PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: PIDA4451. Project Name. Region. Country

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: PIDA4451 Project Name Mother and Child Health Services Strengthening Project (P148052) Region AFRICA Country Chad Sector(s) Health (90%), Other social services (10%) Theme(s) Population and reproductive health (35%), Child health (30%), Health system performance (25%), Other communicable diseases (10%) Lending Instrument Investment Project Financing Project ID P Borrower(s) Ministry of Finance Implementing Agency MINISTRY OF HEALTH Environmental Category B-Partial Assessment Date PID Prepared/Updated 11-Apr-2014 Date PID Approved/Disclosed 11-Apr-2014 Estimated Date of Appraisal 08-Apr-2014 Completion Estimated Date of Board 29-May-2014 Approval Decision I. Project Context Country Context 1. Despite a significant increase in Gross Domestic Product (GDP) per capita since 2003, Chad remains one of the poorest countries in the world. Since becoming an oil-producing nation in 2003, Chad s GDP per capita has tripled, from US$220 (2003) to US$674 (WorldBank, 2010). However, political instability, particularly from the social and political unrest over the period , has affected the economic growth and development of the country. Economic gains have not been accompanied by a substantial drop in poverty: while the poverty levels in N Djamena have declined from 21% (2003) to 11% (2013), more than half of the rural population remains poor (52.5%) and poverty has declined by only 6% over the last ten years. 2. Chad s progress towards the Millennium Development Goals (MDGs) is very slow and human development indicators are alarming. In 2011, the Human Development Index (HDI) ranked Chad at 183 out of 187 countries (UNDP 2011): (i) 53.2% of the population were living with less than $1.25 per day; (ii) life expectancy was 50 years; and (iii) access to education was limited with 34% of children aged 6-11 not attending school. Health indicators were particularly weak: Page 1 of 7

2 communicable, maternal, neonatal and nutritional diseases represent 74% of causes of deaths in Chad, with 20% of child deaths due to malaria and 33% due to malnutrition (WHO, 2011). Additionally, Chad has been ranked 97th out of 102 countries on the UN Gender Inequality Index, showing that Chad has one of the highest levels of gender inequality in the world (UNDP 2011). 3. Indeed Gender inequalities are pervasive in Chad. They are found in education and health status; in labor force participation and economic activity; in the experience of violence, conflict, and insecurity; and in political participation and decision-making. The adolescent fertility rate is quite high with 8% of Chadian women having a child before 15 years of age, and early childbearing is pervasive (47% of women between years old had a child before 18), affecting not only young women and their children s health and nutrition, but also their long-term education and employment prospects (Guengnant 2011). It is observed that early childbearing (20 to 24 years old) tends to be more frequent among the poor. Improving access to family planning would empower women and potentially improve their economic status. 4. Chad has one of the highest population growth rates in the world. Current data for Chad suggests that population growth is still increasing, at 3.5% per year which would double the current population of approximately 12.5 million by This growth is expected to continue, given the country s young age structure, high fertility rates (Total Fertility Rate estimated at 6.9 children per woman in 2010) and low levels of contraceptive use (Guengnant 2011). Attitudes toward and the use of modern contraceptive methods remain a challenge for the country; in 2010, only 2% of women were using a modern contraceptive method and the unmet needs are estimated to be 28.3% (MICS 2010). Furthermore, rapid population growth impedes poverty reduction due to the continuing high dependency ratio estimated at 98% (in India for instance the dependency rate is about 55%). High fertility rates, close birth spacing, and teen-age pregnancies are also major contributors to maternal and child morbidity, mortality, and malnutrition. 5. Continued insecurity and weak management have slowed implementation of the government s development agenda to date, and with the current trend, most MDGs are not likely to be reached. Sectoral and institutional Context 6. Chad is unlikely to achieve either the objectives set forth in its National Road Map for Accelerating the Reduction of Maternal and Child Mortality ( ) or the Millennium Development Goals (MDG). Chad s maternal mortality ratio, estimated at 1,100 per 100,000 live births in 2010, is the highest among the Central African countries and is currently four times higher than the MDG Goal 5. In fact, since 1990, maternal mortality has increased due to a lack of access to quality maternal health care and the low proportion of deliveries attended by skilled health personnel. 7. Chad s infant mortality rate is estimated at 98 per 1,000 live births in The child mortality rate is higher and decreasing more slowly than in other Sub-Saharan African countries; from 1990 to 2010, child mortality has declined from 210 to 170 per 1,000 live births, but will not attain the MDG Goal 4. Children under 5 years old die primarily from malaria (20%), acute respiratory infections (ARI) (19%) and diarrhea-related diseases (14%). Nutritional status among children has not improved since 1997, and malnutrition accounts for more than one third of child mortality in the country. Immunization coverage of children under 12 months old is extremely low and has even decreased since 2001 (WHO 2012). Page 2 of 7

3 8. Chad has stabilized HIV incidence but the promotion of awareness and prevention must continue. HIV/AIDS rates have stabilized since 2005, but are still in excess of 3% in the year old population and higher among the year old population. While knowledge and attitudes about the disease have improved, use of preventive measures (and particularly condoms) has not. The availability of counseling and testing services has increased steadily and covers virtually all of the health districts. HIV testing by the general population and by pregnant women has increased, particularly since the Government introduced free services for HIV/AIDS. The number of testing sites has increased steadily since 2004 and testing is available in all of the country s 54 districts. The number of persons tested (and receiving their results has increased from (PPLS 2 Report 2004) to (PPLS 2 Report 2012). 9. Health service coverage is low and physical barriers are significant. Geographical access to health care services is limited: 30% of households require more than a two hour walk to access a heath facility, and only 10% of poor people are within a 15 minute walk of a health facility (ECOSIT 2013). In addition, lack of education for women and girls (only 22.4% of women between years old are literate) and socio-cultural barriers to health information both constrain women s use of sexual and reproductive health services (including modern contraceptives) and increase the likelihood of early marriage and consequent pregnancy. 10. Financial accessibility is also a major constraint. Given the reliance on out of pocket expenditures as the main source of health financing, the cost and affordability of health services remain the leading barrier for accessing health care in Chad: it is quoted by 58% of people as the main reason not to go to a health center (ECOSIT 2013). Direct payments for health from households account for 70% of total health financing, increasing the risk for catastrophic expenditures by the Chadian population. Thus, differences in terms of access to care between the poorest and wealthiest quintiles are highly significant: only 5% of the poorest women deliver at the health center against 45.8% of women from the wealthiest quintile (and 59.5% of the poorest women did not have at least one ANC visit against 20% of the wealthiest). 11. Access to quality of maternal and child health services is low. Only 53% of women received antenatal care, and less than one quarter of women were assisted by skilled health personnel during delivery (MICS 2010). Among children with diarrhea or ARI, 25% and 31% (respectively) received the appropriate care; 43% of children received anti-malarial drugs in case of fever, but only 29% received them in a timely manner. 12. Coverage of the population by high impact health interventions in particular is low. Among the high impact interventions, immunization coverage in Chad is alarming: only 3% of months old children are totally immunized (MICS 2010) and there has been a decrease of immunization coverage since For instance, according to MICS-4 data (2010), only 15% of children were immunized against DTP before their first birthday compared to 20% in The most significant decrease is related to the Poliomyelitis immunization rate, which halved between 2000 and 2010 (from 42% to 25%). 13. Measures to prevent malaria are inadequate: only 10% of children and 10% of pregnant women sleep under an ITN, and though 72% of pregnant women received anti-malaria drugs, only 22% received the two recommended doses of SP/Fansidar for the Intermittent Preventive Treatment of Malaria (MICS 2010). Page 3 of 7

4 14. The availability and allocation of resources in the health sector is a major concern in Chad. At about 6% of the overall Government budget, financing of the health sector is very low; in 2011 overall Government expenditures were 4.3% of GDP (about US$35 per inhabitant). Moreover, health public spending does not target health priorities. A benefit incidence analysis of health financing concluded that public expenditure does not target the poorest. The poorest portion of the population receives only 6% of the total public subvention whereas the richest portion receives 46.5%. To improve equity in health access, the government extended free health care to pregnant women and children under five in 2013 (emergency care was already free since 2007), but heath facilities have not received adequate human and financial resources to implement this policy. 15. Management of health financial resources is weak and leakage was estimated at 80% of expenditures (PETS 2004). Resources available for primary health facilities are very low: in 2003 it was estimated that less than 1% of their official non-wage budgetary expenditures from the MoH was received by health centers. 16. The distribution of human resources within the country is inequitable. Compared with WHO norms, Chad is far below the required minimum human resources; further, the lack of health workers is exacerbated by their unequal distribution, with a high concentration in Ndjamena. While the capital comprises only 15% of the population, 57% of doctors and 50% of midwives work there. 17. Availability of drugs at an accessible cost is uneven across health facilities. Indeed, weak management and poor organization throughout the pharmaceutical sector have resulted in inadequate supplies of essential drugs: less than 36% of children with fever received antimalarial drugs in 2010; and only 23% of children with diarrhea received oral rehydration (WDI, 2013). Limited access to medicines for the population is one of the consequences of poor drug legislation and regulation governing the pharmaceutical sector and inadequate implementation guidelines. Poor availability has been exacerbated by poor prescription practices and increasing use of a parallel drugs market. 18. In response to the poor service delivery and inefficiencies in health sector management, Chad has been piloting two innovative strategies: 1) Health Service Delivery thru performance based financing (PBF) and 2) financing of Health Mobile Teams. Since October 2011, the Government with support from the World Bank (Second Population and AIDS Control Project) has introduced a Results-Based Financing (PBF) scheme in eight health districts across four regions (Batha, Guera, Mandoul, and Tandijile) covering a total population of 1,450,000 people (102 health centers and 9 hospitals). The Pilot included the financing of two packages of services: One basic package of health services comprising 12 key health services, principally targeting pregnant women and children under five, to be delivered at the health centers in targeted areas. The second package consisted of 12 key complementary health services to be delivered at district hospitals in targeted areas. In addition to these health service packages, a quality checklist was also introduced to improve quality of health services provided. 19. In less than a year, utilization of health services in PBF targeted areas increased substantially, as did the quality. Based on operational data and independent evaluation, achievements of the PBF pilot were documented. The evaluation demonstrated that the pilot program has achieved substantial results: (i) utilization of health services has (on average) doubled in the PBF health centers. For instance, utilization of modern family planning methods increased Page 4 of 7

5 from 0.1% to 0.3% in 18 months. Immunization rate increased by an average of 4.9% in that same period. Finally, assisted deliveries have also increased from 17% at the start of the PBF scheme to 40% after 18 months of implementation (AEDES Report 2013). (ii) Quality of care has improved (with improved availability of drugs, equipment, and motivation of health workers). (iii) Increased autonomy of health facilities to use additional resources to better meet the priorities of their area was also observed. 20. The Government is strongly committed to strengthen and scale up PBF in the health sector and has set up a unit representative of the ministries of Planning and of Health. Indeed, based on these initial operation results, the Government has shown interest in pursuing this strategy and has undertaken steps to strengthen its capacity. For instance fifteen members of the unit have been trained in PBF and visited Rwanda to learn about their experience in scaling up PBF. The Government has also allocated about US$1.5 million in the second half of 2013 to continue implementation of the PBF pilot. However, the funds have not been disbursed yet due to reported budget constraints. 21. The other successful strategy undertaken by the Government, is the financing of the Mobile Health Teams (Equipes Mobiles). This initiative tackled the issue of geographical access and was able to increase utilization of health services in remote areas of the country. The activities involved vehicles with trained health workers (the mobile teams) who visited isolated villages once a month to provide essential services. Positive results of the mobile teams have also been recorded, particularly in comparison with the results of the fixed sites providing health services. II. Proposed Development Objectives 29. The objective of the Project is to increase utilization and improve the quality of maternal and child health services in targeted areas. III. Project Description Component Name Component 1: Improving accessibility and quality of Maternal and Child Health Services through Performance Based Financing and Community Health Comments (optional) Component Name Component 2: Strengthening the institutional capacity to implement and sustain performance-based financing and community-level health care services Comments (optional) IV. Financing (in USD Million) Total Project Cost: Total Bank Financing: Financing Gap: 0.00 For Loans/Credits/Others Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) Page 5 of 7

6 Total V. Implementation VI. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 Natural Habitats OP/BP 4.04 Forests OP/BP 4.36 Pest Management OP 4.09 Physical Cultural Resources OP/BP 4.11 Indigenous Peoples OP/BP 4.10 Involuntary Resettlement OP/BP 4.12 Safety of Dams OP/BP 4.37 Projects on International Waterways OP/BP 7.50 Projects in Disputed Areas OP/BP 7.60 Comments (optional) VII. Contact point World Bank Contact: Aissatou Diack Title: Senior Health Specialist Tel: Borrower/Client/Recipient Name: Ministry of Finance Contact: Title: Tel: Implementing Agencies Name: MINISTRY OF HEALTH Contact: MOH Title: Coordinator Tel: Page 6 of 7

7 VIII.For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C Telephone: (202) Fax: (202) Web: Page 7 of 7