PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB2030 Project Name. Malaria Booster Program for Health SWAp Region

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB2030 Project Name Malaria Booster Program for Health SWAp Region AFRICA Sector Health (80%); Central government administration (10%); Subnational government administration (10%) Project ID P Borrower(s) GOVERNMENT OF MALAWI Implementing Agency Ministry Of Health Environment Category [ ] A [] B [X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared February 3, 2006 Estimated Date of February 28, 2006 Appraisal Authorization Estimated Date of Board June 20, 2006 Approval 1. Key development issues and rationale for Bank involvement Current situation. The social, human and income indicators in Malawi are among the poorest in the world, with a per capita GDP of US$170, about 55% of the population living below the national poverty line, and a Human Development Index rank of 163 among the 173 countries surveyed. The health status indicators in Malawi are also very poor, despite the gains that have accrued in the last 4-5 years. Life expectancy at birth in Malawi currently stands at 39 years, with twenty-three percent of children dying before they reach the age of five years. The maternal mortality rate is 1,120 maternal deaths per 100,000 live births (DHS 2000), and has almost doubled in the past decade. Malaria is the single most important public health problem in Malawi. Even more so than HIV/AIDS, malaria contributes to the poor health indicators in Malawi. The entire population of 11 million people is at risk for malaria, and every year there are approximately 4 million cases. The trend over the last few years has been that malaria accounts for about 18% of all hospital deaths and 40% of the outpatient visits. If anemia which is often attributable to malaria - is included, malaria and its complications account for 53% of all hospital admissions. In financial and economic terms, malaria s direct and indirect costs borne by individuals, households and government are huge. For example, outpatient care costs are approximately US$1.10 per consultation and US$35 per admission. Research shows that countries with a substantial amount of malaria, such as Malawi, grew at 1.3% per year less than their less malarious counterparts. It is estimated that a large proportion of the Malawi s workforce loses about days a year due to malaria and that families spend about 28% of their yearly income treating malaria. A 10% reduction in malaria has been associated with a 0.3% higher growth rate per year. The Malawi Malaria Strategic Plan made several advances in the areas of prevention through the use of insecticide impregnated bed-nets (IIBN) or insecticide treated nets (ITNs), intermittent presumptive treatment, or IPT, of pregnant women, and information, education, communication (IEC)/behavior change initiatives), disease management (through case management - including access to treatment within 24 hours for the under-fives and pregnant women, integrated disease surveillance and response, and operations research) and the overall management of the malaria control program (through capacity building). Achievements include: (a) development of a national malaria policy, as well as considerable capacity building within the national malaria control program (NMCP); (b) improved management of malaria cases in the health facilities, with 3.5 million cases treated per year and 41% of

2 children under-five having access to prompt treatment. Furthermore there are virtually no anti-malarial drug stock-outs, and a strong collaboration with the IMCI program has been established; (c) an average distribution of 3.3 million impregnated bed-nets per year, with high net re-treatment rates (which were initially provided free of charge but are now being made available at a highly subsidized rate of US$0.67). The ITN coverage is currently 35% of under five children (up from 10% in 2001) and 34% of pregnant women (up from 7% in 2001); and (d) high IPT rates for pregnant women; 60% of women receive 2 or more doses during pregnancy (up from 37% in 2001). In fact, on the basis of these achievements, Malawi s NMCP has been acknowledged as one of the stronger programs within Sub- Saharan Africa (RBM Reaping Mission 2005). However, the NMCP still faces several challenges, including, inter alia, the severe human resource constraints that plague the entire health sector, increasing resistance of malaria parasites to Sulfadoxine-Pyrimethamine (SP) (the first line treatment for malaria in Malawi), problems in the supply of mosquito nets, and persistent deficiencies in the monitoring and evaluation of the programmatic inputs, outputs and outcomes. It is also noteworthy that many of the achievements of the national program accrued while it was run as a vertical disease control program, using parallel support systems, and supported primarily by UNICEF and WHO, along with a few bilateral donors. Health sector issues. In order to promote greater cohesion in the health sector, harmonize donor support, and ensure a more targeted and equitable delivery of health services, the Ministry of Health (MOH) has recently implemented a Sector Wide Approach (SWAp) in health. Vertical health programs, such as the malaria program, have been integrated into the sector-wide program. Thus, the systemic issues facing the NMCP are now being dealt with through the SWAp systems, using the same approach to malaria services as for the ten other health interventions that constitute the SWAp Essential Health Package (EHP). The overall objective of the government's SWAp Program of Work (PoW) for the sector, which has been costed at US$750 million over six years, is to improve the effectiveness, efficiency and equity of the essential health care delivery system in Malawi. Increasing numbers of development partners (e.g., DFID, Norway, Sweden, UNFPA, and IDA, through its Health Sector Support Project (HSSP) have demonstrated their confidence in the government-led sector-wide program, whose implementation has been progressing well to-date, by pooling their resources along with those of the Government of Malawi (GoM). The Global Fund for AIDS, TB and Malaria (GFATM) has recently followed the lead of these partners by including its US$40 million support over 5 years for malaria in the pooled funds for the SWAp. However, the impact of the integration on health sector outcomes, in general, and on malaria control, in particular, remains unclear. The capacity of the health system to monitor and evaluate malaria-specific inputs, outputs and outcomes effectively also needs to be improved. Among other things, it is currently difficult to assess either the optimal resource allocation for scaling up of the NMCP to meet the rather ambitious targets adopted by the GoM, or the efficiency and equity of use of the available resources. Furthermore, the report of the first annual review of the health SWAp identified several lingering weaknesses in the monitoring and evaluation (M&E) system, including incomplete data collection, especially for key disease-control programs, variable data quality, delayed analyses/consolidation of data, limited dissemination, an inadequate impact-focus and variable integration of the M&E results in the planning cycle. Borrower s Policies and Strategies. The GoM has a strong commitment to controlling malaria in the country. The new Malaria Strategic Plan ( ) builds on the achievements of the previous fiveyear plan, while addressing the critical gaps and challenges that have been identified. Consistent with the Abuja Declaration and the Roll Back Malaria targets, albeit ambitious, the target for the Strategic Plan is to halve the malaria mortality and morbidity by the year The expected results are based on the scaling up of malaria control interventions in the following strategic areas: (a) ITN coverage of children under five years of age from 35% to 60% and pregnant women from 34% to 60%; (b) access to prompt treatment within 24 hours by children under five years of age from 41% to 70%; (c) access to

3 IPT by pregnant women from 60% to 65%; and (d) further strengthening of overall program management, including at the decentralized levels, and consolidation of the IEC efforts. As noted, it is envisioned that this will be achieved through the delivery of the EHP within the SWAp framework, into which the national malaria strategy has now been fully incorporated. Although, ex ante, it is hard to calculate the optimal allocations for malaria control, the implementation of the five year Strategic Plan has been costed by the MOH at about $78.6 million. Like the malaria strategy, these costs for the NMCP have also been incorporated in the overall costs for the SWAp program of work. Considerable resources have also been mobilized towards the malaria control effort - the total external and domestic commitments for the implementation of the malaria program from are around $83.8 million, including the GFATM grant of US$40 million. These numbers, on the surface, would suggest that there is no financing gap for the malaria control effort. Indeed, if the available resources are used effectively and equitably, they could go a long way towards achieving the Abuja targets. However, it is hard to make an evidence-based estimate of the total resources required for effective malaria control, or gauge the efficiency and equity of use of the mobilized resources, particularly given the recent decentralization of the delivery of health services in Malawi. The GoM and the SWAp partners have, therefore, requested the Bank to provide technical and financial support for malaria control within the context of the SWAp by strengthening the M&E system. While this is a novel concept for a Banksupported Malaria Booster program, inter alia, it is anticipated that the focus of the program on a strong M&E system will help in the scale-up of the NMCP by improving overall program management, strengthening its poverty focus, and providing a solid evidence base for determining whether or not the current financial, technical and human resources are adequate to reach the targets outlined in the national malaria strategy. Project Justification and Modality: On the basis of the above discussion, a persuasive argument (fully supported by the GoM and the SWAp partners, and aligned with the government program) can be made that the Bank can perhaps best contribute to the scaling up of the NMCP in Malawi by sharpening its outcomes-focus, and assisting the GoM in strengthening the M&E of the malaria program within the broader context of the SWAp, rather than investing in malaria-specific interventions, which may or may not be targeted correctly or used efficiently/equitably. The project proposes to use an improved and more focused M&E to strengthen the programmatic aspects of the SWAp, especially those aspects that relate to malaria control and improved maternal and child health outcomes. These include establishing effective linkages of the NMCP to Ante-Natal Care (ANC), the Integrated Management of Childhood Illnesses (IMCI), and hemoglobin testing for anemia. The M&E effort should be seen not as an end in itself, but as a means to identify relevant malaria control and broader health care issues, and make an evidence-based case on what and how much is needed to address them in the current SWAp and/or in subsequent programs. In addition to setting up an M&E framework, the proposed US$5 million support will emphasize capacity building in M&E (through training and the use of TA, as appropriate) at all levels of the system. An issue in this context is whether, given the key importance attached to M&E by the GoM, it could not be financed through existing SWAp resources, rather than through a fresh infusion of IDA funds. In this regard, in addition to the fact the currently available resources are fully allocated to other ongoing SWAp activities, it is becoming increasingly clear that with the implementation of the SWAp, programmatic issues are emerging that had not been anticipated or planned for previously. For example, and relevant to the proposed Booster program, the recent SWAp annual review has pointed to clear gaps at the intersection of malaria control and maternal and child health services, such as in hemoglobin testing and IMCI assessments. A recent functional review of the SWAp has also highlighted, specifically, the need for strengthened M&E capacities at all levels of the health system, and this, in turn, increases the need for computers and trained personnel in several relevant areas of M&E. The reallocation of existing SWAp monies therefore is not feasible, since it would mean diverting scarce resources from other planned

4 priority activities. In addition, it is obvious that the SWAp is only focusing on the delivery of an essential health package, which constitutes a basic foundation for health services delivery (including for malaria), but which will need to be built upon in order to deliver comprehensive healthcare in Malawi. It is proposed that the support for the Malaria Booster Program be provided in the form of Additional Financing to the existing Health Sector Support Project (HSSP), which is a Sector Investment and Maintenance (SIM) Grant that supports the SWAp. Per the requirements for Additional Financing, the HSSP has been well implemented so far, both from a technical and fiduciary perspective. The proposed project, in line with the new policy on additional financing (OP/BP 13.20), expands significantly the scope of the current World Bank support to the SWAp, without increasing the project s complexity or imposing an additional management burden on the GoM. It is anticipated that the Additional Financing will strengthen concurrently the results-focus of both programs, and leverage the significant contributions that GFATM and the pooled partners, among others, have made to the NMCP. Should the proposed M&E reveal gaps in the NMCP, these could then be addressed appropriately by the SWAp partners, including the Bank. Within the Bank, the use of Additional Financing, in addition to streamlining the internal processing of the project, is expected to strengthen the technical and fiduciary aspects of the ongoing HSSP, and enhance its development impact. Relevance to CAS Objectives. The Bank s 2003 Malawi Country Assistance Strategy (CAS), building on the PRSP, makes improved health status in Malawi a priority for poverty reduction. In order to achieve this, malaria control is essential as it is a major public health problem in Malawi and the single most important cause of morbidity and mortality in children under five years of age and in pregnant women. The project will also contribute towards achieving the MDG goals of reducing infant and child mortality, maternal mortality and control of communicable diseases. In addition, the CAS identified the need for a continuous engagement of the Bank in the health sector, taking into consideration changes in the environment and emerging priorities. Accordingly, the proposed project supports a stronger implementation and increased effectiveness of the HSSP, and the information from the M&E system and studies is expected to provide input for improving or refocusing the present sectoral activities, including malaria control, for better impact. The proposed project is also an important contribution to the focus on results of IDA-14 as well as of the Africa Action Plan (AAP). More specifically, it supports the two objectives emphasized in the AAP of measuring and reporting on progress in programs and projects and scaling up of human development. Main lessons from AAA/ICR: ICRs for recent Bank-supported projects in Malawi have emphasized the importance of realistic objectives -- with greater specificity and focus -- that can be translated into operational and monitorable terms. Within the Health Nutrition, and Population (HNP) sector, the Implementation Completion Report (ICR) for the Population and Family Planning (Pop/FP) project similarly demonstrated the importance of effective design and clear-cut indicators, along with continuous monitoring, in achieving better results. The proposed project will support a similar process with regard to the SWAp implementation, focusing on the use of appropriate indicators (to be identified during the proposed joint preparation mission for the Malaria Booster Program, which will bring together technical and M&E experts from within the Bank, the SWAp partners and the GoM) and effective monitoring in order to improve malaria and health sector outcomes. The recent AAA on the financing of health services and human resources for health also highlighted the importance of the demand side in achieving health outcomes. Conclusions relevant to the malaria program and the development of an effective M&E system include that: (a) household knowledge about health and disease prevention is generally high, but utilization remains low for many key health interventions; and (b) behavioral and cultural factors continue to impede good health practices and care-seeking. Finally, the African HNP Strategy made an impassioned plea for avoiding multiple discrete projects, which lead to the fragmentation of services, preclude government ownership and impose an undue management burden on governments. Consistent with this advice, the Task Team has decided to channel the US$5 million allocated by IDA over 2 years

5 for the proposed Malawi Malaria Booster into the pooled funds for the Health SWAp. The Annual Implementation Plans (AIPs) for the SWAp, which are reviewed jointly by all the SWAp partners is expected to provide the opportunity to ensure that the Bank s Booster funds are used appropriately and for its intended purposes, as agreed with the GoM. Borrower interest and partner support. There is strong government and development partner support for a Bank-supported malaria program that is not a stand-alone project, but is embedded instead within the SWAp. There is significant commitment within the GoM to show results from the SWAp initiative, and to demonstrate that previously successful vertical interventions, such as malaria control, are not being compromised through the integration of service delivery. Furthermore, the government and the partners are keen to be able to show that effective health service delivery can have an impact on key malariarelated, as well as other maternal and child health, outcomes. Accordingly, the GoM and the SWAp partners have indicated their strong interest in working with the Bank to undertake an evaluation of its health service delivery, using malaria as a tracer disease, while simultaneously building up the M&E capacity and systems within the health sector. As noted, the proposed malaria booster is also an opportunity to leverage the large contributions to malaria control of other partners, such as the GFATM and other SWAp partners. The commitment on the malaria control program side is also strong because they are keen to access the technical support and resources that the Bank can provide in undertaking such an evaluation. Finally, there is a strong commitment to the proposed project within the MOH M&E Unit and the SWAp Secretariat because it is expected to provide evidence on the adequacy and implications of the integration of vertical programs into the SWAp. Bank s Strategic Role. The Bank has global and regional experience with SWAps, including in the HNP sector, in many countries in Africa and Asia. The Bank has also been providing technical support for M&E in many countries, both through stand-alone projects and in the context of SWAps and PRSPs. For example, in Malawi, the Bank is supporting the Ministry of Economic Planning in the development of a poverty-focused M&E system, in addition to supporting M&E work in individual sectors. Furthermore, through its recent Malaria Booster strategy, the Bank has responded forcefully to the inadequacy of global efforts to control malaria, and the modesty of the Bank s current efforts relative to its potential, by committing itself to supporting country-led malaria control programs in partnership with community service organizations, specialized agencies, and financiers of malaria control at all levels. The Booster Strategy specifically eschews a one-size-fits-all policy, and focuses instead on outcomes, while allowing flexibility in approaches and lending instruments in individual countries. With regard to the proposed Booster program in Malawi, the GoM and the development partners recognize the Bank's comparative advantage in the area of M&E and have welcomed its role in spearheading this effort in collaboration with the GoM and other partners. Overall, its vast and varied experience in programmatic support, M&E and in malaria control, and its strong results orientation -- well amplified in the AAP -- position the Bank ideally to provide effective technical support and analytical input for M&E focused on malaria control, within the framework of the Malawi health SWAp. In particular, the partners have lauded the proposal to leverage the expertise that Bank has in its other units, such as HDN and DEC, in the Booster program, and have welcomed their inclusion in the proposed February 2006 joint preparation/pre-appraisal mission for the Booster program. In the spirit of collaboration, the partners have also offered to identify representatives from their respective institutions for the proposed joint mission. 2. Proposed project development objective(s) The proposed project is expected to contribute to the implementation of the Malawi Malaria Strategic Plan through an expansion of two of the three components of the HSSP, i.e., (a) ensuring the provision of the EHP (through M&E systems strengthening), and (b) strengthening the support and referral systems (though M&E capacity building) relevant to this package of services.

6 Accordingly, the sub-pdos for the proposed Additional Financing, consistent with the HSSP PDOs, are: 1. Improving management and decision-making in the Malawi Health SWAp through the design and implementation of a robust and sustainable monitoring and evaluation system that provides regular information and feedback to policy makers on: (a) the adequacy of resources for, and optimal approaches to, delivering specific malaria control interventions; and (b) the effectiveness and quality of health service delivery (particularly the delivery of the EHP) through the SWAp, using malaria and malaria outcomes as tracers ; and 2. Strengthening the physical, financial, technical and human capacity at all levels of the health system to monitor the delivery of quality malaria control and health services through the SWAp. Principal outcome(s): Improved health M&E systems, including effective demand side assessments, enabling the effective monitoring of the health sector SWAp and the NMCP. Enhanced capacity at all levels of the health system to undertake M&E and amend the SWAp implementation plans (including the NMCP), as appropriate, using the M&E results. Improved monitoring and evaluation of the malaria control program and of specific malaria control interventions within the context of the SWAP, including the identification of technical, human and financial gaps in the malaria response, and the optimal ways to deliver individual malaria interventions (ITNs, treatment, etc.). 3. Preliminary project description Project alternatives considered. The large burden of disease of malaria in Malawi contributes substantially to the high levels of child and maternal mortality. With the need for IDA to help Malawi achieve the MDGs through its financial and analytical contributions, the no project option alternative is not a realistic alternative. Another alternative is a stand alone investment in malaria activities. Currently, there are significant funds being directed at malaria control through the SWAp, including the recent US$40 million grant from the GFATM. Based on the current costing figures for the implementation of the malaria strategy and government and donor financial commitments, there appears to be no financing gap for malaria. However, at the moment there is no way to know how much of an impact these resources are having on malaria. There was a broad consensus within the health sector in Malawi, therefore, that the design of a mechanism by the Bank, along with its partners, to measure the impact of the existing funds on the disease in the context of the SWAp, and to also identify and address technical, human and financial gaps in the response, would provide a major boost to the malaria control efforts within Malawi. Furthermore, the GoM, working closely with its development partners, has made significant strides in the past year in the integrated delivery of the EHP (in which malaria control is a key intervention) through the health SWAp. As such, there was a consensus within the Task Team and among the SWAp partners that the use of Additional Financing to supplement the current support being provided through the HSSP for the Malawi Health SWAp, would be the most appropriate approach to scaling up malaria control. Key project elements. As noted, the World Bank s Malaria Booster Program is focused on outcomes, and provides flexibility to countries to define the best approach for supporting their respective national malaria control programs. In Malawi, there is a consensus that the Booster program can make a significant contribution to the monitoring and evaluation of malaria interventions, and of the overall SWAp, and that this represents the best use of the available IDA funds. To reiterate, then, the proposed project will be in the form of additional financing to the ongoing World Bank financed HSSP, which

7 supports the development of an essential health package of services through a sector-wide approach. The project will expand the scope of two components of the existing HSSP project, namely: Component 1: Delivery of the Essential Health Package, which will be expanded, inter alia, through the strengthening of the M&E systems for the SWAp, including both supply side and demand side assessments; and Component 2: Health Sector Support and Referral Systems, which will be expanded through the strengthening of the central and district level M&E capacities, which are expected to lead to improved planning, budgeting and delivery of the EHP (including the malaria control interventions) through the sectoral SWAp. Specifically, the Malaria Booster Program will scale up the HSSP s (and SWAp s) impact and development effectiveness by strengthening M&E, as a means to scaling up malaria interventions and realizing the desired malaria targets and broader health sector outcomes. The core elements for the proposed project are: (a) strengthening the M&E systems for malaria control and the delivery of health services through the SWAp; (b) assessing, through an impact evaluation, the extent and appropriateness of the integration of the national malaria program into the SWAp; (c) identifying and addressing technical, human and financial gaps for effective malaria control; (d) capacity building of central and district level health staff in M&E; and (e) provision of TA/support to resolve bottlenecks in the delivery of malaria/health services. 4. Safeguard policies that might apply Since the proposed project is in the form of Additional Financing to the ongoing Health Sector Support Project (HSSP), which already supports malaria control efforts in the context of the SWAp Essential Health Package, the environmental safeguards that have been put in place for the HSSP will also apply to this project. However, given the scope of the Malawi Malaria Strategic Plan, the project will focus additionally on: (i) preparation of a Vector Management Plan, relevant to the SWAp requirements; (ii) inclusion of relevant environment-related monitoring indicators in the SWAp M&E system; and (iii) inclusion of a section on how to dispose of chemicals used for re-dipping insecticide-treated bed-nets, and how to provide relevant training in this regard, if not already done by the Roll Back Malaria Program or other partners. 1. Tentative financing Source: ($m.) BORROWER/RECIPIENT 1 IDA Grant 5 Total 6 2. Contact point Contact: Ramesh Govindaraj Title: Sr. Health Spec. Tel: (202) Fax: (202) Rgovindaraj@worldbank.org