The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) Project Information Document (PID) Concept Stage | Date Prepared/Updated: 21-Oct-2021 | Report No: PIDC32323 Sep 06, 2021 Page 1 of 9 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) BASIC INFORMATION A. Basic Project Data OPS TABLE Country Project ID Parent Project ID (if any) Project Name Central African Republic P177003 CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) AFRICA WEST Dec 20, 2021 Mar 17, 2022 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Central African Republic Ministry of Health and Population, Central African Republic Proposed Development Objective(s) To increase utilization of quality essential health services for women and chidren in targeted areas in the Central African Republic. PROJECT FINANCING DATA (US$, Millions) SUMMARY-NewFin1 Total Project Cost 55.00 Total Financing 55.00 of which IBRD/IDA 43.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 43.00 IDA Grant 43.00 Non-World Bank Group Financing Trust Funds 12.00 Sep 06, 2021 Page 2 of 9 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) Global Financing Facility 12.00 Environmental and Social Risk Classification Concept Review Decision Substantial Track II-The review did authorize the preparation to continue Other Decision (as needed) B. Introduction and Context Country Context Central African Republic (CAR) experiences recurrent conflicts, political volatility, and extreme poverty. CAR is considered the third most fragile and violent country in Africa according to the Global Peace Index (2020). By August 2021, 2.8 million people in CAR needed humanitarian assistance, out of a population of 5.4 million.1 Democratic elections were held in 2016 when President Touadera was elected president and the Khartoum Peace Accord was signed between 14 major armed groups and the government in February 2019. By April 2021, one-fifth of the population (738,000) was internally displaced—nearly half of them being children,2 due to the recent presidential electoral turmoil in January 2021 caused by the rebellious opposition. The level of poverty remains high in CAR with the latest 2020 World Bank projections suggesting that approximately 70 percent of the population is living below the international poverty line (defined as US$1.90 per day in terms of PPP). GDP per capita in CAR plummeted from US$1,102 (PPP) current international dollar in 2012 to US$739 in 2013 due to conflict, and has still not reached pre-crisis levels, standing at US$980 in 2020. The Coronavirus (COVID-19) pandemic has had a profound impact on CAR’s economy. While the number of COVID-19 related deaths in CAR remains relatively low, disruption in global value chains, low external demand, and domestic containment measures that significantly affected trade, transport, and tourism. CAR’s economy decelerated in 2020 as compared to 2019. However, its GDP growth of 0.8 percent was higher than regional peers (−2.9 percent) and countries affected by fragility, conflict & violence (FCV) (−1.7 percent).3 The GDP per capita in 2021 is expected to be about the same as in 2019, indicating that the country is expected to lose 2 years in per capita income growth due to the pandemic. Years of conflict and the lack of essential services for human development have translated into low human capital outcomes. CAR is ranked the lowest in the world on the human capital index. A child born in CAR today can only expect to be 29 percent as productive when s/he grows up as s/he could have been if s/he had benefitted from full health status and complete education.4 This is 27 percentage points lower than the worldwide estimate of 56 percent. One out of ten children5 born in CAR today will not survive to age five, and only 59 percent of 15-year-olds will survive to age 60. Life expectancy is at 53 years, roughly 9 years lower than the Sub-Saharan African (SSA) average the same year (61.6 years) 1 World Bank, 2021. 2 UNICEF, 2021 https://www.unicef.org/press-releases/central-african-republic-nearly-370000-children-now-internally-displaced-amidst) 3 World Bank, 2021. 4 This is based on 2020 pre-Covid 19 estimates from the World Bank Human Capital Project. 5 88 out of 100 children born in CAR survive to age 5. Sep 06, 2021 Page 3 of 9 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) and has been consistently below the SSA average for the past 40 years.6 Sectoral and Institutional Context CAR has one of the highest maternal mortality and fertility rates in the world. Despite a slight improvement as compared to 2010, maternal deaths are estimated at 829 per 100,000 live births in 2017, significantly higher than the SSA average of 534.7 Adolescent fertility rate remains high in CAR despite the downward trend since 1960 and is estimated at 184 per 1000 live births in 2019 (MICS 2019). Only 14 percent of women of reproductive age use modern contraception, 41.4 percent of pregnant women receive four antenatal care visits and 58.3 percent deliver in a health facility.8 Child mortality and chronic malnutrition (stunting) levels are extremely high. Despite the measurable improvement between 2010 and 2018 in CAR, with the infant mortality rate decreasing from 116 in 2010 to 65 deaths per 1000 live births in 2018 and under five years mortality rate decreasing from 179 to 99 deaths per 1000 live births, these rates are still highest in the world.9 Likewise, CAR has the second highest neonatal mortality rate in the world, at 28 per live births.10 The three main causes of child mortality are communicable diseases and include diarrhea, respiratory infection and malaria. People in CAR experience inequalities in access and utilization of health services across geographical location and income level. The share of 15-49 pregnant women in rural areas who haven’t received any antenatal care services is 3.8 times higher than 15-49 pregnant women in urban areas. The share of pregnant women in rural areas giving birth outside of a health care facility, either public or private, is also 2.8 times higher than of those in urban areas. There is also an important gap between income groups: the share of women in the poorest quintile who receive antenatal care is 10.6 higher than those in the wealthiest quintile. Similarly, the stunting rate of under five years old children in rural areas is 1.4 times higher than those in urban areas. As for DPT3 vaccines for 12-23 months old children, regional variation is equally wide. With the return of peace and stability in some areas of CAR since 2016, the government has a window of opportunity to re-build the country’s health system and make progress on reducing maternal and child mortality. In 2020, the Ministry of Health and Population (MOH) outlined ten core domains of action to initiate progress towards Universal Health Coverage11 (UHC) by 2030. Following the development of the Health Sector Transition Plan for 2015-2017 and the Interim Health Sector Plan for 2018-2019, MOH is now developing the third phase of National Health Development Plan for 2022- 26, which will outline the country’s long-term vision for the health sector. The Presidential Decree of Targeted Free Healthcare for all pregnant, post-partum women, children under-five, and survivors of GBV was established in 2018, and provides a major step for the government to ensure that vulnerable groups can access basic care. The Decree was reinforced with the adoption of Performance-Based Financing (PBF) as a national strategy for service provision. To tackle the persisting challenge of high maternal and child mortality, the country with support from the Global Financing Facility (GFF) drafted the Investment Case for the Rapid Reduction of Maternal and Child Mortality to prioritize the sector around 6 World Development Indicators, 2021. 7 World Development Indicators 8 Multiple Indicator Cluster Survey (MICS), 2018-2019. 9 ICASEES. (2010). MICS, Final report. Bangui, CAR: UNICEF, UNFPA, WHO, World Food Program, World Bank, ICF international. 10 MICS, 2018-2019. 11 The ten domains of Presidential impetus for Universal Health Coverage in CAR are to: 1) bring health services closer to the population, 2) provide access to essential medicines, 3) provide access to vaccination and to fight against epidemics, 4, 5, 6) fight against HIV/AIDS, tuberculosis (TB) and malaria, 7) provide access to good child nutrition and clean water and sanitation, 8) enhance girls' education, 9) to ensure safe childbirth and family planning needs, and 10) provide road safety. See Annex 4. Sep 06, 2021 Page 4 of 9 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) key health systems strengthening strategies and a core package of high impact interventions to be delivered by health facilities and community health workers.12 Many of the constraints facing the health system are inherently linked to the country’s longstanding fragility, violence and conflict. The recurrent military and political crises in CAR have profoundly disrupted the delivery of basic social services. These crises have resulted in massive displacement of populations fleeing armed conflict, systematic looting and destruction of social and health infrastructures, and human rights violations including gender-based violence (GBV). On the supply side of health service delivery, critical bottlenecks include: (i) severe shortage of personnel, infrastructure, and other critical inputs for health facilities to deliver basic health services, coupled with difficulty in physical access to health services due to poor road conditions and persisting insecurity; (ii) lack of a functioning supply chain and distribution network to efficiently deliver drugs and medical supplies; (iii) limited coverage of community based interventions to more efficiently promote health, prevent and cure diseases to reach the most remote and vulnerable. Weak governance of the health system due to limited administrative capacity, regulations and mechanisms to promote accountability and transparency, and low and inefficient health spending, with high reliance on donor funding that is difficult to coordinate are also critical bottlenecks. Health related data and information to inform policy are also scarce. On the demand side, barriers to increase the uptake of health services include: (i) inability to afford the costs of health services due to high level of poverty, and (ii) a large number of vulnerable populations, including GBV survivors and IDPs, who require specialized care but are unable to access it. Relationship to CPF This project supports the CAR Country Partnership Framework (CPF) for 2021-2025, the Africa Human Capital Plan and the World Bank’s Fragility, Conflict and Violence (FCV) strategy. Human Capital and health are the backbone of the country’s new CPF, with the first focus area of the strategy being Human Capital and Connectivity to Boost Stabilization, Inclusion and Resilience. The project’s focus on health service delivery and health system strengthening as a means to develop human capital of all people in CAR is a major priority in the Africa Human Capital Plan. Furthermore, the project will support the CPF and FCV strategy by rebuilding confidence in government institutions to deliver social services and strengthening social cohesion within communities. The project is relevant to the World Bank’s Response Framework for COVID-19. The response framework focuses on three areas: Relief, Restructuring, and Resilient Recovery. The project supports CAR in the “Restructuring� phase. It aims to restore livelihoods and support enhanced quality and access to basic health services. The project will be closely linked to existing operations that focus on the “Relief� phase as well as the “Resilient Recovery� phase. C. Proposed Development Objective(s) To increase utilization of quality essential health services for women and chidren in targeted areas in the Central African Republic. Key Results (From PCN) a. Number of deliveries attended by a skilled health personnel b. Number of women who received antenatal care 12 The Investment case is currently being updated based on the latest Multiple Indicator Cluster Survey 2019. Sep 06, 2021 Page 5 of 9 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) c. Number of children who have received three doses of Pentavalent OR Number of children (aged 6 to 59 months) receiving vitamin A d. Quality average score of health centers in targeted areas e. Percentage of availability of tracer drugs in targeted health facilities D. Concept Description The proposed SENI-Plus project will build on the gains made under SENI, while pursuing continued improvements in areas that require further adjustment to achieve greater sustainability and efficiency. The project seeks to support the government’s effort to improve the delivery of essential health services and strengthen the country’s health system by: (i) providing continued support to the implementation of the government’s targeted free health care policy, through continued use of PBF as a health system strengthening strategy; (ii) strengthening community level service delivery through support to implementation of the National Community Health Strategy. The project will further strengthen the various pillars of the health system, particularly on: (iii) developing and establishing a functional supply chain system for the country; (iv) strengthening the health system to provide holistic support to GBV survivors; (v) strengthen governance and health financing; (vi) provide support to human resources for health through enhanced capacity building of frontline health workers; and (vii) strengthening the health information systems through introduction of a new DHIS2-based national health information system. Additionally, the project will continue to support expansion of the holistic GBV strategy for GBV survivors with medical, psychosocial response and wide-scale community prevention and behavior change activities. Alignment of partners around core government priorities will be central to the project. The project will benefit from the Global Financing Facility (GFF) Essential Health Services Grant (US$12 million) which will leverage the IDA funds. The grant’s primary objective is to scale up sustainable investments for the continuation of essential service delivery for reproductive, maternal, child and adolescent health and nutrition efforts throughout the COVID-19 pandemic. The country has been benefiting from GFF financing and technical assistance under the ongoing SENI project, which has provided a space and process for MOH to coordinate key partners in health, to address the issue of fragmentation and inefficiency. The additional grant to be made available through SENI-plus will further provide an opportunity to convene the government and partners to better coordinate and align their efforts, including for the implementation of package of high impact interventions identified in the Investment Case as well implementation of key reforms that are supported under this project. Component 1: Improving essential service delivery at health facilities and in communities seeks to (i) continue and expand the delivery of targeted free health care through continued use of PBF as a delivery model but with an adapted approach; (ii) support the implementation of the Community Health Strategy by financing a basic service packages including exploring different approaches to incentivizing the community health workers, as well as development of tools and materials to facilitate coordination. Component 2: Health system strengthening will address critical bottlenecks to a functioning health system in CAR. Activities to be supported under this component will comprise: (i) reconstruction of a national supply chain; (ii) strengthening the health system to provide holistic support to GBV survivors, (iii) implementation support to key reforms that address system bottlenecks, including in the areas of health financing, human resources for health and health information systems. Component 3: Project Management and Monitoring & Evaluation will help ensure an effective and efficient technical and Sep 06, 2021 Page 6 of 9 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) fiduciary management and implementation of the project. The component will support the project implementation through the financing of (i) operating costs, training, and equipment; (ii) paying salaries of international and national consultants; (iii) audits and communications, and (iv) implementation and monitoring of environmental and social standards as well as project results indicators. The project implementation unit that will be responsible for day-to-day management of the project will be the current SENI- REDISSE4 National Technical Unit (Cellule technique national, CTN) who will also assume the responsibilities of the implementation of the SENI-plus project. The SENI- REDISSE4 CTN’s performance is currently satisfactory, and their capacity will be augmented through additional resources to accommodate the increased workload. A capacity assessment of the PIU will be conducted to clearly identify the additional needs. Additionally, Component 4 Contingency Emergency Response Component (CERC) will be included under the project in accordance with World Bank IPF Policy’ paragraphs 12 and 13, for projects in Situations of Urgent Need of Assistance or Capacity Constraints. This will allow for rapid reallocation of project proceeds in the event of a natural or man-made disaster or crisis that has caused, or is likely to imminently cause, a major adverse economic and/or social impact. Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No Summary of Screening of Environmental and Social Risks and Impacts . The environmental risk rating is Substantial. The implementation of project activities will generate risks and potentially reversible impacts on the environment. The improvement in the provision of essential services in health facilities and communities through PBF under component 1 will lead some beneficiary hospitals and health facilities to carry out small- scale rehabilitation of delivery rooms, laboratories, and treatment rooms, in addition to enabling a safe space for GBV survivors to access services without being exposed. The improvement in the provision of services in health facilities will also lead to an increase in the amount of biomedical waste, as well as an increase in the health and safety risks for staff and, to a lesser extent, to communities, especially if the waste is not properly managed. Under component 2, some activities will involve civil works, notably the construction of a national and regional supply warehouses under the subcomponent 2.1. The civil works will generate negative impacts such as: construction waste, noise pollution, space conversion, destruction of vegetation cover, increase in aerosols and engine fumes, risks of transmission of STIs/HIV/AIDS due to the arrival of working personnel, and community and occupational health and safety risks(OHS) (including the risk of spreading COVID-19). All of these potential risks and impacts will be assessed in detail in the ESMF that will be prepared along with other instruments prior to project appraisal. The social risk rating is Substantial at this stage of project preparation. Under Component 1, Improving essential service delivery at health facilities and in communities, activities to be developed include the PBF interventions support targeted free healthcare for maternal and child primary healthcare, preventative interventions, and survivors of GBV, and for the marginalized and poor households, TA and improvements of health service quality within health facilities and communities. All these activities will target beneficiaries such as vulnerable groups (women, GBV survivors, IPs) and poor households. They will need to ensure that any risks of discrimination and exclusion are addressed. Moreover, the criteria for providing free healthcare services should be clearly designed, fixed and publicly disclosed in a transparent process of selection of beneficiaries. An inappropriate or flawed selection process could create social tension among communities. The same attention should be paid under Component 2 concerning the recruitment of community workers (Indigenous Sep 06, 2021 Page 7 of 9 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) people, young people) in the construction of warehouses. In addition, measures need to be taken to mitigate risks related to the expansion of transmissible diseases (STI, HIV/AIDS, COVID-19) given that through these activities, the project will be able to reach a wide range of people, and disseminate training and information. However, while the overall social benefits are expected to be positive, the anticipated social risks and impacts include security risks. The project is intending to be implemented in urban, peri-urban or rural areas in the country. Unfortunately, there may be the presence of non-state armed groups in these areas. Thus, the risk of attacks on project workers, beneficiaries, as well as their personnel should be considered. A project security assessment and management plan should be developed to define mitigation measures. The new wave of COVID-19 risks include COVID-19 related risks of dissemination, uncertainties from new waves, and awareness campaign activities. Measures set by CAR government in its press release of March 2020, and in line with those of WHO and WBG health and safety guidance, should be adapted and implemented in all mass meetings (training sessions, events, information campaign, consultations, etc.) to avoid the spread of COVID-19 among project stakeholders. The Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH) is Substantial at this stage of project development. This risk rating will be reviewed during the preparation phase through the screening tool and will be confirmed during appraisal. This is due to the nature of the activities (especially construction/rehabilitation, technical assistance, training) that will be provided to communities, especially to vulnerable groups (women, poor households). There are risks of SEA/SH that may arise. Therefore, to mitigate this risk, procedures such as an SEA/SH assessment and action plan will be required. In addition, a code of conduct and awareness of sexual exploitation and abuse, especially among all service providers, will also be needed. Furthermore, as one of the focus areas of this project is support to GBV survivors, the project will try to cover that target with a medical response (the provision of PEP kits) and training of health workers and international NGOs (INGOs) in all 15 districts. The Borrower will set up a strong link with the Human Capital Project/ safe spaces (P171158) and ensure that within the holistic approach developed, the local GBV counselors living with communities in intervention zones are recruited and fully involved into the process to better assist in the identification and orientation of GBV survivors. . CONTACT POINT World Bank Tomo Morimoto, Mahoko Kamatsuchi Senior Health Specialist Borrower/Client/Recipient Central African Republic Implementing Agencies Sep 06, 2021 Page 8 of 9 The World Bank CAR Health Service Delivery & System Strengthening Project (SENI-plus) (P177003) Ministry of Health and Population, Central African Republic Pierre Somse Minister of Health psomsep@gmail.com Jean Baptiste Roungou Coordinator, SENI-REDISSE4 projects jbroungou@gmil.com FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Task Team Leader(s): Tomo Morimoto, Mahoko Kamatsuchi Approved By APPROVALTBL Country Director: Han Fraeters 26-Oct-2021 Sep 06, 2021 Page 9 of 9