Document of
The World Bank
FOR OFFICIAL USE ONLY
Report No: PAD3344
INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT
PROJECT PAPER
ON A
PROPOSED ADDITIONAL FINANCING
IN THE AMOUNT OF US$200 MILLION
(INCLUDING AN IBRD LOAN AND SUPPORT FROM THE GLOBAL CONCESSIONAL FINANCING
FACILITY)
TO THE
HASHEMITE KINGDOM OF JORDAN
FOR THE
EMERGENCY HEALTH PROJECT
June 7, 2019
Health, Nutrition, and Population Global Practice
Middle East and North 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.
CURRENCY EQUIVALENTS
Exchange Rate Effective April 30, 2019
Currency Unit = Jordan Dinars (JOD)
JOD 0.709 = US$1
US$ = SDR 1
FISCAL YEAR
January 1–December 31
ABBREVIATIONS AND ACRONYMS
AB Audit Bureau
BOD Burden of Disease
CPF Country Partnership Framework
COA Chart of Accounts
CSB Civil Service Bureau
DA Designated Account
DLI Disbursement-Linked Indicator
EA Environmental Assessment
ECD Early Childhood Development
FM Financial Management
GBV Gender-Based Violence
GCFF Global Concessional Financing Facility
GFMIS Government Financial Management Information System
GFSM Government Finance Statistics Manual
GOJ Government of Jordan
GRM Grievance Redress Mechanism
GRS Grievance Redress Service
HCI Human Capital Index
HNP Health, Nutrition and Population
ICU Internal Control Unit
IFR Interim Financial Report
IPF Investment Project Financing
IsDB Islamic Development Bank
JEHP Jordan Emergency Health Project
JHFR Jordan Health Fund for Refugees
M&E Monitoring and Evaluation
MOF Ministry of Finance
MOH Ministry of Health
MOI Ministry of Interior
MOPIC Ministry of Planning and International Cooperation
NCD Non-communicable Disease
NGO Nongovernmental Organization
PDO Project Development Objective
PHC Primary Health Care
POM Project Operations Manual
PPSD Project Procurement Strategy for Development
STA Single Treasury Account
STEP Systematic Tracking of Exchanges in Procurement
TA Technical Assistance
TOR Terms of Reference
UHC Universal Health Coverage
UN United Nations
UNFPA United Nations Population Fund
UNHCR United Nations High Commission for Refugees
UNICEF United Nations Children’s Fund
USAID U.S. Agency for International Development
UVE Utilization Verification Entity
WHO World Health Organization
Regional Vice President: Ferid Belhaj
Country Director: Saroj Kumar Jha
Senior Global Practice Director: Timothy Grant Evans
Practice Manager: Ernest E. Massiah
Task Team Leader(s): Fernando Montenegro Torres
Hashemite Kingdom of Jordan
Emergency Health Project Additional Financing
TABLE OF CONTENTS
I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ................................................ 6
II. DESCRIPTION OF ADDITIONAL FINANCING ......................................................................... 11
III. KEY RISKS....................................................................................................................... 17
IV. APPRAISAL SUMMARY..................................................................................................... 18
V. SUMMARY TABLE OF CHANGES .......................................................................................... 27
VI. DETAILED CHANGE(S) ....................................................................................................... 27
VII. RESULTS FRAMEWORK AND MONITORING .......................................................................... 30
The World Bank
Jordan Emergency Health Project Additional Financing (P170529)
BASIC INFORMATION – PARENT (Jordan Emergency Health Project - P163387)
Country Product Line Team Leader(s)
Jordan IBRD/IDA Fernando Montenegro Torres
Project ID Financing Instrument Resp CC Req CC Practice Area (Lead)
P163387 Investment Project GHN05 (9320) MNC02 (399) Health, Nutrition &
Financing Population
Implementing Agency: Ministry of Planning and International Cooperation
ADD_FIN_TBL1
Is this a regionally tagged
project?
Bank/IFC Collaboration
No
Original Environmental
Approval Date Closing Date Current EA Category
Assessment Category
13-Jun-2017 29-Jun-2019 Not Required (C) Not Required (C)
Financing & Implementation Modalities Parent
[ ] Multiphase Programmatic Approach [MPA] [ ] Contingent Emergency Response Component (CERC)
[ ] Series of Projects (SOP) [ ] Fragile State(s)
[ ] Disbursement-Linked Indicators (DLIs) [ ] Small State(s)
[ ] Financial Intermediaries (FI) [✓] Fragile within a Non-fragile Country
[ ] Project-Based Guarantee [ ] Conflict
[ ] Deferred Drawdown [✓] Responding to Natural or Man-made disaster
[ ] Alternate Procurement Arrangements (APA)
Development Objective(s)
The Project development objective (PDO) is to support the Government of Jordan in maintaining the delivery of
primary and secondary health services to poor uninsured Jordanians and Syrian refugees at Ministry of Health
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facilities.
Ratings (from Parent ISR)
RATING_DRAFT_NO
Implementation Latest ISR
16-Oct-2017 10-May-2018 14-Nov-2018 18-Dec-2018
Progress towards
achievement of PDO S MU MU MS
Overall Implementation
Progress (IP) S MU MU MS
Overall Safeguards
Rating
Overall Risk M h S S
BASIC INFORMATION – ADDITIONAL FINANCING (Jordan Emergency Health Project Additional Financing -
P170529)
ADDFIN_TABLE
Urgent Need or Capacity
Project ID Project Name Additional Financing Type
Constraints
P170529 Jordan Emergency Health Restructuring, Scale Up Yes
Project Additional
Financing
Financing instrument Product line Approval Date
Investment Project IBRD/IDA 24-Jun-2019
Financing
Projected Date of Full Bank/IFC Collaboration
Disbursement
31-Oct-2023 No
Is this a regionally tagged project?
No
Financing & Implementation Modalities Child
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[ ] Series of Projects (SOP) [ ] Fragile State(s)
[✓] Disbursement-Linked Indicators (DLIs) [ ] Small State(s)
[ ] Financial Intermediaries (FI) [✓] Fragile within a Non-fragile Country
[ ] Project-Based Guarantee [ ] Conflict
[ ] Deferred Drawdown [ ] Responding to Natural or Man-made disaster
[ ] Alternate Procurement Arrangements (APA)
[ ] Contingent Emergency Response Component (CERC)
Disbursement Summary (from Parent ISR)
Net
Source of Funds Total Disbursed Remaining Balance Disbursed
Commitments
IBRD 36.10 34.92 1.18 97 %
IDA %
Grants 13.90 13.41 0.49 96 %
PROJECT FINANCING DATA – ADDITIONAL FINANCING (Jordan Emergency Health Project Additional Financing -
P170529)
PROJECT FINANCING DATA (US$, Millions)
SUMMARY -NewFi n1
SUMMARY (Total Financing)
Proposed Additional Total Proposed
Current Financing
Financing Financing
Total Project Cost 50.00 200.00 250.00
Total Financing 50.00 200.00 250.00
of which IBRD/IDA 36.10 141.10 177.20
Financing Gap 0.00 0.00 0.00
DETAILS - Additional Financing
NewFinEnh1
World Bank Group Financing
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Jordan Emergency Health Project Additional Financing (P170529)
International Bank for Reconstruction and Development (IBRD) 141.10
Non-World Bank Group Financing
Trust Funds 58.90
Concessional Financing Facility 58.90
COMPLIANCE
Policy
Does the project depart from the CPF in content or in other significant respects?
[ ] Yes [ ✔ ] No
Does the project require any other Policy waiver(s)?
[ ] Yes [ ✔ ] No
INSTITUTIONAL DATA
Practice Area (Lead)
Health, Nutrition & Population
Contributing Practice Areas
Climate Change and Disaster Screening
This operation has been screened for short and long-term climate change and disaster risks
Gender Tag
Does the project plan to undertake any of the following?
a. Analysis to identify Project-relevant gaps between males and females, especially in light of country gaps identified
through SCD and CPF
Yes
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b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or men's empowerment
Yes
c. Include Indicators in results framework to monitor outcomes from actions identified in (b)
Yes
PROJECT TEAM
Bank Staff
Name Role Specialization Unit
Fernando Montenegro Team Leader (ADM
GHN05
Torres Responsible)
Procurement Specialist (ADM
Samira Al-Harithi Procurement Specialist GGOPM
Responsible)
Financial Management Senior Financial Management
Jad Raji Mazahreh GGOMN
Specialist (ADM Responsible) Specialist
Amer Abdulwahab Ali Al- Environmental Specialist (ADM
Environmental Specialist GENME
Ghorbany Responsible)
Social Specialist (ADM Senior Social Development
Deborah Beth Berger GSU05
Responsible) Specialist
Claire Louise Greer Team Member Operations Specialist GHN05
Concepcion Aisa Otin Team Member Senior Financial Officer FABBK
Fatima-Ezzahra Mansouri Team Member Program Assistant GHN05
Maiada Mahmoud Abdel
Team Member Finance Officer WFACS
Fattah Kassem
Natalia Robalino Team Member Senior Counsel LEGAM
Takahiro Hasumi Team Member Health Specialist GHN05
Extended Team
Name Title Organization Location
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I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING
A. Introduction
1. This Project Paper seeks the approval of the Board of Executive Directors to provide Additional
Financing (AF) in the amount of US$200 million to the ongoing well-performing Jordan Emergency Health
Project (JEHP) (P163387) to support the Hashemite Kingdom of Jordan. The proposed AF builds on JEHP
performance and rapid implementation progress. The amount of US$200 million is financed by a US$141.1
million IBRD loan and US$58.9 million grant from the Global Concessional Financing Facility (GCFF, see
Box 1).
Box 1. Global Concessional Financing Facility
The GCFF is a partnership sponsored by the World Bank, the United Nations (UN), and the Islamic
Development Bank Group (IsDB) to mobilize the international community to address the financing
needs of middle-income countries hosting large numbers of refugees. By combining donor
contributions with multilateral bank loans, the GCFF enables eligible middle-income countries that are
facing refugee crises to borrow at below-regular multilateral development bank rates for providing
global public good. The GCFF represents a coordinated response by the international community to the
Syrian refugee crisis, bridging the gap between humanitarian and development assistance and
enhancing the coordination between the UN, donors, multilateral development banks, and benefitting
(host) countries. The GCFF includes Jordan, Lebanon, and Colombia as benefitting countries. The GCFF
is currently supported by Canada, Denmark, the European Commission, Germany, Japan, Netherlands,
Norway, Sweden, the United Kingdom, and the United States.
2. The JEHP was approved by the Board of Executive Directors on June 13, 2017 and declared
effective on July 26, 2017. The financing amount was US$50 million, consisting of a non-concessional
portion of US$36.1 million (IBRD loan) and a concessional portion of US$13.9 million (GCFF). In addition,
the IsDB extended US$100 million parallel financing, including US$21.0 million GCFF-financed funds. IsDB
financing will end on June 30, 2019. The GCFF, IBRD, and IsDB provide resources to support the
Government of Jordan (GOJ) in maintaining the delivery of primary and secondary health care services to
Syrian refugees and poor uninsured Jordanians (the target population) at Ministry of Health (MOH)
facilities and to increase the medium- to long-term sustainability of the health system. Funds under
Component 1 were disbursed against the delivery of health services verified by an independent Utilization
Verification Entity (UVE). Component 2 finances the UVE’s activities and consultancies on health care
costing and basic training on health economics and financing.
3. Parent project performance. The project development objective (PDO) of the JEDP is to support
the GOJ in maintaining the delivery of primary and secondary health services to poor, uninsured
Jordanians and Syrian refugees at MOH facilities. The parent project has been rated Moderately
Satisfactory for both progress towards achieving the project development objective and implementation
progress since December 2018 to date. It was rated Moderately Unsatisfactory from May to December
2018, largely due to: (i) the GOJ’s introduction of a cost-sharing policy of 80 percent for Syrian refugees
that created financial barriers for them to access health services, and (ii) implementation delays for
technical assistance (TA) activities under Component 2. In particular, delivery of technical assistance (TA)
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activities under Component 2 was delayed as agreement on terms of references (TORs) took longer than
expected. The procurement process for capacity building activities, including selection of a firm to
undertake a costing study on non-communicable diseases (NCD) prevention and planned trainings on
health financing and economics, research methodology and scientific writing and data collection, is
underway.
4. The parent project ratings were upgraded following implementation of the agreed actions by the
Borrower: (i) change of the cost-sharing policy to its original 20 percent for Syrian refugees, and (ii)
progress made on delivery of TA activities.1 The PDO continues to be highly relevant and all planned
activities are expected to be delivered prior to the proposed closing date of October 31, 2023. The amount
disbursed by the project to date is 96.66 percent (with full disbursement under Component 1). The project
supported financing of human resources needed to deliver primary and secondary health care at MOH
facilities, despite tight fiscal constraints. In addition, the project introduced a more detailed monitoring
system for delivery of services, independent verification tracks and records actual services delivered,
disaggregated by gender and target populations. The most recent annual data from this monitoring
system covers November 2017 to October 2018 and shows that the number of services delivered to the
target population was on target (2.1 million primary health services and 2.9 million secondary services).
When disaggregated by population group, data for the above period suggest that the targets for Syrian
refugees were not met. This was largely due to the decreased demand by Syrian refugees due to the
financial barriers resulting from the change in their co-payment rate, which was rolled back in March 2019
(see paragraph 3)2.
B. Background and Rationale for the Proposed Additional Financing
5. Country context. Despite substantial economic and social progress, Jordan faces a protracted
crisis hosting Syrian refugees, combined with constraints in its fiscal space. The GOJ is committed to taking
actions on its commitments for universal health coverage (UHC) and human capital investment for all
population groups. The GOJ has been providing public services to Syrian refugees, which has added to
fiscal stress and increased demand for public services such as education, health, and wastewater
management.
6. According to the latest census, the Syrian population in Jordan is 1.3 million, of which 670,238
are registered as refugees by the United Nations High Commissioner for Refugees (UNHCR). The
remaining Syrians are considered to have either been living in Jordan for several generations or were living
in Jordan before the Syrian crisis. Of the total number of refugees, about 19 percent live in camps (for
example, Za’atari, Al Azraq) and the rest live in the community.3 About 96.8 percent of interviewed Syrian
refugees responded that they have service cards issued by the Ministry of Interior (MOI).4 This allows
1 In line with World Bank Instructions: Additional Financing for Investment Project Financing, the World Bank management
authorized the preparation of the proposed AF on March 28, 2019, notwithstanding that the parent project was not rated
Moderately Satisfactory or better rating during the previous 12 months.
2 The updated annual data on health services will be published in in June 2019.
3 HCR. 2019. Syria Regional Refugee Response. Available: https://data2.unhcr.org/en/situations/syria/location/36.
4 HCR. 2018. Health Access and Utilization Survey: Access to Healthcare Services Among Syrian Refugees in Jordan.
https://reliefweb.int/report/jordan/health-access-and-utilization-survey-access-healthcare-services-among-syrian-refugees.
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them access to several benefits, including highly discounted care at MOH facilities. The large number of
Syrian refugees, of which 75 percent are women and children, has significant implications for the
Jordanian health system, and with over 80 percent living below the national poverty line, they are
considered an extremely vulnerable group.
7. Limited access to key quality health services for vulnerable populations (including Syrian
refugees) can produce negative consequences not only for non-Jordanians but also for Jordanians. For
example, children without full vaccinations pose the risk of epidemic for the entire population living in
Jordan. Lack of birth documents creates inefficient management of public services. In addition,
complicated interventions (such as late stage cancer treatment) lead to higher health care costs and put
fiscal pressure on the GOJ, rather than saving money from prevention and early diagnosis.
8. The MOH is in charge of stewardship of the entire health sector and is also a major provider of
primary and secondary health care services in the public sector. These services are critical for prevention
and early detection of infectious diseases as well as NCDs. The MOH has developed a large nationwide
network of primary health care (PHC) facilities, including some comprehensive PHC facilities with basic
specialties (including mental health). Specialized inpatient and outpatient health services are delivered at
MOH hospitals, and private hospitals and clinics (both for-profit and not-for-profit) such as the King
Hussein Cancer Center, the University of Jordan Hospital, and the Royal Medical Services (for military
personnel and their families). The GOJ also provides a form of social insurance for civil servants (Civil
Insurance Program) contracting with public and private providers. Individuals who face catastrophic out-
of-pocket health expenditures can petition the Royal Court for subsidization of specific health care
services on a case-by-case basis. As some waiting lists increased with the influx of refugees, the GOJ has
used the existing contracts with public and private hospitals to provide inpatient and outpatient care
alternatives for insured patients with urgent and expensive health care needs but also for Syrian refugees
(particularly for treatment of cancer at not-for-profit facilities).
9. In terms of financial protection, before the refugee crisis, Jordan had reduced regressive health
care out-of-pocket payments by half—from 42 percent to 24 percent of total health spending (2003–
2013). However, increased demand limited the GOJ’s ability to provide financial protection for all.5 From
2012 to 2014, the GOJ allowed registered Syrian refugees to pay the same rate as insured Jordanians at
MOH facilities, which rendered health services as almost free. This led to a steep increase in demand for
health services by Syrian refugees. While access to free health services helped meet the needs of Syrian
refugees in their first years of the crisis, it was fiscally unsustainable, and in November 2014, the MOH
required Syrian refugees to pay the same co-payment rate as poor uninsured Jordanians (20 percent of
the prices listed for MOH services). In February 2018, a new policy came into effect, which substantially
increased the co-payment rate for Syrian refugees to 80 percent of the price of services delivered by the
MOH. This new co-payment policy created financial barriers for Syrian refugees to access health care and
decreased their utilization of public facilities (mainly PHC services). The World Bank and development
partners immediately engaged in discussions with the GOJ to explore options to reduce barriers for Syrian
refugees to access to health care services provided by the MOH. It was agreed that the U.S. Agency for
International Development (USAID) and the Government of Denmark would establish a multi-donor
5 Amnesty International. 2017. Living in the Margins: Syrian Refugees in Jordan Struggle to Access Health Care. Amman.
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account, named the Jordan Health Fund for Refugees (JHFR). The World Bank provided technical inputs
on estimating health care costs for Syrian refugees. On December 16, 2018, the GOJ and donors signed a
joint financing agreement to create the JHFR to finance some inputs and investments needed to provide
services for Syrian refugees. The disbursement of donor contributions from the JHFR was contingent on
the reversal of the co-payment policy to the pre-2018 rate. On March 25, 2019, the Jordanian Cabinet
made the decision to reverse the co-payment policy for Syrian refugees from 80 percent to 20 percent,
the same as for poor uninsured Jordanians.
10. Climate change. The impacts of climate change6 are expected to exacerbate the demand for key
health services, particularly due to increased incidences of waterborne diseases, infectious diseases,
malnutrition, cardiovascular, and respiratory diseases. The impacts of climate change are also expected
to further undermine existing health systems, social protection systems, water and food supplies, and
infrastructure. The AF will support the delivery of primary and secondary health services to the target
population that are the most vulnerable to the impacts of climate change (i.e., poor uninsured Jordanians
and Syrian refugees). This will increase the resilience of these groups, and the health sector more
generally, to climate change. Additionally, it directly contributes to climate adaptation objectives in the
health sector set out in Jordan’s Intended Nationally Determined Contribution and the National Climate
Change Policy (2013–2020).
11. Pre-existing inefficiencies in the health system have been exacerbated by the tight fiscal space
that Jordan is facing and prolonged recovery from the economic slowdown of recent years. Higher
demand for costly services needs to be addressed to create a sustainable UHC system. The health system
in Jordan, similar to many other health systems globally, is plagued by several issues related to technical
and allocative efficiency, including highly fragmented insurance pools without an adequate balance of
revenues and expenditures, and multiple payers and purchasers, including the Royal Medical Service,
MOH, and private sector providers. In addition, there is very little data available on critical components
of the health system, including costing of the services delivered at primary and secondary health care
facilities or usage of services by diagnosis, gender, or income group. As a positive result of the JEHP, the
MOH has started generating new aggregated data that helps monitor the use of services by the target
population, but the system still needs to be strengthened as the MOH needs population health
management data for public policy decision making.
12. Boosting human capital of young Jordanians is a key priority for the GOJ. The Human Capital
Index (HCI) for Jordan is slightly lower than the regional average (overall HCI = 0.56) but higher than that
for the same income groups. Health-related indicators (adult survival rate, under-five mortality, and
stunting under five years old) show relatively good outcomes.7 This is largely due to the comprehensive
6 Jordan is highly vulnerable to the impacts of climate change; especially increased frequency and severity of extreme weather
events, including extreme high temperatures, flash floods, landslides, and droughts. As one of the driest countries in the world,
water scarcity in Jordan is also expected to increase due to climate change. This will have an impact on the health sector. For
example, limited access to clean water contributes to increased incidences of waterborne diseases (typhoid, fever, cholera,
Hepatitis A and E, giardiasis, and bilharzia); food-borne diseases through crop contamination; increased food insecurity; and
malnutrition. This vulnerability is further exacerbated by the influx of refugees into Jordan.
7 The World Bank Group. Human Capital Index: Jordan.
https://databank.worldbank.org/data/download/hci/HCI_2pager_JOR.pdf.
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health service package provided in Jordan for key health services, including mother and child health care.
However, to boost human capital of the younger generations in Jordan, the GOJ has identified two priority
areas to boost human capital: early childhood development (ECD) and NCDs. Strategic investment in these
two priority areas through PHC strengthening would produce desirable health outcomes (healthy
population), health financing efficiency (healthy economy), and human capital development (healthy
workforce for the next generation).
13. Concessional support is vital to move from a humanitarian to a development response. Since
81 percent of Syrian refugees live outside of camps, public health services are the backbone of Jordan’s
response to the refugee crisis for the health sector. Public resources are strained, and the fiscal space is
limited. The combination of limited service delivery capacity and fiscal pressures keep undermining the
sustainability of the health system and the goal of UHC, as well as its ability to provide services at low cost.
This can have implications for investments in human capital for new generations living in Jordan and for
the efficient control and cost containment of NCD burdens, which affect both Syrian refugees and
Jordanians. The proposed AF has been prepared and will be implemented in accordance with paragraph
12, section III of the World Bank Policy for Investment Project Financing (IPF), Projects in Situations of
Urgent Need of Assistance or Capacity Constraints. The use of condensed procedures under the proposed
AF stems from the urgent need to address the challenges for health service delivery and health outcomes
in Jordan, generated by the Syrian refugee crisis, which threatens to reverse gains made by the Jordanian
health sector, exacerbates the existing fiscal constraints and erodes institutional capacity in the public
health system. Thus, the project responds to the impact of conflict (in Syria) and the ensuing ‘fragility
within a non-fragile state’ situation, a result of the refugee influx. Sustainability of health system gains
over the last decade is at risk without financial and technical support as MOH line item budgets have been
reduced. The refugee crisis has also affected the system in other ways—the percentage of uninsured
Jordanians has increased and the goal of attaining UHC by 2030 is, therefore, further away.8 Without
financial and technical support to the sector, access to health care for vulnerable populations may
deteriorate in the short- to medium term.
14. The proposed AF contributes to the World Bank Group twin goals of eliminating extreme
poverty and boosting shared prosperity in a sustainable manner, and corporate and regional priorities.
It contributes to the implementation of the World Bank Group’s enlarged Middle East and North Africa
Strategy by: (a) supporting resilience to systematic shocks due to the inflow of refugees and internally
displaced persons, and (b) addressing gaps in human capital, including modernization of the health
system, pursuit of UHC, and provision and maintenance of basic health services for refugees and host
communities. In addition, the AF also contributes directly to the first pillar of the World Bank Group
Gender Strategy (FY16–23) on narrowing gaps in human endowment by improving maternal health
outcomes.
15. As with the parent project, the proposed AF is aligned with the principles of the World Bank
Group’s Jordan Country Partnership Framework (CPF). The CPF (Report 102746-JO)9 defines the World
Bank Group’s engagement with Jordan. The main goal of the CPF is to renew the country’s social contract
8 High Health Council (Government of Jordan). 2015. The National Strategy for Health Sector in Jordan, 2015–2019. Amman.
9 The World Bank Group. 2016. Country Partnership Framework for the Hashemite Kingdom of Jordan for the Period FY17 –FY22.
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and promote social and economic inclusion. The CPF also plans to analyze the impact of the refugee crisis
on the country’s financial sustainability, which is supported through the component on institutional
capacity to improve the health system’s efficiency. By safeguarding the sustainability of public health
services and focusing on vulnerable populations, the proposed operation is fully aligned with the CPF.
16. The AF contributes to the Health, Nutrition, and Population (HNP) Global Practice’s aim of
assisting countries in accelerating progress toward achieving UHC. Attaining UHC entails both increasing
access to quality services and improving financial protection.10 The proposed AF supports the delivery of
primary and secondary public health services to the target population, and thus contributes to these goals.
17. Under the proposed AF, the following changes will be introduced to the parent project:
• The JEHP closing date (currently June 29, 2019) will be extended to match the closing date
of the proposed AF, i.e. to October 31, 2023.
• The results framework will be modified to reflect the updated baseline and targets for PDO
indicators. The original baselines and targets were based on 2015 data, before the MOH
introduced a monitoring system to track disaggregated data by facilities and governorates,
and before independent verification was implemented. The new baselines and targets are
based on the latest data available from the MOH monitoring system (before the increase in
co-payments for Syrian refugees was introduced).
II. DESCRIPTION OF ADDITIONAL FINANCING
18. The changes to the parent project introduced by the proposed AF will help ensure a stronger
focus on monitoring results, maintain service delivery to the target population (poor uninsured
Jordanians and Syrian refugees), and strengthen a sustainable health system for UHC. Component 1 will
allow for rapid disbursement of funds to cover part of the GOJ’s health care costs to provide primary and
secondary health services to the target population. Component 2 will support the GOJ’s commitment to
UHC and as an early adopter of the Human Capital Project. Thus, the AF will: (a) allow the GOJ to foster
human capital outcomes with an emphasis on PHC (mother and child health care and NCDs); (b) support
the GOJ in improving the coverage and quality of services provided to the target population; and (c) assist
the GOJ in introducing activities to improve critical interventions for PHC, with emphasis on NCDs and
ECD.
19. Component 1: Results-based financing to deliver health care services at primary and secondary
care facilities of MOH for the target population (US$190 million). Component 1 is funded by a
US$133.946 million IBRD loan and a U$56.054 million GCFF grant. Component 1 will reimburse the GOJ
through results-based financing for health services provided to Syrian refugees and poor uninsured
Jordanians at primary and secondary MOH health care facilities nationwide. The services covered include
the package of primary and secondary inpatient and outpatient health care services delivered by the
MOH. The disbursements will be based on verification of: (a) the number of health services provided to
10 The World Bank Group. 2016–2020. Priority Directions for the Health, Nutrition and Population Global Practice.
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the target population verified by an independent UVE, and (b) the expenditures incurred by the GOJ to
deliver these services verified by the Jordan Audit Bureau (AB).
20. The AF will fund part of the cost of delivering health care services to the beneficiaries, which
will be up to US$12 per primary care service and US$63 per secondary care service. The costs will mainly
cover the MOH’s expenditures for key recurrent expenditures such as human resources and operating
costs of health facilities, including rental and utilities (water, electricity, and fuel). The AF will not finance
the cost of procurable medical items, such as vaccines, medicines, equipment, X-Ray plaques, or lab
reagents that will continue to be financed by the GOJ and other donors (USAID and the European Union).
21. The operational definition of a service delivered is either a visit to an outpatient facility (first or
second levels of care) for medical, emergency, or diagnostic services (lab tests, X-rays, etc.) or a hospital
discharge. A ‘PHC service’ is defined as a PHC service delivered, for example, one antenatal care visit for
a pregnant woman. The package of primary health services includes: (a) mother and child health care
services; (b) malnutrition prevention and treatment; (c) integrated management of childhood health; (d)
treatment of communicable diseases; and (e) prevention, early detection, and management of NCDs.
Based on MOH service delivery data from November 2017 to January 2018,11 the current utilization rates
of primary health services among the target population account for about 23 percent of the total
utilization of these services at MOH facilities. Based on the same utilization rate during the above period,
it is estimated that the MOH will provide approximately 135,000 services delivered to registered Syrian
refugees and 2.5 million services delivered to poor uninsured Jordanians at PHC facilities annually.
22. A ‘secondary health care service’ is considered to be a specialized service delivered in outpatient
or inpatient hospitals such as the delivery of a baby or cancer treatment. Secondary health services
include both outpatient and inpatient health care services received by the target population at the 33
MOH hospitals in Jordan. The current utilization rates of secondary health services among the target
populations account for about 41 percent of the total utilization of these services at MOH hospitals. Based
on the utilization rates from November 2017 to January 2018, it is estimated that the MOH will provide
approximately 103,000 services to Syrians and 1.8 million services to poor uninsured Jordanians at
secondary care facilities annually.
23. A portion of the AF will retroactively finance primary and secondary health care services already
delivered to the target population. This will be financed under Component 1 and will cover health care
expenditures that: (a) were incurred prior to the signing date of the Loan Agreement but on or after June
30, 2018, and (b) were not financed by the final IsDB disbursement tranche. Based on the estimated
11As described in paragraph 18, the baselines and targets for PDO-level indicators will be revised based on the latest service
delivery data available. Data from November 2017 to January 2018 is used for the following reasons: (a) this is the latest data
showing service delivery to the target population when the same co-payment rate (20 percent) was applied to the entire target
population; (b) the increased co-payment rate of 80 percent for Syrian refugees was in effect from February 2018 to March 2019,
which resulted in lower utilization of services by Syrian refugees; therefore, service delivery data during this period would not
provide best estimates for the remaining project period; and (c) 20 percent co-payment would be applied to the target population
during the remaining project period.
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amount of eligible expenditures and service utilization by the target population, the retroactive financing
under the proposed AF will not exceed US$30 million.
24. It is critical to provide financing for human resources in public facilities delivering subsidized
health services to reduce the financial burden that vulnerable groups with higher risk of the negative
health impact due to climate changes. Health services provided by the MOH include key interventions to
address significant burden of disease (BOD) and associated risks that stem from or are exacerbated by
climate change in Jordan, including management of NCDs such as hypertension, diabetes, and cancer. In
addition, the interventions are designed to enhance healthier lives throughout the life cycle with
improved mother and child health and ECD interventions.
25. The remaining funds under Component 1 will finance the delivery of primary and secondary
health care services to the target population incurred by the GOJ during the AF period. Funds will be
disbursed by advances that cover six consecutive months.
26. Component 2: Improving coverage and quality of the primary health care services (US$9.647
million). Component 2 is funded by US$6.801 million IBRD loan and U$2.846 million GCFF grant.
Component 2 aims to support the MOH in strengthening PHC services by incorporating a family health
model and emphasizing human resource development. By enhancing the capacity of the MOH to maintain
provision of adequate health services to vulnerable women, mothers and children, this component will
respond directly to closing gender gaps in access to human endowments. This will be achieved by
introducing non-scalable disbursement-linked indicators (DLIs) to measure progress in terms of the
following achievements: (a) an assessment of gaps in human resources and skills needed to incorporate a
family health model (integrated people-centered health services) based on the World Health Organization
(WHO) framework,12 (b) an implementation plan to address the gaps, and (c) evaluation of the first-year
implementation results of the human resources capacity building and training activities. Subcomponent
2.2 will finance the cost of an independent verification of the services utilized by the target population
during the AF period, project management, and other key activities to improve MOH capacity.
27. Subcomponent 2.1: Supporting MOH in strengthening Primary Health Care services by
incorporating a family health model and emphasizing human resource development, through, inter alia,
a comprehensive assessment of gaps in human resources and skills needed to incorporate a national
family health services model based on WHO’s recommendations (US$9 million). This subcomponent
aims to strengthen PHC services by expanding the introduction of a family health model, with emphasis
on human resource development. The proposed family health model is part of envisioned improvements
for quality of care by the MOH. Subcomponent 2.1 seeks to finance and incentivize the MOH to ensure
that PHC services incorporate WHO recommendations on people-centered integrated health services
using evidence-based approaches, such as proactive health promotion and prevention community
outreach and population health management through risk assessment and case management (for
example, including an adequate number of female community health volunteers). The AF strengthens two
key health-related areas of human capital investment: (a) ECD for the first critical 1,000 days (targeting
12 World Health Organization. 2019. Framework on Integrated People-Centered Health Services.
https://www.who.int/servicedeliverysafety/areas/people-centred-care/framework/en/.
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pregnant women, mothers, and children, including through nutrition, growth monitoring, parent
counseling, early stimulation, etc.), and (b) preventive/early detection interventions that contribute to
minimize the BOD of NCDs (i.e., diabetes, hypertension, and cancer). Introducing a family health model
aligns with GOJ priorities, including its commitment to the Human Capital Project as an early adopter.
Furthermore, global evidence suggests that benefits will be higher among the most vulnerable population
groups, including Syrian refugees and poor uninsured Jordanians. For example, this will include improving
prevention, early diagnosis and treatment of breast cancer, the largest burden of NCDs for women. This
will potentially: (i) improve health outcomes for Syrian refugees who will receive earlier stage diagnosis
at PHC centers, and (ii) increase the number of antenatal care visits, particularly during the first fourth
months of pregnancy, thus improving health outcomes for both mothers and children.
28. Funds will be disbursed once achievement of the following DLIs are verified by the World Bank.
The proposed DLIs, estimated timeline, and allocation of financing amounts are detailed in Table 1.
Table 1: Disbursement-Linked Indicators
DLI Source of
Type Verification Baseline Timeline Amount (US$)
Data
DLI 1: Assessment of PHC coverage and quality gaps
DLI #1.1: From the Non- MOH MOH US$776,091,777 Year 2 1,000,000
baseline of scalable expenditure Budget (JOD 550,419,700),
US$776,091,777 (JOD framework Directorate MOH current and
550,419,700) (MOH’s and capital
expenditures in the Ministry of expenditures,
2017 budget), MOH Finance 201713
receives additional (MOF)
budget of approved
US$1,000,000 in the annual
Jordanian fiscal year budget
2020 following
declaration of
effectiveness of the
project
DLI #1.2: MOH Non- Primary World Bank No assessment Year 2 1,000,000
completes an scalable Health Care
assessment of gaps in Department
human resources and MOH
skills needed to
incorporate a
nationwide family
health services model
based on WHO
recommendations
including: (a) mother
13 General Budget Department. General Budget Law 2019. http://www.gbd.gov.jo/GBD/en/Budget/Ministries/general-budget-
law-2019.
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DLI Source of
Type Verification Baseline Timeline Amount (US$)
Data
and child health,
nutrition, growth, and
development
monitoring; and (b)
prevention and early
diagnosis of diabetes,
hypertension, and
breast cancer
DLI 2: Development of an implementation plan to improve quality and coverage of PHC
DLI #2.1: From the Non- MOH MOH US$776,091,777 Year 3 1,000,000
baseline of scalable expenditure Budget (JOD 550,419,700),
US$776,091,777 (JOD framework Directorate MOH current and
550,419,700) (MOH’s and MOF capital
expenditures in the approved expenditures, 2017
2017 budget) MOH annual
receives an additional budget
budget of
US$1,000,000 in the
second consecutive
Jordanian fiscal year
following declaration
of effectiveness of the
project
DLI #2.2: MOH Non- Primary World Bank No implementation Year 3 2,000,000
develops and scalable Health Care plan
approves a costed and Department
phased MOH
implementation
strategy with an M&E
system, incorporating
feedback and inputs
from all health
directorates and
development partners
DLI.3: Human resources capacity building to improve outcomes in PHC
DLI #3.1: From the Non- MOH MOH US$776,091,777 Year 4 2,000,000
baseline of scalable expenditure Budget (JOD 550,419,700),
US$776,091,777 (JOD framework Directorate MOH current and
550,419,700) (MOH’s and MOF capital
expenditures in the approved expenditures, 2017
2017 budget) MOH annual
receives additional budget
budget of
US$2,000,000 in the
third consecutive
Jordanian fiscal year
following declaration
of effectiveness of the
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DLI Source of
Type Verification Baseline Timeline Amount (US$)
Data
project
DLI #3.2: MOH Non- Primary World Bank Implementation End of 2,000,000
provides report on scalable Health Care plan activities not Year 4
Year 1 implementation Department yet launched d
results of the human
resources capacity
building and training
activities as designed
in the implementation
strategy under DLI
#2.2
29. Subcomponent 2.2: Providing technical assistance and capacity building to strengthen the
institutional capacity of Jordan; and financing the cost of an independent verification of the services
utilized by the target population at MOH facilities (US$0.647 million). This subcomponent will finance
TA activities to improve performance and management of the public health system. This includes health
information systems to improve the accuracy of the monitoring of services delivered to the target
population (e.g., Syrian refugees), human resources for health, health insurance financing (balancing
revenues and expenditures to improve sustainability), and strategic purchasing for services in the private
sector. The subcomponent would finance activities to increase MOH capacity to: (a) maintain a grievance
redress mechanism (GRM), and (b) strengthen the health system’s response to gender-based violence
(GBV), through the development and dissemination of materials (specific activities to be identified based
on international best practices and the local context). It will also finance general coordination and project
management to strengthen the capacity of a Coordination Unit at the MOH, and the cost of an
independent verification of the use of services under Component 1. As one of the disbursement conditions
stipulated in the Loan Agreement, these funds cannot be made available until the respective allocations
under the parent project have been fully disbursed. Combining undisbursed funds under Component 2 of
the parent project (US$1.16 million) and funds under subcomponent 2.2 of the proposed AF, the project
will finance a total of US$1.8 million to strengthen MOH technical and managerial capacity to improve the
efficiency of the health system in Jordan.
30. In Jordan, 21 percent of ever married women ages 15–49 have experienced physical violence.
However, only one in five women (19 percent) who have experienced any physical or spousal sexual
violence has sought help to stop the violence. Women under 25 and Syrian women are less likely to seek
help.14 The GOJ has built capacities and systems to provide gender-sensitive services to those in need,
such as Syrian refugees and poor uninsured Jordanians. For example, the National Council for Family
Affairs developed a multisectoral National Protection Framework on family violence and GBV survivors
can receive clinical services at MOH facilities. Although the parent project planned to provide TA for
supply-side capacity building (mainly through training on GBV and barriers to access), supply-side
interventions have been supported by development partners, such as the United Nations Children’s Fund
14DOS (Department of Statistics) and ICF International. 2019. Jordan Population and Family Health Survey 2017–2018. Amman,
Jordan, and Rockville, Maryland, USA.
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(UNICEF) and United Nations Population Fund (UNFPA). This support includes a comprehensive national-
level review of GBV services (multi-sectoral including health), development of training manuals for MOH
service providers, capacity-building training for service providers on GBV. Therefore, based on
consultations with the MOH and development partners, the AF will support provision of psychosocial
support and service delivery by health professionals to survivors of violence (for example, through
targeted outreach by PHC teams and training of PHC service providers on what has worked in countries
with similar cultural and ethnic characteristics and GBV, using relevant international best practices).15 The
World Bank will work closely with development partners, including local civil society organizations that
target women and populations exposed to GBV, to ensure coordination and avoid duplication.
31. In addition to the proposed activities under the AF, complementary analytical work will be
conducted in parallel to strengthening of MOH capacity, to provide sustainable, high-quality health
services to all population groups in Jordan. This TA will include: (a) a costing study on NCDs (under
Component 2 of the parent project), and (b) a study on access and quality-related barriers to health
services for vulnerable populations (including Syrian refugees). These two studies will provide in-depth
information for the MOH to strategize on efficient investment to reduce significant cost drivers in Jordan
and to improve the quality of health care provided at MOH facilities.
32. The Ministry of Planning and International Cooperation (MOPIC) will be the implementing agency
for the proposed AF, in coordination with designated focal points in the MOH. Project implementation
will be managed through a Coordination Unit to be established within the MOH. The Coordination Unit,
acting as the project coordinator, will have dedicated staff, including a project coordinator, a financial
management (FM) specialist, and a procurement specialist. Subcomponent 2.2 will finance individual
consultants and procure goods and services (as deemed necessary) to improve capacity within the
Coordination Unit. The planned support is intended to strengthen general coordination and project
management capacity at the MOH. MOPIC will be responsible for overall implementation of project
activities, including monitoring and evaluation (M&E), FM, and procurement functions.
III. KEY RISKS
A. Overall Risk Rating and Explanation of Key Risks
33. The overall risk to the achievement of the project objective is rated Substantial. Financial and
technical support to the Jordanian health sector through the proposed AF and the multi-donor JHRF will
help address the risk of deteriorating access to health care for vulnerable populations, including policy
reversal. The key risks that may impede the implementation of the project are macroeconomic risks and
risks linked to the geographic and regional context. This section describes the risks which are rated
substantial and associated risk mitigation measures.
15 Garcia-Moreno, et al. 2014. The Health Systems Response to Violence Against Women. The Lancet Series. Violence Against
Women and Girls Volume 385, Issue 9977. According to the study, there is no one model for a delivery of a health-care response
to violence against women; countries ought to tailor their approach based on resources and availability of specialized violence-
support services.
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34. Macroeconomic risk. The macroeconomic risk is rated Substantial. Economic indicators for 2018
further revealed the country’s macroeconomic weaknesses and vulnerabilities, stemming from sizable
external and internal imbalances that generate large external financing needs. In addition, the GOJ’s
efforts to keep debt dynamics sustainable hinges on continued fiscal consolidation, which has an impact
on the population. Poor macroeconomic performance could pose a risk to the PDO if domestic revenues
underperform and the GOJ is required to reduce public spending to meet its deficit targets. However, as
part of its agreement with the International Monetary Fund under the Extended Financing Facility
program and the World Bank-financed Second Equitable Growth and Job Creation Development Policy
Financing, the GOJ has committed to a gradual and sustainable reduction in fiscal deficit through increases
in revenues and efficiencies in expenditures. In terms of risk mitigation, on the expenditure side, the GOJ
has committed to a prudent expenditure policy through: (i) continuing the streamlining of non-priority
current spending; (ii) prioritizing social and capital spending; (iii) arresting the accumulation of fuel, health,
and water-sector arrears; and (iv) continuing support for Syrian refugees.
35. Other risks (geopolitical). Other risks, such as geopolitical and regional risks are rated Substantial.
The ongoing Syrian conflict, insecurity, violence in Iraq, and Israeli-Palestinian tension compound the risks
to Jordan in terms of a potential destabilizing impact, toll on the economy, and provision of public services.
Keeping these risks in mind, the project has been designed to be simple and fast disbursing against health
services delivered.
IV. APPRAISAL SUMMARY
A. Economic and Financial (if applicable) Analysis
36. Public health services are well suited to cover the project’s target population. The project
focuses on highly vulnerable population groups: Syrian refugees (who live mostly below the poverty line),
and poor uninsured Jordanians, who are typically unemployed or out of the labor force. International
experience has shown that private insurance is often not able to provide adequate coverage to poor and
informal workers so public intervention is warranted.16 In addition, Jordan’s public health system provides
over 60 percent of hospital beds, and practically all primary care services.17 Therefore, the nationwide
network of MOH health care providers is in a unique position to respond to the refugee crisis, and to play
a critical role in moving from a humanitarian to a developmental approach and strengthening an
integrated public system to achieve UHC and human capital investment commitments.
37. The proposed AF aims to support the MOH’s vision for improving quality of health services with
an emphasis on the first level of care and interventions that enhance health system sustainability. The
MOH has limited fiscal space to maintain current service levels to the target population. This results from
macroeconomic pressures (including lower GDP growth and higher debt-to-GDP ratio), high public
spending in health, and increased health care demand. Using concessional financing, the proposed AF will
16 Bitran, R. Couverture maladie universelle et le défi de l’emploi informel : enseignements tirés des pays en développe ment.
Publication autorisée, January 2014.
17 Ajlouni, M. 2011. Jordan Health System Profile 2010. World Health Organization - Eastern Mediterranean Office Region (EMRO).
Amman (Jordan).
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support the acceleration and expansion of a family health model that can improve health outcomes and
reduce the BOD in Jordan. It will address the growing expenditures for costly NCD treatment, particularly
breast cancer in women and colon cancer in men. PHC can play a key role in the prevention and early
detection of NCDs. This can result in: (a) better quality of life and survival rates for patients, and (b) more
manageable treatments that enhance the efficiency of health sector performance. Jordan’s demographic
and epidemiological profile is shifting from predominantly younger people and infectious diseases toward
an older population with NCDs as the main cause of morbidity and mortality.
B. Technical
38. The proposed AF is designed to strike a balance between the urgent needs of the health sector
and to build a foundation for a sustainable approach to UHC. The AF aims to strengthen health system
performance by improving the MOH’s approach to the delivery of health services. It is a shift from a focus
on curative and low levels of prevention with late diagnosis of NCDs toward a system that prioritizes
health promotion, prevention, and early diagnosis (for example, the family health approach). This
approach will foster, accelerate, and expand more effective PHC nationwide, as well as better human
capital development impacts and improved health outcomes. The implementation and financing
mechanisms under the AF consider the urgent needs in the sector, the implementation capacity of the
MOH, and the epidemiological and demographical profiles of the target population. Using government
systems to deliver the family health approach for improving quality of PHC services is the most cost-
effective, fit-for-purpose implementation arrangement for the AF.
39. The proposed AF features several ingredients for success. These include the GOJ’s commitment
to UHC and equity principles for the health system, as well as inclusive policies for refugees to access the
same package of services available to Jordanian nationals at MOH facilities; the strong record of MOPIC
in managing World Bank-financed projects; reliance on government health system structures with regard
to financing and service provision; a streamlined FM system; and a greater emphasis on results. The
proposed AF design builds on global and country-specific experience and will be supported through World
Bank TA and implementation support.
C. Financial Management
40. Due to the emergency nature of the AF, the FM approach was streamlined and based on simplified
ex ante requirements while relying more heavily on ex post requirements as additional fiduciary controls
and reviews.
41. The parent JEHP’s FM performance has been rated Satisfactory. JEHP staffing arrangements
were adequate, the verification of utilization of services by the target population conducted by UVE was
acceptable, in addition to the financial verification conducted by the Jordan AB. The parent project’s
financial reports were submitted on time in an acceptable format and content and sound internal controls
and external audit arrangements were in place.
42. The bulk of the proposed AF will fund part of the cost for delivering health services to the
beneficiaries: only costs related to the target population will be financed by the AF. The cost of eligible
primary and secondary health services will be calculated by dividing total actual expenditures
incurred/paid by the GOJ for each period by the total number of health services provided to the target
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population in the same period. The costs will cover the MOH’s expenditures for key recurrent
expenditures such as human resources and operating costs of health facilities, including rental and utilities
(water, electricity, and fuel), i.e. selected budget line items as defined in the Loan Agreement. As with the
parent project, the AF does not finance the costs of medical items such as vaccines, medicines, equipment,
or consumables. The unit cost of delivering one primary or secondary health service will be calculated by
dividing the total actual costs paid by the MOH by the number of health services delivered to the target
population at MOH facilities. The cost of primary and secondary health services provided to the target
population will be estimated by multiplying the cost per unit of services by the number of primary and
secondary care services delivered at MOH facilities.
43. Under Component 1 (reflected in Category 1 in the Loan Agreement Withdrawal Schedule), two
semiannual disbursements will take place, and each disbursement will cover six months of recurrent non-
medical expenditures for delivering health care services. A Health Care Service Delivery Expenditure
Report, using the inputs from verifications conducted by the Jordan AB and UVE, will be submitted to the
Bank no later than six months after the end of the corresponding period, with an exception under the first
two advances. The AB and UVE will verify the outputs and the actual amount due and will submit their
reports to the World Bank through MOPIC.
44. Disbursements under subcomponent 2.1 (reflected under Category 2 in the Loan Agreement
Withdrawal Schedule) will be based on the respective DLIs. Disbursements will be made against actual
expenditures only when related DLIs have been achieved and verified. Disbursements under Category 2
will be contingent upon the GOJ furnishing evidence satisfactory to the World Bank that it has achieved
the respective DLIs and these will be verified by the World Bank and the MOH Budget Directorate.
Reconciliation against actual expenditures will be incurred during the same period. Application for
withdrawal of amounts allocated to individual DLIs will be sent to the World Bank any time after the World
Bank has notified the GOJ in writing that it has accepted evidence of achievement of the DLIs. The
withdrawal amount against the DLIs achieved will not exceed the amount of the financing confirmed by
the World Bank for the specific DLIs, which will be up to the lesser of the actual expenditure incurred or
the DLIs achieved and the verified respective allocation.
45. The proposed AF will follow the same FM arrangements as under the parent project, including
with respect to FM responsibilities, which will be managed by the same qualified financial officer seconded
from the MOPIC Accounting Department. Two new Designated Accounts (DAs) will be used to receive AF
proceeds, DA-A will be used to receive funds for Component 1 and subcomponent 2.1, while DA-B will be
used for subcomponent 2.2. The funds received in DA-A will be eventually credited to the Government
Single Treasury Account (STA). Semiannual unaudited IFRs will be submitted to the World Bank within 45
days after the end of each semester. Disbursements under Component 1 are based on a verification of:
(a) the number of health services provided to the target population during a six-month period, verified by
the UVE, and (b) the actual expenditures incurred by the GOJ during the same six-month period to deliver
these services verified by the Jordan AB. An annual audit of project financial statements will be required
and will be conducted by the Jordan AB. The project’s annual audited financial statements will be due six
months after the end of each year.
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D. Procurement
46. All goods, non-consulting services, and consulting services required for the management of the
project and to be financed out of the AF proceeds shall be procured in accordance with the requirements
set forth in the ”World Bank Procurement Regulations for Borrowers under Investment Project Financing,”
dated July 1, 2016, revised in August and November 2018. Additionally, the “Guidelines on Preventing and
Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants” (dated
October 15, 2006 and revised in January 2011 and as of July 1, 2016) will apply to the project. The
provisions of the Procurement Plan for the project (dated May 21, 2018 and provided for under Section
IV of the Procurement Regulations) may be updated from time to time in agreement with the World Bank.
47. Similar to the parent project, the AF includes provisions for TA training workshops, selection of a
number of international and national experts, supply of office equipment, etc.
48. The overall procurement risk rating is Moderate, given limited procurement activities. The
following measures are proposed to mitigate procurement-related risks: (a) using the Procurement Plan
as a monitoring tool for timely processing of activities; (b) systematizing record keeping and initiating
electronic archiving of procurement processing; (c) enhancing capacity of appropriate support (staff,
training, and tools); (d) recruiting a qualified and experienced procurement officer familiar with the World
Bank’s Procurement Regulations and Guidelines; and (e) preparing the TORs for the required consulting
services in advance.
Market Analysis Summary
49. Consultants. The required consultants for auditing are consulting firms working in the fields of
health management information systems, strategic purchasing for services in the private sector, and
capacity building. Jordan has many experienced local firms with these skills. Additional consultancy
contracts are expected to be few, mostly for individual consultants, where both local and international
capacity may be tapped into, as needed.
50. Methods of procurement. Selection methods and arrangements: procurement methods available
under the World Bank Procurement Regulations and as agreed in the Procurement Plan will be used by
the implementing agency.
51. Goods and non-consulting services. No purchase of equipment or goods is expected under the
project. However, if small items were needed, a Request for Quotations and Direct Selection will be used.
52. Consulting services. The project is expected to use request for proposals with the following
selection methods: (a) Quality- and Cost-Based Selection, (b) Selection under a Fixed Budget, (c) Least-
Cost Selection, (d) Selection Based on the Consultants’ Qualifications, (e) Direct Selection (old single
sourcing), and (f) Selection of Individual Consultants.
53. Prior review thresholds. Based on the procurement assessment and risk rating, the project shall
be subject to Moderate risk prior review thresholds as defined under the World Bank Procurement
Framework. Therefore, most contracts, with exception of TORs, are expected to be post review. Hands-
on assistance will be provided by World Bank staff as needed.
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54. Systematic Tracking of Exchanges in Procurement (STEP). The Procurement Plan for the AF will
be updated by MOPIC through STEP. It will define the market approach options, the selection methods
and contractual arrangements, packaging to implement procurement activities efficiently and effectively,
and shall determine the World Bank’s prior/post review requirements. The updated Procurement Plan
covering at least 18 months of project implementation will be attached to the Loan Agreement.
55. Project Procurement Strategy for Development (PPSD). MOPIC shall prepare a PPSD according
to the Procurement Regulations, and the agreed PPSD including the Procurement Plan should be available
before signing of the AF Loan Agreement.
56. Frequency of post procurement review. The post procurement review is foreseen to be held once
a year. In the post procurement review, a minimum sample of 10 percent of contracts or at least one
contract eligible for post review shall be covered.
E. Gender
57. Analysis. Global evidence suggests that primary care and targeted maternal interventions such as
antenatal care can reduce maternal and child mortality rates by 5 to 40 percent.18 However, in Jordan,
fewer pregnant women today receive adequate care during their first trimester, with a 6-percentage point
drop in only a five-year period. Between 2012 and 2017/18, the rate of pregnant women having their
initial antenatal visit during their first trimester dropped from 91 to 84.8 percent.19 Furthermore, while
antenatal coverage is high overall in Jordan, receiving adequate care (following WHO guidelines of
recommended timing and number of visits) varies significantly by region, nationality, education, and
income. For example, 69 percent of pregnant women in the lowest quintile receive adequate care
compared to 89 percent among those in highest quintile. By nationality, 82 percent of Jordanians had at
least seven or more antenatal care visits as compared to 62 percent of Syrian women. Fewer Syrian
women (83.2 percent) received their initial antenatal visit during their first trimester, compared with the
national average (84.8 percent).20 Thus, there is a significant gap in accessing to antenatal care services
for Syrian refugee women compared with Jordanian women.
58. Action. This AF aims to ensure that essential health services are readily available for men and
women of the vulnerable groups. It will do so by improving PHC through expanding a family health model,
where vulnerable populations will be prioritized to receive adequate health services based on their needs.
18 Bhutta, Zulfiqar A., Ali, Cousens, Ali, Haider, Rizvi, Okong, Bhutta and Black. 2008. “Alma-Ata: Rebirth and Revision 6:
Interventions to Address Maternal, Newborn, and Child Survival: What Difference Can Integrated Primary Health Care Strategies
Make?” The Lancet 372.9642 (2008): 972.
Rosero-Bixby, Luis. 1986. “Infant Mortality in Costa Rica: Explaining the Recent Decline. ” Studies in Family Planning 17.2 (1986):
57–65.
Macinko, James, Frederico C. Guanais, and Maria De Fátima Marinho De Souza. 2006 "Evaluation of the Impact of the Family.”
19 Department of Statistics (DOS) and ICF International. 2019. Jordan Population and Family Health Survey 2017–2018. Amman,
Jordan, and Rockville, Maryland: DOS and ICF International.
20 Department of Statistics (DOS) and ICF International. 2019. Jordan Population and Family Health Survey 2017 –2018. Amman,
Jordan, and Rockville, Maryland: DOS and ICF International. According to the nationwide statistics, 82 percent of Jordanian
women had at least seven antenatal care visits as compared to 74 percent of women of other nationalities and 62 percent of
Syrian women.
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The global evidence suggests that the strongest mechanism to improve health problems for women,
including mother and child health care, is an improved PHC system. The WHO has advocated for a new
model of PHC (sometimes referred to as a Family Health Model) and various OECD countries have
implemented the WHO framework of patient-centric integrated services. These new approaches to PHC
contribute to the reduction of inequalities that stem not only from gender differences, but also from the
intersectionality of gender with poverty, ethnicity and women with different cultural or national
backgrounds. Family health teams at MOH facilities identify various populations at risk to prioritize
women’s health, to reduce gender inequalities by collecting data on households and families from the
catchment areas, and to identify early risks and interventions. Drawing from good community model
health practices in Costa Rica and Djibouti, the project will work with female community health volunteers
through this Family Health Model to raise awareness among all key reference points for both female and
male community members around the importance of early antenatal care, and to communicate services
available at PHCs. This ensures that pregnant women will have the information needed to access earlier
antenatal care and an adequate monitoring system can be implemented for at-risk pregnancies, including
specialist referrals. In addition, the model will strengthen core health system functions (for example,
human resources for health and information systems) for a stronger PHC system with the right balance
between prevention, promotion and inpatient and outpatient care.21 For example, in Nordic countries22,
Canada23, Spain24, and Chile25 an intervention that is considered to have a major positive impact in
reducing social and gender inequalities in health is a family health model of PHC, which includes social
determinants of health and identification of key vulnerable groups. Identifying the health needs of, and
prioritizing interventions for vulnerable populations, such as pregnant women, is expected to improve
access to antenatal care services.
59. M&E. The AF will monitor access to antenatal care services for Syrian refugees. Specifically, it will
measure increases in the proportion of pregnant Syrian refugee women accessing their first antenatal
care visits during the first trimester. The data will be collected from the next round of the Jordan
Population and Family Health Survey (using the 2017/2018 survey data as a baseline).
F. Social (including Safeguards)
60. The project is expected to contribute to positive social outcomes by maintaining access to
primary and secondary health care services for the target population. The activities under the AF are the
same as under the parent JEHP. Involuntary Resettlement (OP/BP 4.12) is not triggered for the AF, because
21 https://www.who.int/servicedeliverysafety/areas/people-centred-care/framework/en/. Accessed May 2018.
22 Olsen, Anell et al. “General practice in the Nordic countries.” Nordic Journal of Health Economics, Vol. 4 (2016), No. 1, pp. 56-
67.
23
Warlmels, Johnston & Turmey. “Improving team-based care for children: shared well child care involving family practice
nurses.” Prim Health Care Res Dev. 2017 Sep; 18(5): 507–514.
24
“Avanzando hacia la equidad: Propuesta de Politicas e Intervenciones para Reducir las desigualdades sociales en salud en
España. Comisión para Reducir las Desigualdades Sociales en Salud en España.” Ministerio de Política Social, May 2010.
25
“Chile, a good place of birth: Maternal and infant morbidity and mortality at global and national level” Revista Médica Clínica
Las Condes (Elsivier). Volume 25, Issue 6, November 2014, Pages 874-878.
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Jordan Emergency Health Project Additional Financing (P170529)
there is no land acquisition, or economic or physical displacement that will result from the project
activities.
61. The potential adverse risks associated with the project relate to barriers to access to health care
services being provided, particularly for vulnerable groups. The project, by design, is already targeting
vulnerable populations of uninsured Jordanians, a portion of whom are poor, and Syrian refugees, most
of whom are poor women and children and are extremely vulnerable. The parent project was successful
in meeting its accessibility targets. Component 1 will continue to maintain access to primary and
secondary services at significantly reduced costs, while ensuring quality through verified audits.
62. The project design is gender-sensitive and aligns well with the World Bank Gender Strategy
which focuses, among other things, on improving gaps in human endowments. The GOJ has built
capacities to provide gender-sensitive services to those in need, such as Syrian refugees and the poor
uninsured Jordanians. The JEHP planned to provide TA for supply-side capacity building (mainly through
training on GBV and barriers to access), the supply-side interventions have been well developed and
supported by other development partners, such as UNICEF and UNFPA. Undisbursed funds under the
parent project, which account for some of the undisbursed balance under the JEHP, initially planned to
deliver supply-side interventions, will be used to strengthen health system’s response to GBV based on
MOH’s priorities and potential shortcomings to address GBV.
63. Other risks relate to ineffective identification and communication to the target populations that
may result in lack of demand for the services available. Uninsured Jordanians such as single-headed
households and those who may be discouraged from seeking health care due to out-of-pocket payments,
may not seek access to health care services. For the same reason, Syrian refugees, particularly those not
holding the MOI service cards, may also face difficulties accessing health care services.
64. The mitigation measures include working with development partners and supporting new MOH
outreach and communications activities to inform the target population about the new co-payment
policies for Syrian refugees and, in collaboration with other relevant stakeholders (e.g., Health
Directorates, UNHCR, health centers in locations with high presence of Syrian refugees, local
nongovernmental organization [NGOs], and international donors) to disseminate information about the
rights of Jordanians and Syrian refugees including on access to health services. For example, USAID, the
Government of Denmark, and UNHCR are collaborating on a communication campaign. The campaign will
include where and how to access health services and the changes introduced with regard to co-payments.
Under the AF, the World Bank will collaborate and support these ongoing efforts. The GRM is in place and
is accessible to the public through a hotline and website. The MOH tracks the number of complaints
received, the number of complaints resolved, and the number of complaints in process.
65. Extensive consultations with relevant beneficiaries and stakeholders were conducted during
the parent project implementation and design of the AF. These included discussions with patients and
health providers at a comprehensive PHC center in Amman; director of the Maternal and Child Health
Department (including family violence unit) at the MOH; bilateral agencies (USAID and the Government
of Denmark); UN Agencies (UNFPA, UNICEF, WHO, and UNHCR); and international and local NGOs.
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G. Environment (including Safeguards)
66. According to OP 4.01 on Environmental Assessment (EA), the AF is classified as Environmental
Category C. Interventions to be supported by the AF are expected to have minimal or no direct
environmental impacts. Similar to the parent project, the AF will not support civil works or construction,
and will not fund any medical consumables (for example, vaccination kits, vials, and syringes), equipment,
goods, or works. If the scope of the AF is revised to include any of the above, then the project will be
subject to EA reclassification.
67. The AF was screened for climate and disaster risk and found to be at high risk from extreme
temperature, precipitation, and drought. Mean annual temperature in Jordan is projected to increase by
2°C by 2050 with a higher projected rate of warming in the summer. This is coupled with a projected
increase in the frequency of heat waves. The total annual hot days of temperature above 35°C will rise by
34.5 days by 2050. Annual precipitation rates show an increase in interannual rainfall variability, but
overall have decreased at most meteorological stations in Jordan and mean annual precipitation is
expected to continue to fall by −7.4 mm by 2050. The variability and expected increases in extreme
weather events will have implications for flooding in Jordan.
68. The changes in extreme temperature may induce heat stress among the project's target
population. Incidents of flooding already claim lives and destroy agricultural lands and infrastructure.
Conversely, the projected increase in interannual rainfall variability is likely to exacerbate drought risk in
the future as well. The combined effect of increasingly limited access to clean water contributes to
increases incidences of waterborne diseases (typhoid, fever, cholera, Hepatitis A and E, giardiasis, and
bilharzia); food-borne diseases through crop contamination; increased food insecurity; and malnutrition.
The GOJ has been providing public services to Syrian refugees, who added to fiscal stress and increased
demand for public services. The impacts of climate change are expected to exacerbate the demand for
key health services, which, if pushed beyond capacity, may produce negative consequences for the health
treatment of populations that are most vulnerable and least resilient to the impacts of climate change.
Additionally, if costs are high for the delivery of key health services, the most vulnerable will be the least
able to adapt to and cope with climate-induced shocks. With increasing risk of extreme weather
disruption, risk to social stability will increase.
69. The AF will contribute to enhanced climate adaptation and resilience through the following
activities. The project directly contributes to climate adaptation objectives of the health sector of Jordan’s
Intended Nationally Determined Contribution and the National Climate Change Policy (2013–2020).
70. Component 1 provides funds to reduce financial barriers of highly vulnerable groups supporting
access to primary and secondary health services. Increased health service access will be critical during
climate change-induced extreme weather events and will particularly enhance the ability of the target
beneficiaries, who are among the most climate vulnerable populations (Syrian refugees and poor
uninsured Jordanians).
71. Component 2 uses non-scalable DLIs to accelerate progress toward sustainable UHC and to foster
human capital development. Each of these will enhance population-level climate adaptation and
resilience to climate change. Specifically, under subcomponent 2.1 (US$9 million), support for sustainable
UHC will reward improved coverage and strengthened PHC services, through expansion of the family
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Jordan Emergency Health Project Additional Financing (P170529)
health model, while fostering human capital development will target pregnant women, mothers, and
children as one of its key health aims. Additionally, strengthening of primary health care will strengthen
day-to-day health resilience to climate change through enhanced community access to services and
increased utilization of health care. This will increase overall population resilience and the health sector
more generally, to climate change.
H. World Bank Grievance Redress
72. Communities and individuals who believe that they are adversely affected by a World Bank
(WB) supported project may submit complaints to existing project-level grievance redress mechanisms
or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly
reviewed in order to address project-related concerns. Project affected communities and individuals may
submit their complaint to the WB’s independent Inspection Panel which determines whether harm
occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints
may be submitted at any time after concerns have been brought directly to the World Bank's attention,
and Bank Management has been given an opportunity to respond. For information on how to submit
complaints to the World Bank’s corporate GRS, please visit http://www.worldbank.org/en/projects-
operations/products-and-services/grievance-redress-service. For information on how to submit
complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org.
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V SUMMARY TABLE OF CHANGES
Changed Not Changed
Results Framework ✔
Components and Cost ✔
Loan Closing Date(s) ✔
Implementing Agency ✔
Project's Development Objectives ✔
Cancellations Proposed ✔
Reallocation between Disbursement Categories ✔
Disbursements Arrangements ✔
Safeguard Policies Triggered ✔
EA category ✔
Legal Covenants ✔
Financial Management ✔
Procurement ✔
VI DETAILED CHANGE(S)
COMPONENTS
Current Component Name Current Cost Action Proposed Component Proposed Cost (US$,
(US$, millions) Name millions)
Results based financing to 48.00 Revised Results-based financing 238.00
deliver health care services to deliver health care
at primary and secondary services at primary and
care facilities of MOH for secondary care facilities
the target population of MOH for the target
population
Independent verification 2.00 Revised Improving coverage and 11.64
and institutional capacity quality of the primary
building to improve health care services
efficiency of health services
delivered
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TOTAL 50.00 249.64
LOAN CLOSING DATE(S)
Ln/Cr/Tf Status Original Closing Current Proposed Proposed Deadline
Closing(s) Closing for Withdrawal
Applications
IBRD-87680 Effective 29-Jun-2019 29-Jun-2019 31-Oct-2023 29-Feb-2024
TF-A5308 Effective 29-Jun-2019 29-Jun-2019 31-Oct-2023 29-Feb-2024
Expected Disbursements (in US$)
DISBURSTBL
Fiscal Year Annual Cumulative
2017 0.00 0.00
2018 0.00 0.00
2019 0.00 0.00
2020 101,160,020.00 101,160,020.00
2021 47,162,000.00 148,322,020.00
2022 19,162,000.00 167,484,020.00
2023 32,161,000.00 199,645,020.00
2024 0.00 199,645,020.00
SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT)
Risk Category Latest ISR Rating Current Rating
Political and Governance ⚫ Moderate ⚫ Moderate
Macroeconomic ⚫ Substantial ⚫ Substantial
Sector Strategies and Policies ⚫ Moderate ⚫ Moderate
Technical Design of Project or Program ⚫ Moderate ⚫ Moderate
Institutional Capacity for Implementation and ⚫ Moderate ⚫ Moderate
Sustainability
Fiduciary ⚫ Substantial ⚫ Moderate
Environment and Social ⚫ Low ⚫ Low
Stakeholders ⚫ Substantial ⚫ Moderate
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Jordan Emergency Health Project Additional Financing (P170529)
Other ⚫ High ⚫ Substantial
Overall ⚫ Substantial ⚫ Substantial
LEGAL COVENANTS2
LEGAL COVENANTS – Jordan Emergency Health Project Additional Financing (P170529)
Sections and Description
The Borrower shall:
(a) cause the Audit Bureau to be responsible to conduct the Expenditure Verifications;
(b) furnish the Expenditure Verification to the Bank no later than six (6) months after each Reported Period;
(c) hire, no later than three (3) months after the Effective Date, and shall thereafter maintain, throughout
Project implementation, the UVE, to conduct the Utilization Verification. The Borrower shall furnish Utilization
Verification Audits no later than six (6) months after each Reported Period; and
(d) furnish the Health Care Service Delivery Expenditure Report to the Bank, no later than six (6) months after
each Reported Period.
The Borrower shall open a dedicated special account within the Central Bank of Jordan for the exclusive benefit of
MOH and transfer, from the Borrower’s budget, on an annual basis, and by no later than September 30, 2019 in the
first year of the Project, and by no later than June 30 thereafter, an amount of $7,500,000 for each of the four
years of implementation of the Project, on terms and conditions acceptable to the Bank, for the purpose of
providing health care services for Syrian refugees.
Conditions
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VII. RESULTS FRAMEWORK AND MONITORING
Results Framework
COUNTRY: Jordan
RESULT_NO_PDO Jordan Emergency Health Project Additional Financing
Project Development Objective(s)
The Project development objective (PDO) is to support the Government of Jordan in maintaining the delivery of primary and secondary health services to poor uninsured
Jordanians and Syrian refugees at Ministry of Health facilities.
Project Development Objective Indicators by Objectives/ Outcomes
RESULT_FRAME_T BL_ PD O
Indicator Name DLI Baseline Intermediate Targets End Target
1 2
PDO Indicators (Action: This Objective has been Revised)
Maintaining number of health services
delivered at MOH secondary health care
facilities to target populations (Number 1,905.00 1,905.00 1,905.00 1,905.00
(Thousand))
Action: This indicator has been Revised
Number of health services delivered at
MOH secondary health care facilities
792.00 792.00 792.00 792.00
to poor uninsured Jordanians, male
(Number (Thousand))
Action: This indicator has been
Revised
Number of health services delivered at
MOH secondary health care facilities
to poor uninsured Jordanians, female 1,009.00 1,009.00 1,009.00 1,009.00
(Number (Thousand))
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RESULT_FRAME_T BL_ PD O
Indicator Name DLI Baseline Intermediate Targets End Target
1 2
Action: This indicator has been
Revised
Number of health services delivered at
MOH secondary health care facilities
46.00 46.00 46.00 46.00
to registered Syrian refugees, male
(Number (Thousand))
Action: This indicator has been
Revised
Number of health services delivered at
MOH secondary health care facilities
to registered Syrian refugees, female 58.00 58.00 58.00 58.00
(Number (Thousand))
Action: This indicator has been
Revised
Maintaining number of health services
delivered at MOH primary health care
2,670.00 2,670.00 2,670.00 2,670.00
facilities to target populations (Number
(Thousand))
Action: This indicator has been Revised
Number of health services delivered at
MOH primary health care facilities to
poor uninsured Jordanians, male 1,115.00 1,115.00 1,115.00 1,115.00
(Number (Thousand))
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RESULT_FRAME_T BL_ PD O
Indicator Name DLI Baseline Intermediate Targets End Target
1 2
Action: This indicator has been
Revised
Number of health services delivered at
MOH primary health care facilities to
1,420.00 1,420.00 1,420.00 1,420.00
poor uninsured Jordanians, female
(Number (Thousand))
Action: This indicator has been
Revised
Number of health services delivered at
MOH primary health care facilities to
registered Syrian refugees, male 59.00 59.00 59.00 59.00
(Number (Thousand))
Action: This indicator has been
Revised
Number of health services delivered at
MOH primary health care facilities to
76.00 76.00 76.00 76.00
registered Syrian refugees, female
(Number (Thousand))
Action: This indicator has been
Revised
Completion and dissemination of a health
sector roadmap to improve the efficiency No No Yes Yes
of services delivered (Yes/No)
Rationale:
Action: This indicator has been Marked
for Deletion This indicator is marked for deletion as the roadmap has already been delivered by the MOH with support from other development partners.
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PDO Table SPACE
Intermediate Results Indicators by Components
RESULT_FRAME_T BL_ IO
Indicator Name DLI Baseline Intermediate Targets End Target
1 2
Results based financing to deliver health care services at primary and secondary care facilities of MOH for the target population (Action: This Component has been Revised)
Grievances registered related to delivery
of project benefits that are actually 100.00 100.00 100.00 100.00
addressed (Percentage)
Action: This indicator has been Revised
People who have received essential
health, nutrition, and population (HNP) 0.00 1,101,290.00
services (CRI, Number)
Number of children immunized (CRI,
0.00 1,101,290.00
Number)
Review of the existing GRM mechanism No review conducted of the existing Review conducted of the existing
(Text) GRM system GRM system
Rationale:
Action: This indicator is New Independent review of the existing GRM mechanism conducted
Percentage increase in proportion of
pregnant Syrian women accessing their
83.2% 84.8%
first antenatal care visits during the first
trimester (Text)
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Jordan Emergency Health Project Additional Financing (P170529)
RESULT_FRAME_T BL_ IO
Indicator Name DLI Baseline Intermediate Targets End Target
1 2
Rationale:
Action: This indicator is New Measures the increase in the proportion of pregnant Syrian refugee women accessing their first antenatal care visits during the first trimester.
IO Table SPACE
Monitoring & Evaluation Plan: PDO Indicators Mapped
Methodology for Data Responsibility for Data
Indicator Name Definition/Description Frequency Datasource
Collection Collection
Governorate
Maintaining number of health services Target will be maintained Every 6 Directorate of Primary
health
delivered at MOH secondary health care within 5% +/- the baseline months Health Care, MOH
directorates
facilities to target populations value of 1,905,000
Number of health services delivered Target will be maintained Governorate
Every 6 Directorate of Primary
at MOH secondary health care within 5% +/- the baseline health
months Health Care, MOH
facilities to poor uninsured value of 792,000: (752,000 directorates
Jordanians, male – 832,000
Number of health services delivered Target will be maintained Governorate
Every 6 Directorate of Primary
at MOH secondary health care within 5% +/- the baseline health
months Health Care, MOH
facilities to poor uninsured value of 1,009,000: directorates
Jordanians, female (959,000 – 1,059,000)
Number of health services delivered Target will be maintained Every 6 Governorate Directorate of Primary
at MOH secondary health care within 5% +/- the baseline months health Health Care, MOH
facilities to registered Syrian refugees, value of 46,000: (44,000 – directorates
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male 48,000)
Number of health services delivered Target will be maintained Governorate
Every 6 Directorate of Primary
at MOH secondary health care within 5% +/- the baseline health
months Health Care, MOH
value of 58,000: (55,000 –
facilities to registered Syrian refugees, directorates
female 61,000)
During the AF
Governorate
Maintaining number of health services period:Target will be Every 6 Directorate of Primary
health
delivered at MOH primary health care maintained within 5% +/- months Health Care, MOH
directorates
facilities to target populations the baseline value of
2,670,000
Target will be maintained Governorate
Number of health services delivered Every 6 Directorate of Primary
within 5% +/- the baseline health
at MOH primary health care facilities months Health Care, MOH
value of 1,115,000: directorates
to poor uninsured Jordanians, male
(1,059,000 – 1,170,000)
Target will be maintained Governorate
Number of health services delivered Every 6 Directorate of Primary
within 5% +/- the baseline health
at MOH primary health care facilities months Health Care, MOH
value of 1,420,000: directorates
to poor uninsured Jordanians, female
(1,349,000 – 1,491,000)
Target will be maintained Governorate
Number of health services delivered Every 6 Directorate of Primary
within 5% +/- the baseline health
at MOH primary health care facilities months Health Care, MOH
value of 59,000: (56,000 – directorates
to registered Syrian refugees, male
62,000)
Target will be maintained Governorate
Number of health services delivered Every 6 Directorate of Primary
within 5% +/- the baseline health
at MOH primary health care facilities months Health Care, MOH
value of 76,000: (72,000 – directorates
to registered Syrian refugees, female
80,000)
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Completion and dissemination of a health
Every year MOH MOH
sector roadmap to improve the efficiency
of services delivered
ME PDO Table SPACE
Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped
Methodology for Data Responsibility for Data
Indicator Name Definition/Description Frequency Datasource
Collection Collection
Directorate of
Controls and
Grievances registered related to delivery Every 6
Internal MOH
of project benefits that are actually months
Auditing,
addressed
MOH
Ministry of
Yearly
Health Ministry of Health
People who have received essential MOH Data Ministry of Health,
Childhood Childhood Immunization
health, nutrition, and population (HNP) by calendar Jordan
Immunization records.
services year.
records.
Ministry of
Yearly
Health Ministry of Health
MOH data
Childhood Childhood Immunization Ministry of Health.
Number of children immunized by calendar
Immunization records.
year.
records.
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An independent review of Once (year
MOH MOH Directorate MOH
Review of the existing GRM mechanism the existing GRM system 4)
will be conducted
Jordan
Population
and Family
Health
Increase in the proportion
Survey,Depart
of pregnant Syrian women
Percentage increase in proportion of ment of Jordan Population and
accessing their first Every 5
pregnant Syrian women accessing their Statistics, Family Health Survey, Ministry of Health
antenatal care visits during years
first antenatal care visits during the first using the Department of Statistics
the first trimester, above
trimester 2017/2018
the baseline 83.2%
survey data as
(2017/2018) to 84.8%.
baseline,
83.2%
ME IO Table SPACE
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Disbursement Linked Indicators Matrix
DLI I N0068 5433 A CTI ON
DLI 1 Assessment of PHC coverage & quality gaps
Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount
Output No Text 2,000,000.00 0.00
Baseline No assessment
Year 1 0.00
MOH completes an assessment of gaps in
human resources and skills needed to
Year 2 incorporate a nationwide family health 2,000,000.00
services model based on WHO
recommendations
Year 3 0.00
Year 4 0.00
Action: This DLI is New
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Jordan Emergency Health Project Additional Financing (P170529)
DLI I N0068 5920 A CTI ON
DLI 1.1 Additional MOH budget allocation
Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount
Intermediate Outcome No Text 1,000,000.00 0.00
US$776,091,777 (JOD 550,419,700), MOH
Baseline
current and capital expenditures, 2017
Year 1 0.00
MOH receives additional budget of
US$1,000,000 in the Jordanian fiscal year 2020
Year 2 1,000,000.00
following declaration of effectiveness of the
project
Year 3 0.00
Year 4 0.00
Action: This DLI is New
DLI I N0069 5560 A CTI ON
DLI 1.2 MOH completes an assessment
Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount
Output No Text 1,000,000.00 0.00
Baseline No assessment
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Jordan Emergency Health Project Additional Financing (P170529)
Year 1 0.00
MOH completes an assessment of gaps in
human resources and skills needed to
Year 2 incorporate a nationwide family health 1,000,000.00
services model based on WHO
recommendations
Year 3 0.00
Year 4 0.00
Action: This DLI is New
DLI I N0068 5462 A CTI ON
DLI 2 Development of an Implementation Plan to Improve Quality & Coverage of PHC
Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount
Output No Text 3,000,000.00 0.00
Baseline No implementation plan
Year 1 0.00
Year 2 0.00
MOH develops and approves a costed and
Year 3 phased implementation strategy with an M&E 3,000,000.00
system
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Jordan Emergency Health Project Additional Financing (P170529)
Year 4 0.00
Action: This DLI is New
DLI I N0068 5921 A CTI ON
DLI 2.1 Additional MOH budget allocation
Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount
Intermediate Outcome No Text 1,000,000.00 0.00
US$776,091,777 (JOD 550,419,700), MOH
Baseline
current and capital expenditures, 2017
Year 1 0.00
Year 2 0.00
MOH receives an additional budget of
US$1,000,000 in the second consecutive
Year 3 1,000,000.00
Jordanian fiscal year following declaration of
effectiveness of the project
Year 4 0.00
Action: This DLI is New
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DLI I N0069 5581 A CTI ON
DLI 2.2 MOH develops an implementation plan
Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount
Output No Text 2,000,000.00 0.00
Baseline No implementation plan
Year 1 0.00
Year 2 0.00
MOH develops and approves a costed and
Year 3 phased implementation strategy with an M&E 2,000,000.00
system
Year 4 0.00
Action: This DLI is New
DLI I N0068 5435 A CTI ON
DLI 3 Human resources Capacity Building to Improve Outcomes in PHC
Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount
Output No Text 4,000,000.00 0.00
Human resources capacity building and
Baseline training plan completed, and evaluation
finalized
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Year 1 0.00
Year 2 0.00
Year 3 0.00
MOH provides report on Year 1
implementation results of the human
Year 4 4,000,000.00
resources capacity building and training
activities
Action: This DLI is New
DLI I N0068 5922 A CTI ON
DLI 3.1 Additional MOH budget allocation
Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount
Intermediate Outcome No Text 2,000,000.00 0.00
US$776,091,777 (JOD 550,419,700), MOH
Baseline
current and capital expenditures, 2017
Year 1 0.00
Year 2 0.00
Year 3 0.00
Year 4 MOH receives additional budget of 2,000,000.00
US$2,000,000 in the third consecutive
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Jordanian fiscal year following declaration of
effectiveness of the project
Action: This DLI is New
DLI I N0069 5573 A CTI ON
DLI 3.2 MOH provides report on results
Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount
Output No Text 2,000,000.00 0.00
Implementation plan activities not yet
Baseline
launched
Year 1 0.00
Year 2 0.00
Year 3 0.00
MOH provides report on Year 1
implementation results of the human
Year 4 2,000,000.00
resources capacity building and training
activities
Action: This DLI is New
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Jordan Emergency Health Project Additional Financing (P170529)
Verification Protocol Table: Disbursement Linked Indicators
DLI_T BL_VERIFICATI ON
DLI 1 Assessment of PHC coverage & quality gaps
MOH completes an assessment of gaps in human resources and skills needed to incorporate a nation-wide family health
services model based on WHO recommendations including (i) mother and child health, nutrition, growth and development
Description
monitoring,); and, (ii) prevention and early diagnosis of diabetes, hypertension and breast cancer
Primary Health Care Department, MOH
Data source/ Agency
World Bank
Verification Entity
Review by World Bank
Procedure
DLI_T BL_VERIFICATI ON
DLI 1.1 Additional MOH budget allocation
DLI#1.1: From the baseline of US$776,091,777 (JOD 550,419,700) (MOH’s expenditures in the2017 budget), MOH receives
Description additional budget of US$1,000,000 in the first Jordanian fiscal year 2020 following declaration of effectiveness of the project
MOH expenditure framework and Ministry of Finance (MOF) approved annual budget
Data source/ Agency
MOH Budget Directorate
Verification Entity
MOH Budget Directorate confirms that the intended additionality from the baseline is reflected
Procedure
DLI_T BL_VERIFICATI ON
DLI 1.2 MOH completes an assessment
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The World Bank
Jordan Emergency Health Project Additional Financing (P170529)
MOH completes an assessment of gaps in human resources and skills needed to incorporate a nation-wide family health
services model based on WHO recommendations including (i) mother and child health, nutrition, growth and development
Description
monitoring,); and, (ii) prevention and early diagnosis of diabetes, hypertension and breast cancer
Primary Health Care Department, MOH
Data source/ Agency
World Bank
Verification Entity
Review by World Bank
Procedure
DLI_T BL_VERIFICATI ON
DLI 2 Development of an Implementation Plan to Improve Quality & Coverage of PHC
MOH develops and approves a costed and phased implementation strategy with a M&E system, incorporating feedback and
Description inputs from all health directorates and development partners
Primary Health Care Department, MOH
Data source/ Agency
World Bank
Verification Entity
Review by World Bank
Procedure
DLI_T BL_VERIFICATI ON
DLI 2.1 Additional MOH budget allocation
From the baseline of US$776,091,777 (JOD 550,419,700) (MOH’s expenditures in the 2017 budget) MOH receives additional
Description budget of US$1,000,000 in the second consecutive Jordanian fiscal year following declaration of effectiveness of the Project
Data source/ Agency MOH expenditure framework and MOF approved annual budget
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The World Bank
Jordan Emergency Health Project Additional Financing (P170529)
MOH Budget Directorate
Verification Entity
MOH Budget Directorate confirms that the intended additionality from the baseline is reflected
Procedure
DLI_T BL_VERIFICATI ON
DLI 2.2 MOH develops an implementation plan
MOH develops and approves a costed and phased implementation strategy with a M&E system, incorporating feedback and
Description inputs from all health directorates and development partners
Primary Health Care Department, MOH
Data source/ Agency
World Bank
Verification Entity
Review by World Bank
Procedure
DLI_T BL_VERIFICATI ON
DLI 3 Human resources Capacity Building to Improve Outcomes in PHC
MOH provides report on year 1 implementation results of the human resources capacity building and training activities as
Description designed in the implementation strategy under DLI 2.2
Primary Health Care Department
Data source/ Agency
World Bank
Verification Entity
Review by World Bank
Procedure
DLI_T BL_VERIFICATI ON
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The World Bank
Jordan Emergency Health Project Additional Financing (P170529)
DLI 3.1 Additional MOH budget allocation
From the baseline of US$776,091,777 (JOD 550,419,700) (MOH’s expenditures in the 2017 budget) MOH receives additional
budget of US$2,000,000 in the third consecutive Jordanian fiscal year following declaration of effectiveness of the Project
Description
MOH expenditure framework and MOF approved annual budget
Data source/ Agency
MOH Budget Directorate
Verification Entity
MOH Budget Directorate confirms that the intended additionality from the baseline is reflected
Procedure
DLI_T BL_VERIFICATI ON
DLI 3.2 MOH provides report on results
MOH provides report on year 1 implementation results of the human resources capacity building and training activities as
Description designed in the implementation strategy under DLI 2.2
Primary Health Care Department
Data source/ Agency
World Bank
Verification Entity
Review by World Bank
Procedure
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The World Bank
Jordan Emergency Health Project Additional Financing (P170529)
Annex 1: Financial Management
1. The World Bank updated the assessment of the FM systems that was conducted during the
preparation of the ongoing JEHP. The assessment concluded that, with the implementation of agreed-
upon actions, the proposed FM arrangements will satisfy the minimum requirements under the World
Bank Policy on Investment Project Financing. The FM risk is rated Moderate.
2. Project expenditures and funds flow arrangements. The bulk of the AF proceeds will finance part
of the cost for delivering health care services to the target populations, which will be up to US$12 per
beneficiary for primary care and US$63 per beneficiary for secondary care. The costs will mainly cover the
MOH’s expenditures for key recurrent nonmedical expenditures, such as human resources and operating
costs of health facilities, including rental and utilities (water, electricity, and fuel). As with the ongoing
JEHP, the AF will not finance the cost of medical items such as vaccines, medicines, equipment, or
consumables. The unit cost of delivering one primary or secondary health service will be calculated by
dividing the total actual costs paid by the MOH by the number of health services delivered to the target
population at MOH facilities. The cost of primary and secondary health services provided to the target
population will be estimated by multiplying the cost per unit of services by the number of primary and
secondary care services delivered at MOH facilities.
3. Two DAs will be used to receive the AF proceeds. One DA-A will be used to receive funds under
Component 1 and subcomponent 2.1, while the DA-B will be used to receive the funds under
subcomponent 2.1. The DA-A funds will be ultimately credited to the STA at the Central Bank of Jordan
(CBJ). For Component 1, up to US$30 million is envisaged as part of the retroactive financing for primary
and secondary health care services eligible expenditures, as long as they were made before the signing of
the Loan Agreement but on or after June 30, 2018, and were not financed by the ongoing JEHP.
4. Under Component 1 (reflected in Category 1 in the Loan Agreement Withdrawal Schedule), two
semiannual disbursements will take place, and each disbursement will cover six months of recurrent
nonmedical expenditures. Each disbursement will be verified by the Jordan AB and UVE within 6 months
following each reported period, with an exception for the first two advances. The AB and UVE will verify
the outputs and the actual amount due and will submit their reports to the World Bank through MOPIC.
5. Disbursements under subcomponent 2.2 (reflected under Category 2 in the Loan Agreement
Withdrawal Schedule) will be based on respective DLIs. Disbursements will be made against actual inputs
(i.e., expenditures) only when related DLIs have been achieved and verified. Disbursements under
Category 2 will be contingent upon the GOJ furnishing evidence satisfactory to the World Bank that it has
achieved the respective DLIs and these will be verified by the World Bank team. Reconciliation against
actual expenditures will be incurred during the same period. Applications for withdrawal of amounts
allocated to individual DLIs may be sent to the World Bank any time after the World Bank has notified the
GOJ in writing that it has accepted evidence of achievement of the DLIs. The withdrawal amount against
the DLIs achieved will not exceed the amount of the financing confirmed by the World Bank for the specific
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Jordan Emergency Health Project Additional Financing (P170529)
DLIs, which will be up to the lesser of the actual expenditure incurred or the DLIs achieved and the verified
respective allocation.
6. The AF proceeds will be disbursed in accordance with the World Bank’s disbursements
guidelines. This will be outlined in the Disbursement Letter and in accordance with the World Bank’s
Disbursement Guidelines for projects. The project will follow IFR-based disbursement. Therefore, requests
for payments will be initiated through the use of withdrawal applications either for direct payments,
reimbursements, and replenishments to the DA. All withdrawal applications will include appropriate
supporting documentation. The documentation supporting expenditures (including the financial audit
report of retroactive financing) will be retained at the MOH and readily accessible for review by the
external auditors and World Bank supervision missions. All disbursements will be subject to the provisions
of the Loan Agreement and disbursement procedures as defined in the Disbursement Letter.
7. FM implementation arrangements. MOPIC will continue to manage the FM and disbursement
functions of the AF. The current financial officer from the MOPIC Finance Department will continue to
follow on the project’s FM and disbursement issues. In addition, a part-time financial officer will be hired
at the MOH to work closely with MOPIC/financial officer on providing necessary financial information and
documentation.
8. Planning and budgeting through the use of the existing GFMIS system. MOPIC and the MOH use
systems for budget classification and a Chart of Accounts (COA) that conforms to international standards
and deploys a basic, but effective, results-oriented budgeting framework, which provide the means to
track government spending. Line ministries, including the MOH, have a robust classification system
broadly consistent with the Government Finance Statistics Manual (GFSM) 2001. This system includes
administrative, economic, functional, geographical, and program classifications. These classifications are
included in the current COA allowing for all transactions to be reported in accordance with the appropriate
standards. A GFMIS is used for budget preparation.
9. Accounting and financial reporting. Much like other line ministries in Jordan, the MOH has a cash
basis for accounting. The Government adopts a COA that is compatible with GFSM 2001. The MOF has
rolled out the GFMIS to all line ministries in Jordan, including the MOH and MOPIC. The current GFMIS
implementation uses a subset of the functionalities of the underlying application software. The current
core application software comprises: (a) Hyperion for budget preparation; (b) ORACLE financials for
budget execution; and (c) software for interfacing with other software for debt management, payroll,
bank reconciliation, and revenue management. The GFMIS is fully used for budget execution. Yet, for
budget preparation, there are manual interventions with various information and communication
technology tools being used. MOPIC will be responsible for preparing the semiannual IFRs and annual
project financial statements. For annual financial reporting of the project, it is proposed to rely on existing
arrangements to capture financial transactions. However, annual and semiannual financial reporting will
be generated using Excel sheets. The IFRs will be submitted by MOPIC to the World Bank within 45 days
after the end of the concerned period.
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10. Internal controls and internal audit. Budget execution controls are implemented and applied
consistently by MOPIC and the MOH in accordance with the applicable Financial Bylaw (1994) and its
Amendment (2015), and the Financial Control Bylaw (2011) and its Amendment (2015). The budget
execution systems at MOPIC and the MOH implement prescribed controls, which include: (a) technical
approval by the beneficiary department; (b) finance staff checking and approval; (c) periodic, ad hoc
reviews by resident internal auditors; and (d) exercise of an expenditure controlling function by the MOF’s
financial controllers assigned to respective spending units. The MOF assigned financial controllers to
oversee transaction-based compliance controls over payments, recording of transactions, and production
of periodic and final accounts by responsible entities. In practice, no payments can be authorized and
processed before financial controllers verify and sign off on payment vouchers. In addition to resident
financial controllers from the MOF, MOPIC and the MOH have internal auditors who mainly perform the
job of internal/financial controllers. Internal audit activities are primarily confined to ex ante review of
receipts, expenditure vouchers, and disbursements. Ex ante controls are performed by financial
controllers and internal auditors.
11. Payroll. Because salaries and wages make up a significant part of the cost of primary and health
services provided by the MOH and financed by the project, a review of diagnostic public financial
management reports and an assessment of the MOH payroll system was conducted. According to the
2017 Public Expenditure and Financial Accountability Assessment for Jordan, the controls over payroll
were rated as ‘A’, with a key role being played by the Internal Control Unit (ICU) in each ministry, including
the MOH. The ICU exercises a preaudit role that involves the review of individual salaries and ensures
compliance with the bylaw. It submits four reports per year to the MOF and the AB of Jordan and informs
the Civil Service Bureau (CSB). Payroll audits are carried out by both the CSB and the AB. The CSB’s role
relates to administrative matters such as whether the MOH is following the performance appraisal system
correctly and matching job descriptions correctly to posts. Employing the International Organisation of
Supreme Audit Institutions (INTOSAI) standards, the AB carries out an annual payroll audit of all ministries
including the MOH using a specially developed audit program that incorporates a system review,
sampling, and review of the regulatory framework.
12. The payroll system in place has a good degree of integration and reconciliation between the
position controls, personnel records, and payroll registers. The payroll system at the MOH follows the
CSB’s instructions and is in line with the national financial law and internal controls regulation, in addition
to instructions issued by the MOF. The Human Resources Department at the MOH is responsible for
receiving and entering the information for the appointed employee into the automated human resources
database system. The Human Resources Department safeguards the information and the data entry
through an automated system with record archival both in the system and in paper files. Human resources
input in the system is subject to both automated and human checks. A payroll schedule is prepared on a
monthly basis and subject to several layers of approvals (payroll officer, head of Payroll Unit, department
manager (budget holder), Internal Control Department, MOF financial controller, and FM manager).
Salaries are transferred to employees’ personal bank accounts. Monthly reconciliations are prepared in
the system and shared with the ICU and MOF representative. Daily time attendance sheets, based on an
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Jordan Emergency Health Project Additional Financing (P170529)
automated attendance register, are maintained by the attendance supervisor, who reports absences to
HR and the responsible department. Supervisors confirm that they strictly ensure all employees are in
place and functional. For additional assurance over payroll, the external auditor hired for the project will
also provide an opinion on the internal controls over payroll at the MOH and the MOH hospitals and
centers that provide primary and secondary services financed by the loan.
13. External verification and auditing. The project will have three types of audits: (a) an expenditure
verification to check the eligibility of expenditures made, which will be carried out by the AB within six
months of each advance; (b) a utilization verification to track the delivery of health services to the target
populations, which will be carried out by a UVE, within six months of each advance; and (c) annual financial
statement audit due six months after the end of each year, which will be carried out by the AB. The latter’s
scope of work will also include providing an audit opinion on the internal controls over payroll at the MOH
and the MOH hospitals and centers that provided primary and secondary services financed by the loan.
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