PROJECT INFORMATION DOCUMENT (PID) ADDITIONAL FINANCING Report No.: PIDA2938 Project Name Uganda Health Systems Strengthening Project (P145280) Parent Project Name Uganda Health Systems Strengthening Project (P115563) Region AFRICA Country Uganda Sector(s) Health (80%), Other social services (20%) Theme(s) Health system performance (70%), Population and reproductive health (30%) Lending Instrument Investment Project Financing Project ID P145280 Parent Project ID P115563 Borrower(s) Government of Uganda Implementing Agency Ministry of Health Environmental Category B-Partial Assessment Date PID Prepared/Updated 27-Dec-2013 Date PID Approved/Disclosed 27-Dec-2013 Estimated Date of Appraisal 03-Jan-2014 Completion Estimated Date of Board 28-Feb-2014 Approval Decision The Decision Review Meeting for the proposed Additional Financing of the Uganda Health Systems Strengthening Project was held on Wednesday, December 11, 2013 chaired by Ahmadou Moustapha Ndiaye, Uganda Country Manager. The meeting cleared the team to proceed with appraisal and negotiations I. Project Context Country Context Uganda has experienced sustained economic growth between 1990 to 2010 averaging 7 percent. Growth rate in recent years has slowed down and is characterized by increased volatility. Growth rate dropped to 3.4% in 2012 and is projected to grow at around 5% in 2013. Uganda's GDP per capita is estimated at US$490. While poverty has been consistently dropping, poverty levels remain high with about 40 percent of the population subsisting on less than US$1.25 per day. Uganda's population growth rate of 3.2% is among the highest in the world and is driven primarily by the high Total Fertility Rate (TFR). Uganda's TFR of 6.2 births per woman in the reproductive age group is among the highest in the world. Uganda is on track to achieve the MDG targets on poverty and improving gender equality and Page 1 of 5 empowerment of women, and has made significant progress in improving access to HIV/AIDS treatment and access to safe water. Child and infant mortality also recorded a significant drop in between 2006 and 2011. Progress has been slow for MDGs related to maternal mortality, access to reproductive health services, and control of malaria and other communicable diseases. Although the 2011 Demographic and Health Survey (DHS) reported improvements in skilled delivery attendance and contraceptive prevalence rate (CPR) from 42 percent to 59 percent and 24 percent to 30 percent between 2006 and 2011, respectively, maternal mortality ratio stagnated at 438 deaths per 100,000 live births. The high maternal mortality is attributed to limited access to emergency obstetric care. Sectoral and institutional Context Peri-natal and maternal morbidity and mortality are major causes of the high disease burden in Uganda, accounting for 20.4 percent of the burden. Coverage of skilled delivery services and especially comprehensive emergency obstetric care is low. According to the 2011/2012 Annual Health Sector Performance Report, only 7 percent of sampled facilities provided comprehensive emergency obstetric care. Adolescent reproductive health services are generally limited. In addition, vertical transmission of HIV to children by mothers contributes over 15 percent of HIV new infections annually. Although the delivery of health services is improving, capacity for service provision is constrained at the front line. The provision of health services is devolved to the Local Governments at the district level. Coupled with running primary health care activities and lower level health facilities (health centers), the districts manage hospitals and are responsible for the recruitment and deployment of staff. With proliferation of districts, their capacity has been significantly eroded. The majority of hospitals in Uganda were built over 40 years ago and are dilapidated owing to poor maintenance but also for having attained and surpassed their lifespan. The policies and strategies for the sector program are outlined in the Health Sector Strategic and Investment Plan (HSSIP, 2010/11 – 2014/15) and the National Development Plan (NDP, 2011 – 2015). The sector strategy seeks to improve overall health of the population, reduce health inequalities and enhance socio-economic development by scaling up a minimum package of cost- effective interventions, strengthening capacity of the health workforce and increasing availability of medicines and supplies as well as improving functionality of the existing health infrastructure. The Uganda National Minimum Health Care Package is a set of cost-effective health care interventions organized around four clusters comprises: (a) health promotion, environmental health, disease prevention and community health initiatives, including epidemic and disaster preparedness and response; (b) maternal and child health; (c) prevention, management and control of communicable diseases; and (d) prevention, management and control of non-communicable diseases. While project support extends to all the clusters, the project places greater emphasis on the third cluster on improving maternal health. II. Proposed Development Objectives A. Current Project Development Objectives – Parent The project development objective (PDO) is to deliver the Uganda National Minimum Health Care Package (UNMHCP) to Ugandans, with a focus on maternal health, newborn care and family planning. This will be through improving human resources for health, physical health infrastructure, and management, leadership and accountability for health service delivery. B. Proposed Project Development Objectives – Additional Financing (AF) Page 2 of 5 The revised project development objective is to increase utilization of the Uganda National Minimum Health Care Package, with a focus on maternal health and family planning. III. Project Description Component Name Improved health workforce development and management (US$ 5 million, AF US$0.0 million) Comments (optional) No Changes made to the component Component Name Improved infrastructure of existing health facilities (US$85 million, AF US$90 million). Comments (optional) AF of US$ 90 M is to cover the funding shortfall for the health infrastructure component of the original project and scale up civil works activities by adding three additional hospitals Component Name Improved Leadership, Management, and Accountability for health service delivery (US$10 million, AF US$0) Comments (optional) The component is not restructured. But the activities under the component are to be refined and consolidated to ensure better alignment of the activities and consistency with the project objectives. Component Name Improved maternal, newborn and family planning services (US$30 million, AF US$0) Comments (optional) The component is being restructured to support output based aid activities based on the successful Reproductive Health Voucher Project (P104527) IV. Financing (in USD Million) Total Project Cost: 90.00 Total Bank Financing: 90.00 Financing Gap: 0.00 For Loans/Credits/Others Amount BORROWER/RECIPIENT 0.00 International Development Association (IDA) 90.00 Total 90.00 V. Implementation The project is making satisfactory progress towards achievement of the development objective. During the April 2013 Mid-Term Review the project was rated satisfactory on the Development Objective, and moderately satisfactory on Implementation Progress. The annual targets for four of the five PDO targets had been achieved. Procurement under the project is progressing well, and with exception of procurement of equipment requiring pre-installation works, the rest of the procurements including civil works have commenced and are at different stages of implementation. Various medical equipment including for obstetric care were received and are currently being distributed to 230 facilities countrywide. In addition, the project procured an assortment of reproductive health medicines and commodities including family planning implants and manual Page 3 of 5 vacuum aspirators (MVA) for the management of abortion and initiated training/mentorship of front line health workers in inserting implants using MVAs. The improved availability of reproductive health equipment and commodities is expected to contribute to improved access to emergency obstetric care and family planning services. The project has disbursed US$ 51.0 million, representing about 40 percent of the original credit of US$ 130 million equivalent. The disbursement rate reflects delays with procurement of the civil works. The contracts for the first nine facilities (US$ 54.7 million) were signed and civil works started in the sites. The civil works procurement for the remaining facilities (37) is at an advanced stage. On account of the progress, disbursement is expected to pick up by mid-2014 and the IP rating upgraded to satisfactory. VI. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 ✖ Natural Habitats OP/BP 4.04 ✖ Forests OP/BP 4.36 ✖ Pest Management OP 4.09 ✖ Physical Cultural Resources OP/BP 4.11 ✖ Indigenous Peoples OP/BP 4.10 ✖ Involuntary Resettlement OP/BP 4.12 ✖ Safety of Dams OP/BP 4.37 ✖ Projects on International Waterways OP/BP 7.50 ✖ Projects in Disputed Areas OP/BP 7.60 ✖ Comments (optional) Based on the Environmental and Social Impact Assessment Report of the original project, the project will not have large scale or irreversible adverse environmental or social impacts. The main environmental safeguard issues relate to civil works on existing grounds of hospitals and health centers. These include refurbishment or addition of specialized wards, construction of incinerators and staff houses, and connections to water, sewerage and power facilities for the functionality of the health facilities. Key environmental impacts are those associated with construction phase activities. Some potentially adverse impacts are associated with operation of hospitals and health centers (e.g. medical waste generation and disposal through incineration, waste water disposal, general waste disposal). The civil/construction works for the phase 1 nine hospitals commenced in November 2013 and the EMPs have since been updated but with no substantial change of identified impacts and mitigation measures, mainly because the sites remain the same. The EMPs were used to inform the detailed designs for the renovation works. The civil works Supervising Consultants have Environmental and Social Management Specialists. The borrower has substantial experience in hospital renovation and construction in compliance with Uganda's National Environment Management Authority guidelines, and some experience with World Bank safeguards. According to the Environment and Social Impact Assessment (ESIA), OP 4.12 is not triggered by the project. The MoH and the relevant facilities provided acceptable proof of land ownership and there are no disputes over the land. Land taking for construction of health and ancillary facilities has not been a common occurrence. VII. Contact point World Bank Page 4 of 5 Contact: Peter Okwero Title: Senior Health Specialist Tel: 5393+2227 Email: pokwero@worldbank.org Borrower/Client/Recipient Name: Government of Uganda Contact: Keith Muhakanizi Title: Deputy Secretary to the Treasury Tel: 256-414-230290 Email: keith.muhakanizi@finance.go.ug Implementing Agencies Name: Ministry of Health Contact: Dr. Asuman Lukwago Title: Permanent Secretary Tel: (256-414) 340-872 Email: ps@health.go.ug, VIII. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop Page 5 of 5