shopping procedures based on comparing price quotations obtained from
several contractors, with a minimum of three, to assure competitive prices.
26. Procurement of goods and non-consulting services: Goods to be procured under the Project
are likely to include: drugs, nutrition and medical supplies; vehicles, IT equipment, office
equipment, teaching and laboratory equipment, office furniture, among others. The procurement
will be done using the World Bank’s Standard Bidding Documents for all International
Competitive Bidding contracts. National Competitive Bidding (NCB) documents, in accordance
with the Zambia Procurement Regulations and with the exceptions listed above, may be used for
contracts estimated to cost less than US$2,000,000 equivalent per contract. Small value goods
estimated to cost less than US$200,000 for motor vehicles and US$100,000 for the rest of the
goods per contract may be procured under the Shopping procedures based on comparing price
quotations obtained from several suppliers, with a minimum of three, to assure competitive
prices, and is an appropriate method for procuring readily available off-the-shelf goods.
27. Consulting services: Particular methods of procurement for consulting services are: (a)
Quality and Cost-Based Selection (QCBS). Except as otherwise provided in the paragraph below,
consultants services shall be procured under contracts awarded on the basis of Quality and Cost-
Based Selection. (b) Other methods of procurement of consultants’ services. The following list
specifies selection methods, other than Quality and Cost-Based Selection, which may be used for
70
consultant services. The Procurement Plan shall specify the circumstances under which such
methods may be used: (i) Quality-based Selection (QBS), (ii) Selection based on the
Consultant’s qualifications (CQS), (iii) Least-cost selection (LCS), and (iv) Single-source
selection (SSS) for firms and Individual Consultants (IC). Specific consulting services will be
identified at the time of appraisal.
28. Schedule for Consulting Services: The Project will finance technical assistance towards
strengthening project management, implementation, monitoring and evaluation and evidence-
based policy analysis and health financing innovation approaches. To undertake independent
verification of both RBF and Disbursement Linked Indicator Results, the Government will select
an independent verification agent to verify these results. Government Research / Training
Institution or University (outside the Ministry of Health and Community Development Mother
and Child Health) will be eligible to compete. The selection will be based on the quality of the
proposals and will utilize Quality Based Selection (QBS) procedures which allow firms and
institutions with different business objectives to compete.
D. Environmental and Social (including safeguards)
29. This is an environmental category B project. The Project will be implemented in rural and
peri-urban districts in five provinces: Luapula, Muchinga, Northern and North-Western and
Western. These provinces have been selected based on set criteria including: (i) poverty levels,
(ii) two key indicators-skilled birth attendance coverage and malnutrition prevalence, (iii)
complementarity with other cooperating partners supported initiatives, and (iv) implementation
capacity of districts. Project activities do not involve land acquisition for project activities. There
will be no land acquisition under this project, no losses of assets or restriction of access to
resources is anticipated. The MOH, MCDMCH and training institutions have acceptable proof of
ownership of the existing project activity sites and there are no disputes in this regard. Thus,
there are no involuntary resettlement issues associated with this project, and OP 4.12 is not to be
triggered.
Assessment of the implementation of the Health Care Waste Management Plan (HCWMP)
for the period of 2010-2014
30. The current HCWMP covers the period of 2010-2014. Many of the critical issues identified
in this assessment, remain the same as the ones identified at the time of the preparation of this
plan, such as inter alia: (i) inadequacies of the regulatory framework; (ii) poor health-care waste
practices; (iii) poor information systems on health care waste generation and disposal; (iv)
inadequate knowledge and practical skills of those involved in health care waste management;
(v) lack of appropriate equipment and technologies; (vi) lack of regional/centralized disposal
facilities in non-urban areas; (vii) low segregation of waste according to categories such as by
type, color of p\bags and bins and size.
31. In 2009, the General Auditor’s report on medical waste management in the health institutions
revealed serious weaknesses. In June 2013, a national assessment of the HCWM was carried out
to assess legislative, institutional and infrastructural challenges. The assessment was carried out
in Lusaka, Copperbelt, Southern, North-Western, Northern and Muchinga provinces. The
assessment took into consideration issues in generation, storage, transportation, final disposal,
knowledge gap for members of staff and expenditure for HCWM.
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32. Due to poor implementation performance, the MOH, on its own initiative, decided that a
review of the current HCWMP was deemed necessary and the plan is currently being reviewed.
The Bank commends GRZ for this initiative.
33. The findings and recommendations are presented below.
a) Legislative, regulatory and policy relating to sound management of HCW. Inadequacies
remain in the legal regulatory, policy and administrative framework of health care waste
management and treatment.
b) Health care waste management practices with regard to handling waste collection,
storage transportation and final disposal. The key to minimization and effective management of
health care waste is identification and segregation of the waste. Segregation of health care waste
is not consistent, and funding is a big issue. Absence of appropriate equipment such as bins, bin
liners, colored plastic bags and appropriate labeling, makes it difficult to adequately segregate
the waste. (Transportation and disposal is also an issue, in particular from peri-urban to central
sites). Segregating waste should be done according to the following categories: (i) infectious or
clinical waste (Hazardous waste), (ii) non-infectious or general waste; and (iii) sharp waste.
Recommendations: For effective segregation, handling and disposal the following practices
should be followed:
Segregation should be done as close to the point of generation as possible;
HCW receptacles shall be readily available at the point of generation, located away from
patient areas to avoid cross infections; should be safe; and should be monitored regularly
to ensure that the procedures are respected;
Receptacles of appropriate color, size and number should be used, to accommodate and
label the different waste types being generated ;
Staff involved in health care waste management must ensure that the waste bags are
properly labeled, sealed, and separated;
Loading and unloading of waste shall take place within the designated collection area ;
Separate schedules and separate collection times for different colour coded containers,
and separate vehicles should be used for different types of waste;
Transportation must be done only by accredited Waste Management Contractors;;
Health care waste must be transported directly to the disposal or treatment site within the
shortest possible time; treatment and disposal of HCW should focus in minimizing
negative impacts on health and on the environment;
Capacity building of health facility workers in health-care waste management at all
levels; and
Segregation system should be uniformly applied throughout the country and should be
maintained throughout the entire waste cycle up to disposal.
c) Providing support on equipment and appropriate technology for those handling waste. In
September 2012, a report on the status of macro burn incinerators (funded by various donors
such as the World Bank Project, WHO/UNICEF; VII health facilities in Zambia) was issued. The
situation is grime. Out of 45 incinerators, only 16 are in good working condition (36%), 4 are
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working but are not in good working condition (10%); 19 incinerators are not working (42%)
and 6 are not yet installed (12%). Some of the issues identified are: (i) lack of adherence to
current legislation; (ii) appropriate funding leading to poor maintenance of the incinerators
country wide; (iii) lack of health workers’ training and skills to identify and report problems
related to the operation and working conditions of the generators; and (iv) lack of evidence of
ownership of incinerators.
Recommendations:
Funding needs to be allocated to repair all the defective incinerators;
Maintenance of the generators should be performed and budgeted on a regular basis;
Preparation of a training program on key aspects of management of health care waste;
Budget line for the training of staff dealing with health-care waste; management;
Designation of a focal point staff to be in charge of the operation of the incinerators;
Budget e to re-train hospital workers handling health care waste in standard procedures;
Strengthen communication and awareness for better management;
Develop communication plans for health care waste management and support the
implementation of this plan;
Fencing and signage in areas where the incinerators are located; and
Adequate spill kit and protective gear such as gloves, overall, masks and boots must be
provided at the storage sites.
d) Improving the health care waste management information system within the context of
Health Management Information System (HMIS) and Strengthening its Monitoring and
Evaluation. There is no evidence that there is a health care waste system within the HMIS. For
most part, existing reports are inaccurate, non-reliable, and incomplete.
Recommendations:
Reliable health care waste information system should be created and integrated in the
HMIS, to enable the preparation of timely reports that will allow timely interventions;
Strengthen monitoring and coordination with an M&E position, and regular reporting;
Enhance public awareness in health care waste management
e) Promoting public private partnership (PPP) for better health care waste management.
As an innovative activity, the Project could promote a PPP with the private sector to improve
national health-care waste management practices and create a sustainable health-care waste
management system.
Recommendation:
Design and develop a PPP for testing the system at facilities in districts that are in close
proximity to Lusaka. The main idea is to develop and test a pilot program to collect, treat and
dispose of hazardous medical waste, by contracting services of a local service provider. The
minimum requirements for the contractor will be: (i) experience in providing transportation
services for a period of at least two years and conversant with handling of hazardous wastes; and
(ii) compliant with country norms and standards for operating transport fleet including required
licenses and certificates.
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E. Monitoring & Evaluation
34. The logical framework for the proposed project has been developed in a consultative manner
with Government, joint performance indicators agreed, and a detailed performance monitoring
plan is to be developed on the basis of the logical framework and the selected indicators. It will
be detailed with specific indicators before project effectiveness, and include monitoring and
evaluation plans for each level and structure, incorporating monitoring and evaluation across a
number of dimensions: (i) technical, (ii) operational, (iii) financial and procurement, and (iv)
learning. Monitoring and Evaluation systems will collect data broadly categorized into two
groups:
a) Operational data: This will be derived from the day-to-day project activities, including
project inputs, supervisory information and the outputs resulting from project's activities.
This category of information will focus on the process aspects of project implementation and
align those processes with the overall project development objectives. The information will
be collected by the M&E units in MOH and MCDMCH from the various health facilities,
training institutions and other implementing agencies such as Medical Stores Limited (MSL)
and the General Nursing Council (GNC).
b) Health data: These data relate to the outcomes on MNCH and nutrition. These data will
track the performance of strengthened MNCH and nutrition in project target areas.
35. The Project will support project M&E systems in the Directorate of Policy and Planning in
MOH and Directorate of Planning in MCDMCH. The M&E units in MOH and MCDMCH will
be the central clearing houses for this information. The units will synthesize the information to:
Provide easily accessible, timely information on the Project inputs, outputs and
outcomes so that project management can be more responsive and proactive.
Identify intra-country variations in MNCH and nutrition health data and coverage of
services.
Facilitate CP engagement by sharing information on progress done, lessons learned
and improvements to be done through a participatory evaluation of project activities
at all levels.
36. M&E institutional capacity within the two Ministries at national and sub-national levels will
be strengthened early on during project implementation by providing specific technical
assistance. Continuous monitoring, annual reviews, midterm review and end of project
evaluation will be based on pre-determined indicators, which will measure inputs, outputs, and
outcomes. Program performance and monitoring indicators (set forth in Annex 1), will be refined
during appraisal. A geographic mapping approach will be incorporated into the M&E system.
37. The M&E systems will build on past experiences, including what has and is being done
under the health SWAp, and with the RBF pilot project. With the engagement of the MCDMCH
and the emphasis on being closer to the districts, and communities, the need to improve
information feedback and the loop between the national health information management system
and District health information management systems will be part of the Project effort. With the
shift to disbursement linked indicators, the Project will be providing resources for an
independent verification mechanism, one which will closely monitor outputs under Component 1
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and Component 2, and possibly for other project sub-components. As this results-based financing
approach is a new dimension for Zambia, the operational aspects will be closely scrutinized
during the first two project years. As described in the financial and procurement sections,
measures are to be supported which will monitor fiduciary arrangements to assure satisfactory
performance.
38. For all aspects of the Project, the Joint Coordination Committee co-leaders (MOH and
MCDMCH) will bear responsibility for regular and reliable information. Reports on the progress
of each sub-component will be provided on a timely basis including updated information on
project implementation, highlighted problems and recommended actions to be taken. Because
this is a new mechanism and requires close coordination between two Ministries, intention is to
provide intensive assistance and guidance in the early phases of JMT operations. At the national
level, the M&E Unit will consolidate the information from all the sources and use it as a valuable
monitoring tool on an on-going basis for project management. The linkages between the Project
reporting mechanisms and the national program level M&E have been clearly established.
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Annex 4: Operational Risk Assessment Framework (ORAF)
Zambia: Health Services Improvement Project (P145335)
Project Stakeholder Risks
Stakeholder Risk Rating Substantial
Risk Description:
Unfamiliarity and lack of clarity on new roles and
responsibilities following the transfer of primary mother
and child health services from the MOH to the
MCDMCH, the health supply functions of the MSL, and
devolution of decision authority.
Coordination of the large number of MNCH and nutrition
cooperative partners in Zambia and avoidance of
duplication of effort.
Risk Management:
Roles and responsibilities of MOH and MCDMCH, as well as MSL for the project will
be clarified in the PIM and closely followed by the Bank team. The mechanism for
resolving working relationships will be a task of the project Joint Management Team.
This will include Provincial and District level oversight for operational coordination.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Both
Risk Management:
There is an established mechanism for donor coordination under the SWAp mechanism
and key partners have a track record in working together. Moreover, there is already a
broad agreement on the appropriateness of the proposed interventions and close linkage
to national plans. Efforts will be made to strengthen Government-led donor coordination
mechanisms.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Both
Implementing Agency (IA) Risks (including Fiduciary Risks)
Capacity Rating Substantial
Risk Description: Risk Management:
Inadequate financial and procurement management
capacity, as well as M&E capacity at MOH and
MCDMCH could pose the risk that financial management,
procurement, and reporting tasks as well as fiduciary
covenants are not adequately complied with. MOH and
MCDMCH may not have sufficient technical knowledge
and operational capacity to lead and manage all aspects of
Hands-on technical assistance and capacity building support will be provided by the
Bank to implementing bodies (of the MOH and the MCDMCH), on all aspects of
managing and implementing the project, at the central level, district level and facility
level. Technical assistance will be provided by Bank fiduciary specialists in working
with GRZ counterparts to understand and execute the DLI mechanism.
76
the project at centralized and decentralized levels.
Introduction of the Disbursement Linked Indicator (DLI)
approach represents a challenge.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Bank Not Yet Due Implementation
Governance Rating Substantial
Risk Description:
The health sector has shown considerable governance
progress since the 2009 corruption scandal but there
remains further need to strengthen structures and
processes to improve the governance within the health
sector. Related is the evolving decentralization to local
authorities for decision making, financial resources, and
implementation of activities.
Effective coordination issues between MOH and
MCDMCH, and their decentralized offices, may cause
delays to project implementation.
Risk Management:
The Bank, together with other CPs, will continue to be actively engaged in helping the
government implement its Governance Management Strengthening and Capacity
Building Plan, and support local government capacity to manage health sector
responsibilities.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Implementation
Risk Management:
Clear definition of roles and responsibilities of the implementation agencies, at national,
Provincial, and District levels will be developed and written into the PIM. Monitoring
of performance of these roles will be strengthened with active involvement of the Joint
Management Team
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Implementation
Risk Management:
The task team will closely monitor the procurement and financial processes. In addition,
based on the findings of a fiduciary assessment and implementation experiences of
earlier Bank projects, specific remedial measures may be agreed with the government.
They could be - either in the form of a "governance action plan" or through
complementing the audits/procurement report reviews with "external fiduciary oversight
agencies" on a periodic basis rather than waiting for the annual audit.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Implementation
Risk Management:
The Bank and GRZ have significant experience in managing RBF related mechanisms,
77
experience in other countries with DLIs, and lessons learned will be applied to ensure
that gaming is minimized throughout including by: closely monitoring the procurement
processes; and establishing appropriate verification systems to ensure that records are
authentic.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Implementation
Project Risks
Design Rating Moderate
Risk Description:
The project is multi-sectoral and complex, with different
activities in different geographic areas and with multiple
implementing entities.
The focus is on geographic regions with high poverty, low
MNCH and nutrition outcomes and to benefit very
vulnerable populations at community level is difficult
where capacity is limited.
It is possible that one project component or another may
not perform well.
With results based financing under Component 2, some
well-performing aspects could be adversely affected.
There is a risk that the newly trained ENs and RNs will
not be fully absorbed on the payroll once they graduate, or
significant delays in absorption or deployment to project
areas because of the Wage freeze (2 years) and Hiring
Freeze (1 year, expected to end by December 31, 2014).
Health workers may not be retained because of the wage
Risk Management:
Project design was undertaken through an extended participatory process with the GRZ,
training institutions, professional associations, and other cooperating partners. Reliance
will be on existing institutions and implementing mechanisms, to the extent possible.
Capacity-building and coordination mechanisms activities will be provided at national,
provincial, and district level, and to communities, to assist in effective delivery, use and
monitoring of services.
Incentive mechanisms will be provided for supportive supervision and community
engagement to enhance the quality of services provided and to motivate community
volunteers and the active engagement of communities.
Mechanisms will be put in place between the ministries and various components to
ensure progress is made along the various dimensions of the project. Further, the design
includes a process to reallocate resources among project components, if necessary.
RBF and DLI disbursements will allow for partial payment against targets, depending on
performance.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Implementation
Risk Management:
Consultations with the MOH and MDCMCH have provided initial assurance this will
not significantly affect deployment in the next two years. The project team will closely
78
freeze and more attractive offers from CPs or the private
sector.
Health supply chain policy and operational aspects,
including system reform to move to a "pull" system,
improving the distribution system of essential health
commodities and other supplies, as well as delegation of
responsibilities, have not been fully resolved.
Medical Stores Limited (MSL) is under new management
and its operational role vis-a-vis the MOH needs to be
clarified.
follow hiring and wage freeze developments as they could impact project success.
Health worker salaries have been raised in recent years, and the public sector dominates
the Zambian health sector, with limited options for workers to go elsewhere
domestically, if they stay in health.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Client In Progress Both
Risk Management:
Confirm with Government the medium to long term plans for its National Health Supply
Chain Strategy. This will include: (i) dialogue with MOH to introduce a more evidence
based rationing system to ensure small health facilities in underserved areas are not
disadvantaged by big institutions that are close to the MSL; (ii) contribute to ensuring
improved availability of health commodities; and (iii) support associated plans and
reforms to make supply chain systems being implemented by MSL, including the
regional hubs strategy, more efficient and effective.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Both
Social and Environmental Rating Low
Risk Description: Risk Management:
The proposed activities are not expected to entail major
safeguard issues, but some aspects, including related to
skills labs upgrading and minor rehabilitation of training
institutions nevertheless require attention. Moreover, the
management and disposal of medical waste is associated
with primary health care services and therefore OP/BP
4.01 applies.
The project is to be covered by the current Zambia Healthcare Waste Management Plan
(2010-2014), which will be updated in 2014.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Client In Progress Both
Program and Donor Rating Moderate
Risk Description:
In 2010 approximately 39 percent of total health
Risk Management:
Zambia is an IHP+ country and there is recognition by government and partners to
improve aid harmonization and predictability. The GRZ is actively exploring ways to
79
expenditures came from donors. Continued external
support at this level is dependent on both donor resource
ability and Zambian needs as well as performance
Expected complementary support to the program
components, from donors and TA agencies does not
materialize, or is less than expected.
improve the efficiency and effectiveness of health sector resources; for example, through
a focus on training more cost effective cadres for better impact to the poor (to serve the
community and primary health level), improving efficiency of the supply chain, service
delivery (through RBF in the previous project), exploring better use of volunteers to
lessen impact of demand on health services, and efforts to expand fiscal space and
efficiency in spending through plans to develop a solid health financing strategy.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both In Progress Both
Risk Management:
Bilateral and multi-lateral donors, TA entities, and professional associations, have
shown significant interest in harmonizing approaches as well as potential for supporting
and complementing key components through various mechanisms including joint
technical support. This will be further pursed during project implementation.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Bank In Progress Both
Delivery Monitoring and Sustainability Rating Substantial
Risk Description:
National, district and community level data collection,
monitoring, and reporting are in need of strengthening.
Particularly this is needed for community and primary
level service delivery given that community HMIS are not
yet fully developed, and there is limited capacity in
monitoring and reporting such a scheme at the local level
The Government depends heavily on external resources
but this funding going forward may be less predictable.
While this project, in combination with support from other
cooperating partners, will improve the situation for a
specific population, sustainability cannot be guaranteed
unless the GRZ particularly, and other donors are prepared
Risk Management:
The project will include technical assistance support specifically on monitoring aspects,
and will encompass enhancement of the national HMIS to the DHIS-2 and to connect
with communities. The project will draw on the lessons learned from supervision
incentives work done under the RBF pilot project.
Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both Not Yet Due Implementation
Risk Management:
The Bank team will work closely with the government and other cooperating partners to
develop and implement a strategy to ensure long-term financial sustainability of the
different project components, including improving efficiency of current resources
.
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to continue and scale up the project approach. Resp: Status: Stage: Recurrent: Due Date: Frequency:
Both Not Yet Due Implementation
Overall Implementation Risk: Rating Substantial
Risk Description:
Overall implementation risk is Substantial. The Project seeks to strengthen primary care and community level health service delivery systems,
introduction of training programs at central, provincial and district levels, and incentive mechanisms. The two ministries are going through a
transition phase in dealing with significant changes in implementing MNCH and nutrition interventions, including sorting out primary
responsibilities and coordination between themselves and across the entire sector. Additionally, GRZ is actively pursuing devolution of activities to
local authorities and this will impact MOH and MCDMCH mandates and responsibilities. The Project will introduce results based approaches: at a
higher level paying for results through the DLIs and at facility level through the RBF. The fiduciary management capabilities of the MOH and
MCDMCH are vulnerable to varying degrees, and depth. The objective of bringing services closer to communities will depend on governance
structures at various levels, taking into account the decentralization process. Finally, prospects for public sector recruitment and timely deployment
of new nursing and midwife graduates pose a further implementation risk element, given GRZ's announcement of a hiring freeze for 2014.
These implementation challenges will be mitigated by a number of factors: (i) there is a history of delivering MNCH and nutrition services at
community level supported by faith-based organizations, non-governmental organizations, and external donors that can be strengthened; (ii) where
there are new activities that depend on strengthened capacity and the sequencing of actions, the intention is to plan for gradual scale-up, training and
technical assistance; (iii) Government assurances were provided that new nursing graduates will be absorbed because vacancies can be filled (and
attrition annually represents a significant number of vacated posts), additional MCH positions in 2013 were secured and will require new hires, and
that the hiring freeze is limited to 2014; (iv) there is significant and relevant CP technical and financial assistance, inter-CP technical coordination
mechanisms to exchange information and plans; (v) the Project design provides for extensive investment in information systems from the district to
the community levels, and to monitor performance on a regular basis; (vi) a JMT will be put in place to effectively coordinate the various activities
under the Project. The intention is to hold monthly joint project reviews to assess successes, challenges, and to implement mitigating measures; and
(vii) provision of technical support to the MOH and MCDMCH in fiduciary management.
The Project will introduce additional RBF performance based financing in the health sector. Experience suggests that risks associated with the RBF
include: (i) an enhanced focus on quantity of services over quality; (ii) gaming the system by inflating service delivery records or inflating the
results of the quality evaluation or establishing too easily achieved DLIs; (iii) favoring service delivery to easier reach populations; and (iv) focusing
on only targeted services to the detriment of other equally important health interventions. In addition, community based RBF is particularly
challenging given the dispersed nature of activities, the difficulty in verification and capacity challenges. The Project will mitigate these risks by: (i)
incorporating quality measures as an integral part of the process of determining payouts to facilities/health workers; (ii) establishing strong internal
and external verification systems to ensure that records are authentic; (iii) involving communities in the verification process; and (iv) regularly
monitoring service delivery to the most disadvantaged, and making the necessary adjustments to service tariffs to favor service delivery in remote
areas.
81
Annex 5: Implementation Support Plan (ISP)
1. The approach for implementation support has been developed based on the nature of the
Project, including its risk profile. It will aim to make such support flexible and efficient, and
address the risk mitigation measures defined in the ORAF. The ISP will be reviewed annually to
assure it is responding to Project needs.
2. The Project will require intensive supervision given the geographic spread of the proposed
operation (five provinces and multiple districts within the provinces), and given the
implementation capacity at national, provincial, and district levels, reaching into the
communities. The Project will be implemented principally at two levels: the central MOH and
MCDMCH; and at provincial and district levels. With service delivery to be focused on health
facility and community levels, multiple training institutions involved, and innovation programs
such as the performance based approach for essential commodities and the supply chain and
other innovations for results at the community level, the breadth of implementation tasks are
significant.
3. Implementation support by the Bank will be leveraged or coincide with supervision carried
out by MOH and MCDMCH personnel on a regular basis. In addition to their onsite staff, each
Ministry will have teams visiting the districts several times per year, and jointly on some
occasions, producing action-oriented implementation support reports which will be provided to
the Joint Coordination Committee, and subsequently the Bank. This system will allow the
implementing entities to distinguish better and lesser performing areas (provinces, districts,
health facilities, and communities), and the ability to provide more technical support or possibly
reallocate funds. A much more intensive than normal supervision program should be carried out
during the first year of the Project to put in place a sound and functioning institutional structure,
attention to the DLI process, and responsive guidance so that interventions to be undertaken by
the Project start as planned and any unanticipated questions quickly resolved. A separately
contracted independent verification entity will be in place for the supply chain system
component. Sufficient funds for such purposes will be included in the Project design to over the
five-year life span of the Project. The GRZ also recognizes the need for intensive oversight and
is prepared to commit staff for this purpose.
4. The overall implementation supervision of the Project will be the responsibility of each of the
Ministries for the specific activities assigned to it. Within each Ministry the units in charge of
planning, procurement, financial management, monitoring and evaluation will carry out the
necessary functions. The health SWAp will provide the basic operating procedures to be
followed both in the MOH and the MCDMCH.
5. Bank implementation support management will be the responsibility of the Task Team
Leader to assure that the skill mix of qualified staff or consultants is available, and responsive to
effective project implementation. Some of the skills required by the Bank team will be needed on
a regular basis, while others will be resourced based on need. It is proposed to establish a core
implementation support group that will emphasize financial, procurement, RBF, and operational
basic needs, complemented by specialists in human resources for health, nutrition, health
systems and financing, and monitoring and evaluation.
82
6. The Implementation Support team includes the following members: (i) the Task Team
Leader, (ii) an HNP specialist who has extensive knowledge of the Zambian health system, (iii) a
health systems specialist who has extensive knowledge of the Zambian health system, (iv) an
HRH specialist with familiarity with HRH challenges in providing non-urban MNCH training,
(v) a nutrition specialist, (vi) an RBF specialist, (vii) a monitoring and evaluation specialist
whose experience includes national and sub-national health information systems and utilization
of generated data, (viii) a financial management specialist who will review adherence to Bank
procedures, (ix) a procurement specialist who will similarly review adherence to Bank
procedures as well as provide advice on supply chain management and performance-based
procurement reporting aspects.
7. While regular Bank implementation support will take place at least twice a year, this will be
leveraged by country-based Bank staff in more frequent meetings with the JMT, MOH and
MCDMCH staff, as well as field visits by country-based Bank health sector, procurement, and
financial management specialists who will review progress and provide ongoing assistance to the
GRZ implementing entities. They will also stay in close touch with the main CPs engaged in
MNCH and nutrition, reviewing with them project development areas, lessons learned, as well as
draw from the experience of other CP programs.
8. Financial Management. The Bank will provide support in the drafting of the FM chapter of
the Project Implementation Manual, and through the regular review of quarterly reports, internal
audits, and audit reports of the Office of the Auditor General or its designated private firm, and
will follow up on any issue as the need arises. Given the risk rating, and that the DLI process is
new to Zambia, intensive FM support will be provided with two FM onsite visits per year
(possibly more in the first year), as well as desk reviews of documents. There will be regular
interaction with the country-based Bank Financial Specialist in terms of guidance and training
with regard to Interim Financial Reporting, Bank disbursement and procurement procedures,
internal auditing and strengthening of the audit committees. MCDMCH budget monitoring
capacity is weak and its staff will be provided with Bank training. In sum, intensive support will
be provided during the first year to ensure that the financial systems are functioning effectively.
9. Procurement. The Bank will provide support in assisting the MOH and MCDMCH
procurement staff in understanding what is needed in the procurement chapter for the Project
Implementation Manual, and in its application. In this regard, the in-country Procurement
Specialist will provide training and mentoring in areas such as the appropriate roles and
responsibilities of those in the procurement chain, internal governance processes, including
bidder selection and monitoring of contract compliance. Procurement specialists in results based
operations will be made available to assure this innovative aspect of the Project performs as
planned. The country based Bank Procurement Specialist will undertake onsite visits per year
and desk reviews of procurement documents. Intensive Bank support will be provided during the
first year to ensure timely delivery and distribution of goods and services.
10. Coordination with other Cooperating Partners. Implementation support will include: (i) close
coordination with other CPs, health training institutions, professional associations as well as
other non-government organizations active in the health and community development spheres in
Zambia.
83
Implementation support plan
11. The Project will require substantive technical support given the complex and technical nature
of the activities to be financed. Most of the World Bank team members are based in Zambia or
the region, which will ensure timely, efficient and effective implementation support to the client.
Formal implementation support missions and field visits will be carried out at least every six
months and there will be a mid-term review. A detailed time line and skills required from the
Bank team, are outlined below:
Table A.8: Timeline of main focus of implementation Time Focus Skills Needed Resource
Estimate
Partners and Partner Roles
First 12
months
Institutional
modalities, training
and mentoring, sub-
component
implementation
Team leadership, HNP
Specialist, Health Systems
Specialist, HRH, specialist,
supply chain specialist, RBF
and outputs approach
specialist, M&E specialist,
finance management and
procurement specialists
a) Partners: European Union,
Ireland, Sweden, United Kingdom,
United States, UNICEF, WHO,
and WFP
b) Role: Technical knowledge
sharing and training, resource
contributions, scaling up of
approaches, implementation
knowledge
12- 36
months
Same as above for
ongoing supervision
and mid-term
review
Same as above Same as above
36-60
months
Same as above for
ongoing supervision
and implementation
completion report
preparations
Same as above Same as above
Table A.9: Skill mix required Skills Needed Number of Trips Comments
Team Leader 3 trips each of the first two years; 2 trips thereafter Washington based
HNP Specialist 2 field trips more as needed Based in country
Health Systems Specialist 2 field trips more as needed Based in country
HRH Specialist 2 trips annually (includes MTR) Washington based
Nutrition Specialist 2 trips annually (includes MTR) Washington based
RBF Specialist 3 trips the first year, then 2 trips annually (includes
MTR)
Washington based
M&E Specialist 2 trips annually (includes MTR) Washington based
Supply Chain/Operations 2 field trips, and more as needed Based in country
Financial Specialist 3 field trips, multiple MOH and MCDMCH onsite
visits, with more as needed
Based in country
Procurement Specialist 2 field trips, multiple MOH and MCDMCH onsite
visits, with more as needed
Based in country
84
Annex 6: Economic and Financial Analysis
1. The Zambia Health Service Improvement Project aims to improve health delivery
systems and utilization of maternal, newborn and child health and nutrition services in the five
targeted provinces. The main project activities include: (i) strengthening capacity for primary
and community level MNCH and nutrition services, (ii) strengthening primary MNCH and
nutrition service delivery using Results Based Financing Approaches, and (iii) strengthening
project management, and policy analysis.
Project development impact
2. The proposed project will contribute to Zambia’s development through the following
pathways: improving child survival, saving unnecessary health care costs and social care costs,
increasing productive labor force, promoting equity and shared prosperity and improving health
system efficiency.
3. The project will contribute to improving child survival by decreasing the incidence of
malnutrition, increasing the coverage of effective child health interventions such as vaccinations,
post-natal care and integrated management of childhood illnesses, and improving child care by
decreasing maternal deaths. According to WHO, around 70 percent of early childhood deaths
are due to conditions that can be prevented or treated with access to some simple and affordable
interventions. Malnutrition is the underlying contributing factor in about 45 percent of all child
deaths and this can be prevented through improved nutrition practices.
4. The project will contribute to saving health care costs related to disease treatment by
focusing on cost-effective preventive measures, and save social economic burden that is related
to extra care needed for children who are stunted or have lost their mother at birth. Globally,
nearly 10 million women per year who survived childbirth suffer from pregnancy related
injuries, infections, diseases and disabilities, often with lifelong consequences. Research has
shown that 80 percent of these deaths could be averted if women had access to essential
maternity and basic health care services. As part of the service continuum, reproductive health,
including family planning, saves infant lives by spacing planned births and limiting unintended
births. Family planning also saves maternal lives by reducing exposure to the risks of pregnancy
and childbirth, including recourse to unsafe abortion, one of the main causes of deaths among
young women.
5. This project will generate long-term economic benefit by increasing active and
productive labor force who can potentially contribute to economic growth and poverty
elimination. With improved health and nutrition status, more children will survive into adulthood
and work more productively as a result of better cognitive development. Women who are saved
from maternal deaths will contribute directly to productive activities or relieve household
members who would have had to provide child care without their presence.
85
The most recent empirical estimates of the negative effects of stunting on worker
productivity and adult earnings range from about 10 percent per year34
, to as high as 20
percent per year35
. Anemia is associated with a 2.5 percent reduction in wages.
Productivity losses at the individual level are estimated to be more than 10 percent of
life-time earnings, which at the macro level can lead to a 2‐3 percent loss in GDP.
One study that estimates the effect of maternal mortality on GDP in Africa shows that
maternal mortality has a statistically significant negative effect on per capita GDP. An
increase in MMR by one death decreases per capita GDP by US$ 0.36 per year on
average.
6. This project will promote equity and shared prosperity by targeting areas that are poor
and human development is behind. The five project provinces were selected on the basis of: (i)
high poverty levels, (ii) low human opportunity index–immunization, (iii) high under-five
mortality, (iv) low coverage of skilled birth attendance, and (v) high prevalence of stunting
among children aged below five.
7. The project will contribute to improvement of technical efficiency of health service
delivery system. Shortages of key inputs that are necessary to deliver the defined package of
basic health services will be addressed through increased availability of skilled frontline and
community health workers, increased availability of critical drugs and commodities, and
enhanced supervisions from higher level. By putting the key elements together at the same time
and in the same location, more facilities will be pushed to the production function frontier, and
therefore, deliver better services to the extent possible at a given cost.
8. The project will also contribute to improvement of allocative efficiency at health facilities
and community levels. It focuses on primary health care with active community participation,
which is the most cost-effective modality to provide a defined package of high impact services. It
will support the Zambia health system to be more results-focused and to get value from the
money invested by supporting a Results-based-financing approach. It will enable decision
makers and managers at all levels to be more evidence-based in policy analysis, planning, and
budgeting by supporting the country’s M&E system, analytics, and capacity building in
evidence-based decision making. In addition, it will facilitate efficiency improvements by
allocating resources to where marginal benefits and utility are highest by focusing on areas that
are lagging behind. For example, this project aims to strengthen human resources for health
through the rural pipeline by strengthening capacity of rural training institutions and enhancing
measures to retain rural health workers. It is expected to contribute to the scarcity of health
workers in rural areas that is exacerbated by geographical remoteness of these areas.
Cost-benefit analysis focusing on selected benefits
9. Cost-benefit analysis provides a basis for comparing projects by comparing the total
expected cost of each option against the total expected benefits, and examining whether the
34 Hoddinott 2003, World Bank 2006, Quisumbing, Gillespie and Haddad 2003, Alderman Hoddinott and Kinsey 2002, Ross and Horton 2003 35 Granthan-McGregor.S et al 2007
86
benefits outweigh the costs, and by how much. Such approach fits well with Bank’s projects in
earlier decades, because projects at that time were typically of the “bricks-and-mortar” variety —
physical rehabilitation of a road, for example. In such cases, expected project costs and benefits
could usually be readily monetized at least to a reasonable approximation. Consequently the
analyst could quickly arrive at an estimate of the rate of return.
10. Cost-benefit analysis may not capture all aspects of the potential development impact
related to the proposed project because some of them cannot be easily translated to monetary
values given constrains of existing data and methodology, e.g., efficiency improvement and
equity improvement. This is not unique to this proposed project. As a matter of fact, the Bank’s
current portfolio comprises more complex and innovative operations involving institutional
redesign, incentive restructuring, decentralized decision-making, and so on.
11. A cost-benefit analysis nevertheless, is conducted for project appraisal by focusing on
some selected benefits to demonstrate the soundness of the proposed project investment.
Specifically, in the cost-benefit analysis for this project, only economic growth benefits from
lives saved are estimated and discounted as present values. The present value of benefits is then
compared with the present value of the total cost of the project, yielding a benefit-cost ratio and
net present value of benefit for this proposed project. The result of this analysis should be
interpreted as an underestimation of the return of this project given the fact that it does not
include all expected benefits.
12. There are three potential measures for estimating benefits from saving lives: Life Years
(LYs), Quality Adjusted Life Years (QALYs) or Disability Adjusted Life Years (QALYs). LYs
is a pure measure of mortality, while QALYs and DALYs are measures that combine mortality
with morbidity in single numerical units, an exercise involving trade-offs between quantity for
quality of health (Robberstad 2005).
13. LYs saved rather than QALYs and DALYSs were chosen for the main following reasons.
First, LYs saved is as indicated a relatively easy and transparent method for measuring
population health, and there are few value choices involved. Second, QALYs and DALYS
request Health Related Quality of Life (HRQoL) weights to be defined to take into account a
potential impaired quality of life after the interventions. Regarding the complex combination of
interventions of the project, HRQoL weights are highly difficult to define.
14. The analysis uses population data (Table A.10), under-five mortality rate (89 per 1,000
live births), maternal mortality ratio (440 per 100,000 live births), and a number of assumptions
for estimated effect on reducing child and maternal mortality.
87
Table A.10. Number of beneficiaries in project provinces – 2014 estimates Province Population Children
0 –11
months*
Children
< 5 yrs*
Women in
child bearing
age*
Expected
pregnancies*
Expected
deliveries*
Expected
live
births*
Luapula 992,000 40,000 198,000 218,000 54,000 52,000 49,000
Muchinga 712,000 29,000 142,000 157,000 38,000 37,000 35,000
Northern 1,106,000 44,000 221,000 243,000 60,000 58,000 55,000
North-Western 727,000 29,000 145,000 160,000 39,000 38,000 36,000
Western 903,000 36,000 181,000 199,000 49,000 47,000 45,000
TOTAL 4,440,000 178,000 887,000 977,000 240,000 232,000 220,000
Source: 2010 Census of Population and Housing * Calculated based on proportions provided under Zambia HMIS
Given that 70 percent of child deaths are preventable through MNCH and nutrition
actions supported by this proposed project, it is assumed that this project will lead to an
extra decline of under-five mortality (Table A.11) on top of counterfactual decline over
time (e.g., through economic development, education improvement and regular health
intervention activities).
Literature shows that up to one-third of maternal death may be prevented through the
presence of skilled birth attendance. It is assumed that this proposed project will lead to
an extra decline of maternal mortality (Table A.11) on top of counterfactual decline over
time.
Table A.11. Expected impact on child maternal mortality and maternal mortality
2015 2016 2017 2018 2019
Under-5 mortality 1.0% 1.5% 2.0% 2.5% 2.5%
Maternal Mortality 1.0% 1.5% 2.0% 2.5% 2.5%
For simplicity, it is assumed the average age of each saved children cohort is two years
old, and their life years will only be counted as benefit after 13 years when they become
active labor force. It is assumed the average age of saved delivering women is 20 years
old.
15. In order to assess benefits in monetary value, GDP per capita and life expectancy are
used. Benefits represent the value of the difference between the number of lives saved by
implementing project activities and the number of lives saved only through the status quo
scenario, all other things being equal. Beyond the philosophical and social considerations, each
death is a loss for the national economy. The annual value of a life lost is roughly equivalent to
the Gross Domestic Product per capita. Data for GDP as well as all other macroeconomic
indicators are extracted from official International Monetary Fund (IMF) documents. For this
specific purpose, only productive labor years are considered as project benefits, i.e., 15-49 years
old. The upper limit of 49 years old is selected because that is the current life expectancy at birth
in Zambia. This assumption represents a very conservative estimate, knowing the country will
experience significant increase in this indicator during next few decades. For the purpose of this
analysis, US$1,350, per capita gross national income (GNI) for Zambia in 2012 is used.
88
16. The analysis uses a five-year time frame that is consistent with the project
implementation period. However, understanding that investment in human development
produces long term economic benefit, the analysis only counted working age years as benefit.
Both cost and benefits are discounted with a 3 percent discounting rate. Discounting is the
process of converting future costs and benefits to their present value, to reflect the fact that, in
general, society prefers to receive benefits sooner rather than later, and pay costs later rather than
sooner. A number of guidelines recommend a 3 percent discount rate, both for cost and benefits
(WHO guide to CEA, 2003).
17. The results in Table A.12 show that this proposed project in health sector is a sound
investment for the country. The present value of benefit related to improved maternal health and
child health is estimated to be US$152.7 million. The present value of cost based on expected
disbursement is estimated to be US$63.1 million. As a result, net present value of benefit is
estimated to be US$89.6 million and benefit-cost ratio is estimated to be US$2.42 (152.7/63.1 =
2.42). This implies that for every US$1 invested through this project, there will be a yield of US$
2.42. Sensitivity analysis suggests that the benefit-cost ratio is as high as 1.7 even if the project
only achieves 70 percent of the expected impact.
18. It is likely that the real benefit and efficiency have been underestimated by this analysis.
Conservative assumptions have been used for the expected impact of this project. Only economic
growth benefit related to increased productive years is considered in this analysis. This analysis
does not include benefit of increased life-years of saved children before they become active labor
force. Many other benefits are also excluded because they cannot be measured or translated to
monetary value easily, e.g., efficiency improvement.
Table A.12. Cost-benefit analysis results
2015 2016 2017 2018 2019 Total
Child Health Benefit
Number of children under-five 887,000 914,522 941,957 970,216 999,322
Saved children under-five 789 1221 1677 2159 2223 8,069
Gained productive life-years per child under-five
(present value) 14.82 14.39 13.97 13.56 13.17 70
Total gained productive life-years (present value) 11,693 17,570 23,428 29,276 29,277 111,244
Economic gains related to improved child health
(US$, million, present value) 15.8 23.7 31.6 39.5 39.5 150.2
Maternal Health Benefit
Number of women delivering babies 232,000 238,960 246,129 253,513 261,118
Saved women from Maternal Death 10 16 22 28 29 105
Gained productive life-years per saved women
(present value) 19.19 18.63 18.09 17.56 17.05 91
Total gained productive life-years (present value) 192 298 398 492 494 1874
Economic gains related to improved maternal
health (US$, million, present value) 0.3 0.4 0.5 0.7 0.7 2.5
Total Health Benefit
Total gained productive life-years (present value) 11,885 17,868 23,826 29,768 29,771 113,118
89
Economic gains related to improved child and
maternal health (US$, million, present value of
benefits)
16.0 24.1 32.2 40.2 40.2 152.7
Total Cost (nominal, US$, million) 12.1 13.58 13.67 13.28 14.37 67
Total Cost (present value, US$, million) 12.1 13.19 12.85 12.16 12.82 63.1
Net Present value of benefits (US$, million) 3.9 10.9 19.3 28.0 27.4 89.6
19. A number of low and middle income countries have been exploring the role of
communities as well as results based approaches in improving health outcomes. Zambia has not
been an exception in considering the feasibility, potential benefits and costs of these innovative
approaches. The main thrust of the community‐based program is behavior change, which can be
implemented as a lower cost yet effective alternative, and which also has favorable pro-poor
properties. The community‐based platform aims to improve utilization of essential services that
have previously been underutilized, partly, as a result of information asymmetries between the
consumer and the provider. Given that approximately 60 percent of Zambia’s population lives in
rural areas and a significant share36
of communities are beyond 5 km from a facility, the
community‐based platform is expected to substantively contribute to coverage expansion and do
this in a cost‐effective manner. RBF is an intervention that is gaining significant momentum as a
solution to poor performance and the health worker crisis in low‐income countries, particularly
in Africa. Results indicate that RBF can play a role in increasing the productivity of health
workers and have positive effects on health service utilization. However – given the novelty,
heterogeneity, and context‐specificity of RBF – to date the evidence base has been limited,
especially so in the context of community performance‐based financing, where the incentive
regime design goes beyond the facility staff and must include considerations regarding
community dynamics. To inform project design, implementation, and policy decisions
operational research will be valuable to gather evidence on the effectiveness, cost‐effectiveness,
and equity implications of the proposed community-based and RBF interventions.
Rationale for working with public sector
20. Working with the public sector through this project is economically justified because
public intervention is necessary when there is market failure. The focus of this project is on high
impact and cost effective MNCH and nutrition interventions, which have positive externalities
through the consumption and/or production of goods. Without public intervention, these services
would otherwise have not been consumed or produced.
21. Although public-private partnership is a feasible idea to provide critical public health
interventions based on its demonstrated effectiveness elsewhere, it is not feasible in Zambia. In
Zambia, it is the overwhelmingly the public sector which provides health services. Only 13
percent of the health facilities are owned by for-profit private health providers. In the five-
targeted provinces, there are only 9 private health facilities out of 811 in total, accounting for
only one percent (Figure A.7). Therefore, it is neither effective nor efficient to rapidly expand
36
46 percent based on the LCMS Survey III of 2002/2003
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coverage of high impact cost-effective interventions through the private sector in the five
provinces.
Figure A.7: Presence of the private health sector – Zambia by province
Source: MOH, 2012 List of Health Facilities
Financial analysis
Macroeconomic situation
22. Zambia has been recording high economic growth and capital inflows in the past few
years just like other Sub-Saharan countries. High commodity prices have induced large foreign
direct investment (FDI) flows, mainly in extractive industries but also in service sectors, mostly
infrastructure-related projects. In 2012, the Gross National Income per capita37
is US$1,350, and
the IMF projects economic growth in Zambia at an average of seven percent per annum in real
terms in the next few years. General government revenue as a proportion of the GDP is expected
to grow from 20 percent in 2010 to 23 percent in 2016.38
37
Atlas method (current US$). 38
IMF 2012
0% 0% 1% 1% 2% 3% 3% 5%
27%
53%
1% 0%
25%
50%
75%
100%
91
Figure A.8. Economic growth in Zambia and SSA countries
23. Despite the positive economic outlook, the 2013 budget came under stress due to several
unplanned expenditures and a shortfall in revenue collection. Additional expenditures include
public sector wage awards (0.8 percent of GDP), accumulated fuel supply losses not initially
budgeted for (1.0 percent of GDP), and expected high spending on the Farm Input Supply
Program (0.4 percent of GDP). Preliminary data on domestic tax collection for the first half of
2013 suggests an estimated shortfall of 1.0 percent of GDP. As a result, the fiscal deficit is
expected to be higher than the budgeted 4.5 percent of GDP even after the government’s active
adjustments, including cutting recurrent spending (such as on travel and motor vehicles), cutting
capital projects, and stepping up revenue collection.
24. According to the recently published Economic Brief, the main economic challenges in
Zambia remain to be widespread poverty and systemic youth unemployment. Overall, 60.5
percent of the population lives below national poverty line, but it is much higher in rural areas,
about 77 percent as of 2010. Formal jobs are being created at a very slow pace that is nowhere
close to being able to absorb the new cohorts of youth that enter the labor market. While the
revenues from mining have grown, they have not contributed much to the human capital building
because they have gone mostly to consumption. The same study also pointed out that
disadvantaged youth would need equitable opportunities to improve their basic skills. Currently,
the poor youth, particularly girls in rural areas, cannot benefit much from the broad efforts of
improving job environment because they are unable to transcend the barriers of poverty, gender
and location.
Health sector expenditure
25. Zambia spends 6.3 percent of its gross domestic product (GDP) on health. As a
proportion of the total government budget, the health budget has been on average 9.5 percent per
annum for the past five years (2010-2014). In nominal terms, the government health budget has
been growing by an average of 30 percent per annum between 2010 and 2014, and by 16 percent
between 2013 and 2014. On the other hand, flow of financial resources from external sources has
been declining since 2006. For example, disbursement by CPs to the basket funding at MOH
declined from 103 percent in 2006 to zero percent in 2010. Nonetheless, CPs are still present in
92
the health sector in Zambia and are funding numerous vertical projects particularly in
HIV/AIDS, Malaria, MNCH, and Nutrition. Hence, fiscal space for health in Zambia critically
depends on the sustainability of external funding, the extent to which additional Government and
other domestic resources can be used to finance health services, harmonization of all funding
sources, and efficient use of the money available.
Table A.13. Historical trend of government budget for health sector
Year
Health budget (nominal, US$,
million)
Proportion of health budget
out of total GRZ budget
2007 166.0 9.6%
2008 194.8 11.2%
2009 220.0 11.8%
2010 280.0 8.2%
2011 360.0 8.8%
2012 516.0 9.3%
2013 686.4 11.3%
2014 797.8 9.9%
26. Within the Health Sector it is possible to track resources from MOH to districts (as
records are kept up-to-date). What happens to these resources when they are received and
allocated to the different lower level health centers and district hospitals by the District Health
Management Team (DHMT) is not clear, as it is hard to “decipher” the actual expenditures
because of lack of new information. However, available data from the 2009 Public Health
Expenditure Review showed that more than 33 percent of the DMOs delay the release of district
grants to health facilities39
. And almost 20 percent of the health facilities reported receiving less
than the budgeted amounts.
27. It is expected that this project will be financially sustainable, because the proposed
project investment, US$13.4 million per year during a five-year period, accounts for a small
portion of the annual government budget on health. Taking 2014 as an example, the proposed
annual investment of US$13.4 million per year is 1.7 percent of the government budget for
health sector, US$798 million. This estimate will become smaller over time given the
government budget is expected to grow with economic growth and an overall increasing trend
has been observed for the proportion of health budget out of total budget. In addition, the
Ministry of Health and Ministry of Community Development, Mother and Child Health, have
been actively engaged during project preparation, and have had strong ownership of the project.
39
World Bank 2009
93
Annex 7: Country map
