Sub-national government administration (10%);Health (57%);Central government administration (18%);Other social services (15%) Project ID

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Project Name PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB5554 Malaria Booster Project Additional Financing Region AFRICA Sector Sub-national government administration (10%);Health (57%);Central government administration (18%);Other social services (15%) Project ID P Borrower(s) GOVERNMENT OF THE REPUBLIC OF ZAMBIA Implementing Agency Government of Republic of Zambia Ministry of Health Ndeke House P.O. Box Zambia Tel: Fax: Environment Category [ ] A [] B [] C [ ] FI [ ] TBD (to be determined) Date PID Prepared October 19, 2010 Date of Appraisal April 19, 2010 Authorization Date of Board Approval December 7, Country and Sector Background Zambia is a country which despite its mineral wealth and fertile soil is one of the poorest countries in the world. Its rank in the 2009 UN Human Development Index is 164 out of 182 countries. Despite positive, relatively broad-based and stable growth record since the late 1990s and immense untapped potential in agriculture, mining and services, Zambia s poverty rates remain high. According to a household survey conducted in 2006, 64 percent of the population are still poor. Poverty rates remain highest in rural areas (80 percent) where two-thirds of Zambia s inhabitants reside. This implies that the vast majority of the poor (72 percent) live in rural areas. Over the past two decades, the country has been grappling with the challenge of meeting the healthcare needs of its growing population in the face of an escalating disease burden and a national health system weakened by years of chronic under-funding. The advent of the HIV/AIDS epidemic and the resurgence of other major infectious diseases, including TB and malaria, have further exacerbated the situation. Starting in the 1990s, the Government of the Republic of Zambia (GRZ) made notable efforts to increase operational efficiencies throughout the health sector. A number of reforms were introduced, including decentralization of service delivery and a focus on the provision of costeffective basic health care package intended to improve health outcomes, especially among the rural poor.

2 Possibly as a result of these changes a downward trend in key health indicators has been observed in recent years. The latest Demographic and Health Surveys (DHS) show a decrease in the maternal mortality rate (MMR) from 729/100,000 in 2002 to 591 in Similarly, there has been significant reduction in the infant mortality rate (IMR) from 95 to 70 per 1000 live births during the same period. Under-five mortality rate (U5MR) also dropped from 168 per 1000 live births in 2002 to 119 in 2007 (DHS 2002 and 2007). The drop in mortality rates is also likely to be associated with the tremendous progress that has been made in the area of malaria prevention in recent years. The percentage of households owning at least one insecticide-treated net (ITN) increased from 38% in 2006 to 62% in 2008, the population covered by IRS increased from 1.2 million to 3.5 million during the same period and the share of mothers taking 2 doses of IPT during their last pregnancy increased from 59% in 2006 to 66% in 2008 (2006 and 2008 Malaria Indicator Surveys [MIS]). The efforts to expand preventive services have translated into a significant drop the percentage of children with parasitaemia, from 29% in 2006 to 10% in Some achievements have also been made in the area of HIV/AIDS resulting in a reduction in the national HIV adult seroprevalance rate from 15.6% in 2005 to 14.3% in However, Zambia remains a hyper endemic country. Although these statistics show that the country has made progress, service delivery is still characterized by poor quality and low coverage. Persistent service delivery constraints sharpened recognition of key underlying problem of the health system, such as the overall inadequacy and poor management of the health workforce. In summary, while Zambia is making progress towards achieving the health related Millennium Development Goals (MDGs), the current figures are still poor, particularly in the area of maternal and child health. The country faces a tremendous challenge in reaching the healthrelated MDGs by Objectives The Zambia Malaria Booster Project (MBP) was approved on November 15, 2005 and became effective on March 13, 2006 as a US$20 million IDA credit with a closing date of January 31, The original Project Development Objective (PDO) was to increase access to, and use of, interventions for malaria prevention and treatment by the target population. The target population was the population of Zambians living in all the 72 malaria endemic districts of the country. The priority groups among this target population were children under the age of five years, pregnant women and all those infected with malaria. In November 2009, the project was approved for a Level 1 restructuring. There were available co-financing resources to support this restructuring from the results-based financing (RBF) grant 1 which Zambia received through a competitive selection process. The grant provided an 1 The Results-Based Financing grant is a multi-donor trust fund primarily supported by the Norwegian government that supports a results-based approach to health sector development.

3 opportunity to broaden the scope of the project which now includes some of the original malaria interventions as well as additional maternal and child survival interventions. In the restructured project, the specific activities to be financed through the grant will use RBF as a tool for improving coverage of a core set of maternal and child health interventions. The new additional financing of US$30 million provides an opportunity to scale up the malaria component of the restructured project while maintaining the successes in the malaria program supported during the first phase of the program. The PDO will remain the same: To increase coverage of interventions for malaria prevention and treatment and other key maternal and child health interventions. The PDO indicators have been revised to reflect the scaled up project: (i) To increase the percentage of children under age five who slept under an insecticide- treated net (ITN) last night from 50% to 55% by (ii) To increase the percentage of pregnant women receiving more than two doses intermittent preventive treatment (IPT) for malaria from 70% to 75% by (iii)to increase percentage of households sprayed in the previous 12 months from 23% to 26% by (iv) To increase the percentage of women delivering in facilities by skilled birth attendant in RBFeligible districts from 34% to 40% by Rationale for Bank Involvement The original project has performed very well and it has made a significant contribution to the recent improvements in coverage of key malaria prevention activities in Zambia. The project funds have been almost fully disbursed. Key results of the project are summarized in table 1 2. Table 1: Key outcome indicators of the Zambia Malaria Booster Project Indicator Baseline Status at mid-term (2006) (2008) (2010) Percentage of children under age 5 who sleep under a 30% 41% 60% treated bed net from 30% to 40% by 2008 (a) Percentage of pregnant women who receive a complete 45% 66% 70% course of intermittent presumptive treatment for malaria from 45% to 55% by 2008 (a) Percentage of households that have at least one insecticide treated net from 14% to 30% by 2007 (b) 14% 53% 64.3% Source: (a) based on the 2006, 2008 and 2010 Malaria Indicator Surveys. (b) based on the 2001/2 and 2007 Demographic and Health Surveys 2 During the design phase of the Malaria Booster, mid-term targets were defined (2008). Data is collected biannually. The next Malaria Indicator Survey is scheduled for July 2010.

4 The stewardship, coordination and implementation of the Project by the Ministry of Health (MOH) and the National Malaria Control Program has been mostly satisfactory, with strong performance on the technical side and procurement. The financial management of the project has been weak and a detailed plan has been developed to address this issue. The MOH has shown a strong commitment to sustaining the success of the project and addressing the weaknesses in the financial management. Fluctuations in donor financing,, caused disruptions in the implementation of many of the activities in preparation for the 2009/2010 malaria season. Because of the specific nature of malaria interventions, with continuous annual investments 3 needed to avoid resurgence of malaria, these disruptions have already resulted in serious consequences for the population in certain provinces. For instance, in Luapula province, malaria incidence rates increased from 12 percent to 51 percent between 2008 and During the same period, severe anemia 4 in children increased from 3 percent to 11 percent in the same province. This implies an increased number of children and mothers dying of malaria. In response to this situation, the GRZ raised concerns regarding the financing gap of the malaria program and requested the Bank for AF for the MBP. The financing gap between 2010 and 2013 has been estimated to US$38 million in total. The MBP AF will cover a large part of the financing gap, while other partners will cover the remaining US$8 million. The AF will be allocated to the following key program areas: US$20.0 million for Long Lasting Bed nets, US$3.5 million for the Indoor Residual Spraying, US$4.0 million for malaria case management, including the supply of pharmaceuticals and diagnostics 5, US$1.5 million for community mobilization and US$1.0 million for program management and monitoring and evaluation. The proposed AF is fully aligned with the CAS through the "Improving health performance, education, and training" pillar. There are three main goals for health under this pillar: 1) Health policy and planning: mobilize resources and ensure efficient use of resources to promote equity of access to cost-effective and quality health care; 2) Integrated reproductive health: to reduce Maternal Mortality Rates by 3/4: and 3) malaria control and prevention: to reduce morbidity and mortality due to malaria in the general population. The related outcome under this pillar is CAS outcome 4.1-improved health programming. The CAS recognizes that health is one of the Bank s comparative advantages in Zambia and one of the GRZ s priority areas and the proposed AF directly contributes to the achievement of these goals. 4. Description There will be no changes to the main components of the project. Similar interventions will be financed as under the original project. The interventions (COMBOR, LLIN distribution) will be 3 E.g. replacement of bednets, Indoor Residual Spraying Campaigns, etc 4 Many African children die because they develop severe anemia. As many as 5 million cases of severe malarial anemia occur in African children every year, and 13% of these cases are fatal. Turning the statistics around, more than half of young children in African countries where malaria is endemic are anemic. Nutritional deficiencies and various infections account for some of this disease burden, but malaria is one of the most important factors contributing to anemia. The malaria parasite destroys red blood cells as part of its life cycle, releasing hemoglobin (Hb) an iron-containing protein that carries oxygen around the body into the circulation. Free Hb can cause oxidant stress, which is itself associated with anemia in malaria. 5 These are all activities under part 1a of the project components.

5 used to scale up coverage in areas where gaps exist and will also be focused on sustaining malaria control activities that are recurrent on a periodic basis (IRS). The following activities will be financed by the additional financing: Part 1(a) Strengthening the Health System to Improve Service Delivery 1. Procurement and distribution of Insecticide Treated Nets (ITNs), Rapid Diagnostic Tests (RDTs), insecticides and other equipment and supplies for the Indoor Residual Spraying (IRS) campaign; 2. Scaling up access to malaria drugs and Rapid Diagnostic Tests through procurement of goods and strengthening the logistics and supply chain management. Part 1(b) Improved Environment Health Management Support for improved environmental safeguards through the implementation of the Environmental Management Activity Plan. Part 2 Community Booster Response to Malaria (COMBOR) Provision of support to strengthen local capacities of communities to effectively prevent, control and treat malaria and deal with the demand-side constraints to effective malaria control programming, based on community demand-driven interventions through financing on a grant basis ( Community Sub-Grants ) of selected sub-projects to be carried out by community based organizations. The additional financing will support the scale-up of the COMBOR. Part 3 Monitoring and Evaluation and Program Management Support (a) Monitoring and evaluation of the malaria program achievements; (b) Program Management Support including capacity strengthening in procurement, financial management, and internal audit as well as recruitment of a IFRA to provide fiduciary oversight to the project; (c) Operational Research 5. Financing Source: ($m.) BORROWER/RECIPIENT 0.0 INTERNATIONAL DEVELOPMENT ASSOCIATION 30.0 Total Implementation The MOH will continue to be responsible for the implementation of the credit. More stringent fiduciary measures will be put in place, including the contracting of an IFRA, as well as intensified

6 World Bank supervision and support for the overall governance strengthening in the sector. The financial terms and conditions will be standard IDA terms. Closing date extension: The project closing date will be extended from January 31, 2012 to January 31, 2013, which is within the allowed 3 year limit of extension of the original project. Financial Management and Disbursement Arrangements: To address the weaknesses identified in the financial management in the MOH the project will put in place several measures to ensure strong fiduciary management of the project s resources. These measures include the use of a designated account and exclusion of the pooled fund, the recruitment of a Fiduciary Review Agent to provide oversight for the financial management and procurement transactions that take place under the project, intensified Bank supervision and support from INT for capacity building of the internal audit function to carry out forensic audits and allocation of project resources for governance strengthening of the health sector more widely. More details on the financial management safeguards are provided in the appraisal section of this document. The AF will be added to the original funds and will be made available under the same disbursement arrangements as the original credit. The original credit will be fully disbursed, by category, prior to the AF being disbursed. Environmental Safeguards: The original credit was classified as Category B due to the planned procurement of DDT for the IRS campaign. During project preparations a Vector Management Plan and Health Care Waste Management Plan were developed and disclosed on September 15, During the implementation of the original project, IDA financed a safeguards activity plan that included capacity building of MoH and provincial staff in health care waste management, preparation and dissemination of waste management guidelines, and rehabilitation of the environmental health school to start a Bachelor of Science Program in Environmental Health. The Bank also provided support for a survey to review health care waste management in Zambia, which was used to develop the updated Health Care Waste Management Plan During regular supervision missions, including from a Senior Environmental Specialist, progress on the implementation of the environmental activity plan was reviewed. Implementation has been consistently rated as satisfactory. With the proposed additional financing, the project is still classified as category B given the risks associated with indoor residual spraying (IRS) and disposal of health care waste. Recently, the National Malaria Control Centre is moving away from the use of DDT. It was agreed during appraisal to solely focus on the procurement of other insecticides (pyrethyroids) as part of the support under the additional financing. Two safeguard policies remain triggered: Environment Assessment (OP/BP/GP 4.01) and Pest Management (OP 4.09). The two current safeguard instruments (Integrated Vector Management Action Plan and the Health Care Waste Management Plan have been developed and disclosed as stated above). The Health Care Medical Waste Management Plan was amended and disclosed on June 29, 2009 as part of the restructuring process of the project and is valid until These safeguard instruments are

7 sufficient to manage all safeguard risks under this additional financing. The ISDS has been updated to reflect this change. The additional financing does not involve any exceptions to Bank policies. There are no changes in the financial Analysis, economic Analysis and Beneficiary and Social Assessment from the original credit. There are no changes in the institutional and implementation arrangements of the project. The proposed additional financing will have no major effect on the original economic, financial, technical, institutional, or social aspects of the project as appraised. 7. Sustainability The considerations regarding sustainability of the original Project are still highly relevant for the interventions on prevention and treatment of malaria.. 8. Lessons Learned from Past Operations in the Country/Sector Lessons learned from the original PID are still important for the restructured project and for the AF. The Implementation Completion Report (ICR) for the last World Bank financed MAP project in Zambia, Zambia National Response to HIV/AIDS (ZANARA) project highlighted the following lessons learned that are relevant for the restructured project: Fiduciary issues: Misappropriation of funds can be avoided by (i) the use of simplified and clear guidelines for financial management, procurement, and reporting; (ii) the effort undertaken at the outset to build capacity in fiduciary issues at all levels; and (iii) the tracking of processes at all levels, which permitted timely identification and resolution of bottlenecks. Procurement: An important area that had a positive impact on the pace of project implementation, in the case of ZANARA, was procurement. It was concluded that initial investments to build procurement capacity resulted in improved pace of project implementation. 9. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No OP/BP 4.00 Environmental Assessment (OP/BP 4.01) Natural Habitats (OP/BP 4.04) Pest Management (OP 4.09) Physical Cultural Resources (OP/BP 4.11) Involuntary Resettlement (OP/BP 4.12)

8 Indigenous Peoples (OP/BP 4.10) Forests (OP/BP 4.36) Safety of Dams (OP/BP 4.37) Projects in Disputed Areas (OP/BP 7.60) * N/A Projects on International Waterways (OP/BP 7.50) N/A 10. List of Factual Technical Documents 11. Contact point Monique Vledder Title: Sr Health Specialist Tel: (202) Fax:(202) mvledder@worldbank.org 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C Telephone: (202) Fax: (202) Web: * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties claims on the disputed areas

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