FOR OFFICIAL USE ONLY Report No: PAD4829 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON A PROPOSED GRANT IN THE AMOUNT OF SDR 42 MILLION (US$58 MILLION EQUIVALENT) AND A GRANT FROM THE GLOBAL FINANCING FACILITY IN THE AMOUNT OF US$12 MILLION TO THE CENTRAL AFRICAN REPUBLIC FOR A HEALTH SERVICE DELIVERY AND SYSTEM STRENGTHENING PROJECT (SENI-PLUS) May 4, 2022 Health, Nutrition, and Population Global Practice Western and Central 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 March 31, 2022) CFA franc (CFAF) Currency Unit = Special Drawing Rights (SDR) SDR 0.723 = US$1 US$1.38 = SDR 1 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS ACVs Contracting and Auditing Agencies (Agence de Contractualisation et de Vérification) ARMP Public Procurement Regulatory Authority (Autorité de Régulation des Marchés Publics) AWPB Annual Work Plan and Budget CAR Central African Republic CBO Community-Based Organization CERC Contingent Emergency Response Component CHW Community Health Worker COPIL National Health Steering Committee (Comité de Pilotage unique du Ministère de la Santé et Population) COVID-19 Coronavirus Disease 2019 CPA Complementary Package of Activities CPF Country Partnership Framework CTN-FBP National Technical Unit for Performance-Based Financing (Cellule Technique Nationale du Financement Basé sur la Performance) CTN-PS National Technical Unit for Health Projects (Cellule Technique Nationale des Projets de santé) DFF Direct Facility Financing DGMP General Directorate of Public Procurement (Direction Générale des Marchés Publics) DHIS2 District Health Information System ver. 2 DPT3 Diphtheria, Tetanus Toxoid, and Pertussis E&S Environmental and Social ESCP Environmental and Social Commitment Plan ESF Environmental and Social Framework ESMF Environmental and Social Management Framework ESMP Environmental and Social Management Plan ESS Environmental and Social Standards EU European Union FCV Fragility, Conflict, and Violence FM Financial Management GBV Gender-Based Violence GBVIMS Gender-Based Violence Information Management System GDP Gross Domestic Product GEMS Geo-Enabled Monitoring and Supervision GFF Global Financing Facility GII Gender Inequality Index GPN General Procurement Notice GRM Grievance Redress Mechanism HeRAMS Health Resources Availability Mapping System HMIS Health Management Information System IDP Internally Displaced Person IFR Interim Financial Report IP Indigenous Peoples IPF Investment Project Financing M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Survey MOH Ministry of Health and Population MPA Minimum Package of Activities MSF Doctors without Borders (Médecins Sans Frontiers) NGO Nongovernmental Organization NHDP III Third National Health Development Plan NPV Net Present Value OHS Occupational Health and Safety OOP Out-of-Pocket PASA Programmatic Advisory Services and Analytics PBF Performance-Based Financing PDO Project Development Objective PEP Post-exposure Prophylaxis PFM Public Financial Management PIU Project Implementation Unit POM Project Operations Manual PPP Purchasing Power Parity PPSD Project Procurement Strategy for Development PSDG Public Sector Digital Governance REDISSE IV Regional Disease Surveillance System Enhancement Project RMNCAH-N Reproductive, Maternal, Neonatal, Child, and Adolescent Health and Nutrition SARA Service Availability and Readiness Assessment SDG Sustainable Development Goal SDR Special Drawing Rights SEA Sexual Exploitation and Abuse SENI Health System Support and Strengthening Project SEP Stakeholder Engagement Plan SH Sexual Harassment STEP Systematic Tracking of Exchanges in Procurement STI Sexually Transmitted Infection TFP Technical and Financial Partner UHC Universal Health Coverage UNDB United Nations Development Business UNFPA United Nations Family and Population Agency UNICEF United Nations Children’s Fund WHO World Health Organization Regional Vice President: Ousmane Diagana Country Director: Abdoulaye Seck Regional Director: Dena Ringold Practice Manager: Magnus Lindelow Task Team Leaders: Tomo Morimoto, Mahoko Kamatsuchi, Avril Kaplan The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) TABLE OF CONTENTS DATASHEET ........................................................................................................................... 1 I. STRATEGIC CONTEXT ...................................................................................................... 8 A. Country Context................................................................................................................................ 8 B. Sectoral and Institutional Context .................................................................................................... 9 C. Relevance to Higher Level Objectives............................................................................................. 17 II. PROJECT DESCRIPTION.................................................................................................. 18 A. Project Development Objective ..................................................................................................... 18 B. Project Components ....................................................................................................................... 19 C. Project Beneficiaries ....................................................................................................................... 30 D. Results Chain .................................................................................................................................. 32 E. Rationale for World Bank Involvement and Role of Partners......................................................... 32 F. Lessons Learned and Reflected in the Project Design .................................................................... 33 III. IMPLEMENTATION ARRANGEMENTS ............................................................................ 34 A. Institutional and Implementation Arrangements .......................................................................... 34 B. Results Monitoring and Evaluation Arrangements......................................................................... 35 C. Legal Operational Policies ............................................................................................................... 35 D. Sustainability .................................................................................................................................. 36 E. Technical, Economic, and Financial Analysis .................................................................................. 36 F. Fiduciary .......................................................................................................................................... 38 G. Environmental and Social ............................................................................................................... 40 IV. GRIEVANCE REDRESS SERVICES ..................................................................................... 43 V. KEY RISKS ..................................................................................................................... 44 VI. RESULTS FRAMEWORK .................................................................................................. 47 ANNEX 1: IMPLEMENTATION ARRANGEMENT AND SUPPORT PLAN .............................. 56 ANNEX 2: DETAILED PROJECT DESCRIPTION .................................................................. 66 ANNEX 3: CLIMATE CHANGE RISK AND VULNERABILITIES .............................................. 77 ANNEX 4. ECONOMIC ANALYSIS .................................................................................... 79 DATASHEET BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name Central African CAR Health Service Delivery and System Strengthening Project (SENI-Plus) Republic Project ID Financing Instrument Environmental and Social Risk Classification Investment Project P177003 Substantial Financing Financing & Implementation Modalities [ ] Multiphase Programmatic Approach (MPA) [✓] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [✓] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] 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) [ ] Hands-on Enhanced Implementation Support (HEIS) Expected Approval Date Expected Closing Date 25-May-2022 30-Sep-2027 Bank/IFC Collaboration No Proposed Development Objective(s) To increase utilization of quality essential health services, especially for women and children, in targeted areas in the Central African Republic. Components Component Name Cost (US$, millions) Page 1 of !Syntax Error, ! The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Component 1: Supporting Essential Health Service Delivery 36.00 Component 2: Strengthening Health System Performance and Preparedness 32.00 Component 3: Project Management, Coordination and Monitoring & Evaluation 2.00 (M&E) Component 4: Contingent Emergency Response Component (CERC) 0.00 Organizations Borrower: Central African Republic Implementing Agency: Ministry of Health and Population, Central African Republic PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 70.00 Total Financing 70.00 of which IBRD/IDA 58.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 58.00 IDA Grant 58.00 Non-World Bank Group Financing Trust Funds 12.00 Global Financing Facility 12.00 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount Central African Republic 0.00 58.00 0.00 58.00 Page 2 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) National PBA 0.00 58.00 0.00 58.00 Total 0.00 58.00 0.00 58.00 Expected Disbursements (in US$, Millions) WB Fiscal Year 2022 2023 2024 2025 2026 2027 2028 Annual 0.00 13.00 13.00 11.00 12.00 14.00 7.00 Cumulative 0.00 13.00 26.00 37.00 49.00 63.00 70.00 INSTITUTIONAL DATA Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population Fragile, Conflict & Violence, Gender, Governance Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating 1. Political and Governance ⚫ High 2. Macroeconomic ⚫ Substantial 3. Sector Strategies and Policies ⚫ Substantial 4. Technical Design of Project or Program ⚫ Substantial 5. Institutional Capacity for Implementation and Sustainability ⚫ Substantial 6. Fiduciary ⚫ Substantial 7. Environment and Social ⚫ Substantial 8. Stakeholders ⚫ Moderate 9. Other 10. Overall ⚫ Substantial Page 3 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✓] No Does the project require any waivers of Bank policies? [ ] Yes [✓] No Environmental and Social Standards Relevance Given its Context at the Time of Appraisal E & S Standards Relevance Assessment and Management of Environmental and Social Risks and Impacts Relevant Stakeholder Engagement and Information Disclosure Relevant Labor and Working Conditions Relevant Resource Efficiency and Pollution Prevention and Management Relevant Community Health and Safety Relevant Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Relevant Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Relevant Local Communities Cultural Heritage Relevant Financial Intermediaries Not Currently Relevant NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS). Legal Covenants Page 4 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Sections and Description Schedule 2 I.A.4. (a) not later than one month after the Effective Date, establish and thereafter maintain, the National Technical Unit for Health Projects with terms of reference, composition, powers, functions, staffing, facilities and other resources satisfactory to the Association, with the main responsibility of providing technical support to the PIU. Sections and Description Schedule 2 I.A.5 (c) not later than six months after the Effective Date, recruit and appoint to the PIU focal point under terms of reference, integrity and with qualifications and experience satisfactory to the Association. Sections and Description Schedule 2 I.A.5 (d) not later than six months after the Effective Date, recruit, and thereafter retain, an external auditor with qualification and experience satisfactory to the Association. Sections and Description Schedule 2 I.A.5 (e) not later than three months after the Effective Date, the Recipient shall have updated, installed, and customized a computerized accounting software, satisfactory to the Association. Sections and Description Schedule 2 I.B.1 (b) not later than one month after the Effective Date, the Recipient shall update and adopt the POM. Schedule 2 I.B.1 (c) no later than one month after the Effective Date, the Recipient shall update and adopt a Project procedures manual. Sections and Description Schedule 2 I.G.1 (a) not later than two months after the Effective Date, recruit one or more Service Provider(s) and enter into a Service Agreement (“Service Agreement”) with the Service Provider(s), whose form and substance shall be satisfactory to the Association and in accordance with the Environment and Social Standards; (ii) ensure that all Project activities to be undertaken by the Service Provider(s) under the Service Agreement(s) shall be carried out with due diligence and efficiency and in accordance with sound technical and managerial standards and practices acceptable to the Association; and (iii) exercise its rights and carry out its obligations under the Service Agreement(s) in such a manner as to protect the interests of the Recipient and the Association and to accomplish the purposes of the Financing. Sections and Description FA, Schedule 2, Section I, A, 3 (a): The Recipient shall, not later than one (1) month after the Effective Date, establish and thereafter maintain at all times during Project implementation, the Technical Monitoring Committee with terms of reference, composition, powers, functions, staffing, facilities and other resources satisfactory to the Association. Sections and Description FA, Schedule 2, Section I, A, 3 (b): The Technical Monitoring Committee shall include focal point staff from the different ministries and agencies involved in the implementation of the Project. Page 5 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Sections and Description FA, Schedule 2, Section I, I 2: The Recipient shall furnish to the Association, not later than November 30 of each year, the annual work plans and budgets approved by the Technical Monitoring Committee for the Association’s review and approval; except for the annual work plan and budget for the Project for the first year of Project implementation, which shall be furnished no later than one (1) month after the Effective Date. Only the activities included in an annual work plan and budget expressly approved by the Association (each an “Annual Work Plan and Budget”) are eligible to be financed from the proceeds of the Financing. Sections and Description Per ESCP: final version of LMP shall be prepared, disclosed, consulted upon and adopted no later than two months of project effective date. Sections and Description Per ESCP: the specific section on “Environmental and Social Measures” in Project Operations Manual shall be revised and adopted within two months after the project effective date. Sections and Description Per ESCP: the Recipient will establish a grievance mechanism for project workers, as described in the LMP and consistent with ESS2, prepared, disclosed, consulted upon, approved, and adopted no later than two months after project effective date. Conditions Type Financing source Description Effectiveness IBRD/IDA FA, Article 4.01(a): (a) The Co-financing Agreement has been executed and delivered and all conditions precedent to its effectiveness or to the right of the Recipient to make withdrawals under it (other than the effectiveness of this Agreement) have been fulfilled. Type Financing source Description Effectiveness Trust Funds, IBRD/IDA FA/GA, Article 4.01(b): The Recipient shall have established the PIU as further described in Section I.A.5 of Schedule 2 to this Agreement, with functions and a composition satisfactory to the Association. Type Financing source Description Effectiveness Trust Funds, IBRD/IDA FA/GA, Article 4.01(c): The Recipient shall have recruited and appointed (i) one international procurement specialist; and (ii) one financial management specialist, all of them under terms of reference and with qualifications, integrity and experience satisfactory to the Association. Page 6 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Type Financing source Description Effectiveness Trust Funds, IBRD/IDA FA/GA, Article 4.01(d): The Biomedical waste management plan, the Indigenous People Plan, Security Risk Assessment, the GBV/SEA/SH Action Plans each in form and substance acceptable to the Association, shall have been duly adopted and disclosed by the Recipient in accordance with the ESCP. Type Financing source Description Disbursement IBRD/IDA FA, Schedule III.B.1(c): for payments under Category (2) until and unless the Recipient has prepared and adopted the PB Manual in form and substance acceptable to the Association. Type Financing source Description Disbursement Trust Funds, IBRD/IDA FA/GA, Schedule III.B.1(b): for payments under Category (2), unless and until the Recipient has: (i) prepared and adopted the PBF Manual in form and substance satisfactory to the Association; and (ii) recruited and engaged an Independent Verification Agency, as described in Section I.D of this Schedule 2. Type Financing source Description Effectiveness Trust Funds GA, Article 4.01(a): the financing agreement dated the same date as this Agreement, between the Recipient and IDA, providing financing in support of the Project (“Financing Agreement”), has been executed and delivered and all conditions precedent to its effectiveness or to the right of the Recipient to make withdrawals under it (other than the effectiveness of this Agreement) have been fulfilled. Page 7 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) I. STRATEGIC CONTEXT A. Country Context 1. The Central African Republic (CAR)’s political and governance context remains extremely fragile. The December 2020 presidential election was marked by violence following the creation of a rebel coalition and the subsequent government counter-offensive. The Government had regained control over most of its territory by end 2021. While the country has recently seen important gains in terms of consolidation, fighting continues in some areas of strategic interest. Armed groups, government troops and their allies are accused of human rights violations. The government has set up an investigation commission to shed light on those accusations and is committed, should the accusations be proven, to take proper measures to end those practices, by referring each case to the competent jurisdiction. Furthermore, the choice of bilateral partnerships in the security sector is creating tensions with some of CAR’s traditional partners. 2. The level of poverty remains high in CAR. The latest 2020 World Bank projections suggest that approximately 70 percent of the population is living below the international poverty line (defined as US$1.90 per day in terms of purchasing power parity [PPP]). Gross domestic product (GDP) per capita in CAR plummeted from US$1,102 (PPP) current international dollar in 2012 to US$739 in 2013 due to the conflict and has still not reached pre-crisis levels, standing at US$980 in 2020. The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on CAR’s economy. There is uncertainty around the data of COVID-19 cases but the number of COVID-19-related deaths recorded in CAR remains relatively low. However, disruption in global value chains, low external demand, and domestic containment measures have affected trade, transport, and tourism. CAR’s economy decelerated in 2020 compared to 2019. However, its GDP growth of 0.8 percent in 2020 was higher than regional peers (−2.9 percent) and countries affected by fragility, conflict, and violence (FCV) (−1.7 percent).1 The GDP per capita in 2021 is expected to be about the same as in 2019, indicating that the country is expected to lose two years in per capita income growth due to the pandemic. 3. Years of conflict and lack of essential services for human development have translated into low human capital outcomes. CAR is considered the third most fragile and violent country in Africa according to the Global Peace Index (2020). By April 2021, one-fifth of the population (738,000) was internally displaced (nearly half of them being children) due to recurrent conflict and political volatility2 and 2.8 million people in CAR needed humanitarian assistance, out of a population of 5.4 million.3 CAR is ranked the lowest in the world on the Human Capital Index. A child born in CAR today can only expect to be 29 percent as productive when s/he grows up as s/he could have been if s/he had benefitted from full health status and complete education.4 This is 27 percent lower than the worldwide estimate of 56 percent. One out of ten children5 born in CAR today will not survive to age 5, and only 59 percent of 15-year-olds will survive to age 60. Life expectancy was 53 years in 2019, roughly nine years lower than the Sub-Saharan 1 World Bank 2021. 2 UNICEF 2021. https://www.unicef.org/press-releases/central-african-republic-nearly-370000-children-now-internally- displaced-amidst). 3 World Bank 2021. 4 This is based on 2020 pre-COVID-19 estimates from the World Bank’s Central African Republic Human Capital and Women and Girls' Empowerment (Maïngo) (P171158) Project. 5 88 out of 100 children born in CAR survive to age 5. Page 8 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) African average the same year (61.6 years) and has been consistently below the Sub-Saharan Africa average for the past 40 years.6 B. Sectoral and Institutional Context 4. CAR has one of the highest maternal mortality and fertility rates in the world. Despite a slight improvement compared to 2010, maternal deaths were estimated at 829 per 100,000 live births in 2017, significantly higher than the Sub-Saharan African average of 534.7 The total fertility rate is high, estimated at 6.4 children with a gap between urban (4.9 children) and rural areas (7.3 children). About 12 percent of women ages 20–24 had given birth before the age of 15, and 43 percent by the age of 18.8 High maternal mortality and fertility, including adolescent pregnancies and short birth spacing, are linked to the country’s poor underlying social determinants of health—including women’s lack of empowerment—and limited access to and quality of health services. Only 14 percent of women of reproductive age use modern contraception, 41 percent of pregnant women receive four antenatal care visits, and 58 percent deliver in a health facility. 5. Child mortality and chronic malnutrition (stunting) levels are extremely high. Despite the measurable improvement between 2010 and 2018, these rates are still the highest in the world.9 Likewise, CAR has the second highest neonatal mortality rate in the world, at 28 deaths per 1,000 live births. The three main causes of child mortality include diarrhea, respiratory infection, and malaria.10 They have not changed since 1990 and constitute more than half of child deaths. Four out of ten children are stunted and at risk of cognitive and physical limitations. Access to basic health services remains limited—in 2018, only 34 percent of infants received their third diphtheria, tetanus toxoid, and pertussis (DPT3) vaccination, substantially lower than the Sub-Saharan African average of roughly 73 percent in 2018. Low uptake of key preventive and promotive behaviors also explains these poor outcomes: for example, only one-third of children younger than six months old were exclusively breastfed and up to about two-thirds of households do not have a dedicated setting or installation for handwashing. Box 1. Health System Structure in CAR The Ministry of Health and Population (MOH) is responsible for overseeing public health and health service delivery. It consists of four technical units: (a) the General Directorate of Population and Primary Health Care; (b) the General Directorate of Epidemiology and Disease Control; (c) the General Directorate of Research, Studies, and Planning; and (d) the General Directorate of Pharmacy and Health Care Organization. The health system is disaggregated into seven regional health directorates and 35 associated health districts. The country has a total of 52 hospitals, 387 health centers, and 434 health posts. This equates to 0.1 hospitals, 0.7 health centers, and 0.8 health posts per 10,000 people. 6. Inequalities in access to and utilization of health services across geographical locations and income levels are significant. Low-income women and children, as well as those living in rural areas, fare 6 World Development Indicators 2021. 7 World Development Indicators 2021. 8 Unless otherwise stated, all data in paragraphs 4,5, and 6 are from Multiple Indicator Cluster Survey (MICS) final report. Bangui, CAR: United Nations Children’s Fund (UNICEF), United Nations Family and Population Agency (UNFPA), World Health Organization (WHO), World Food Programme, World Bank, ICF international (MICS 2018–2019). 9 Infant mortality rate decreased from 116 to 65 deaths per 1,000 live births and under-five mortality rate decreased from 179 to 99 deaths per 1,000 live births between 2010 and 2018. ICASEES 2010 and MICS 2018–2019. 10 Institute for Health Metrics and Evaluation 2021. Page 9 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) much worse than those who are better-off or settled in urban areas. For instance, while 33 percent of the poorest women have no access to antenatal care, only 3 percent among the wealthiest women are in this situation; for family planning, these figures are 33 percent (wealthiest) and 12 percent (poorest) (figure 1). Similarly, children born in wealthier households are three times more likely to be vaccinated and twice less likely to be stunted than those in poor households, with similarly large gaps observed to the detriment of children in rural areas. Differences across regions (not presented here) also show large inequalities in access to services between the capital Bangui where health service coverage is higher than the rest of the country. Figure 1. Utilization of Health Services by Geographical location and Income Groups (a) Use of family planning, facility-based deliveries, (b) Stunting, DPT3 vaccine coverage, and access to and access to antenatal care for women diarrhea treatment for children under five 29% Use of any Family Planning 33% Children under 5 who received 21% 12% whichever form of ORS 31% Services for 15-49 married or 28.8% 20% in union women 12% 11% Children under 5 who received 5% 89% ORS and Zinc 11% Birth in a health facility (15-49 39% 7% pregnant women) 82% 48% 24% Stunting (Children under 5) 44% 30% 44% 3% No access to Antenal Care (15- 33% 49 pregnant women) 7% 64% Children (12-23 months) who 21% 27% 51% received the DPT3 Vaccine 28% 0% 50% 100% 0% 50% 100% Income Group Wealthiest Income Group Poorest Income Group Wealthiest Income Group Poorest Place of Residence Urban Place of Residence Rural Place of Residence Urban Place of Residence Rural Source: MICS 2018–2019. 7. The COVID-19 pandemic, with the large disruption in essential health services felt by the most vulnerable groups, has proven that health system strengthening and preparedness go hand in hand. CAR is particularly vulnerable to outbreaks because it is landlocked and surrounded by six fragile countries11 that have weak disease surveillance capacity and a history of outbreaks, including Ebola Virus Disease, yellow fever, rabies, and measles. The movement of people and the crossing of borders for commercial purposes increase the risk of importing emerging diseases. Further, there are internal risks of cholera and other diseases due to low vaccination coverage. CAR’s Joint External Evaluation score12 of 1.4 out of 5 indicates that the country is not prepared to respond to a new disease threat. On the Global Health Security Index,13 CAR ranked 189 out of 195 countries in 2021 with an overall score of 18.6 out of 100, illustrating an extremely low capacity to prevent, detect, and respond to disease outbreaks. 11 Democratic Republic of Congo, Cameroon, Chad, Sudan, and South Sudan. 12 It measures a country’s capacities to prevent, detect, and rapidly respond to public health risks. 13 The index measures indicators in six dimensions related to preparedness, alongside indicators regarding the country context that could shape their abilities to prevent, detect, and rapidly respond to outbreaks. Page 10 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) 8. CAR’s health system is characterized by profound supply- and demand-side constraints that are inherently linked to the country’s long-standing FCV. The recurrent military and political crises in CAR have profoundly disrupted the delivery of basic social services. On the supply side of health service delivery, critical bottlenecks include (a) severe shortage of health workers, infrastructure, medical equipment, and other critical inputs for health facilities to deliver basic health services, coupled with difficulty in physical access to health services due to poor road conditions and persisting insecurity; (b) lack of a functioning national supply chain to efficiently deliver drugs and medical supplies; and (c) limited coverage of community-based interventions to more efficiently promote health and prevent and treat diseases among the most remote and vulnerable populations. On the demand side, barriers to increase the uptake of health services include (a) inability to afford the costs of health services due to high level of poverty and (b) a large number of vulnerable populations, including gender-based violence (GBV) survivors and internally displaced persons (IDPs), who require specialized care but are unable to access it. In addition, there are considerable system-level constraints that prevent the Government from being able to deliver quality health services to the population such as (a) weak governance of the health system due to limited administrative capacity, regulations, and mechanisms to promote accountability and transparency including weak public financial management (PFM); (b) low and inefficient health spending, with high reliance on donor funding that is difficult to coordinate; and (c) scarce health-related data to inform policy. • Severe shortage of health workers. In 2019, they were only 7.3 health professionals per 10,000 inhabitants - far short of WHO’s threshold of 2314 per 10,000 inhabitants. Geographical distribution is uneven with greater concentration of health workers in the capital. Among the 1,971 health workers on the Government’s payroll in 2020, only 47 percent were frontline health workers with the remaining 43 percent being administrative workers.15 The country’s capacity to produce new health workers is limited. The medical school produces approximately 50 new doctors every 18 months, and in the past three years, only one new medical graduate has been absorbed into the civil service. The salaries of government health workers are low—for example, a doctor’s average monthly wage is only US$463. To address these challenges, the Government is planning to develop a National Health Workforce Strategy using results from the National Health Workforce Accounts and the 2021 Health Resources Availability Mapping System (HeRAMS) survey that are currently ongoing. The strategy will serve to coordinate the various actors in CAR who are already training and paying salaries of health workers and set the vision for development of the health workforce. • Poor health infrastructure, equipment, and other critical inputs. Conflict in CAR has resulted in destruction of core health system infrastructure. Approximately one-fifth of the country’s health facilities have been totally or partially destroyed due to conflict.16 Among the functional health facilities, availability of essential medicines is inadequate with on average only 27 percent of essential 14 While there are no gold standards for assessing the sufficiency of the health workforce, 2019 WHO estimates suggest that countries with fewer than 23 health care professionals (counting only physicians, nurses and midwives) per 10,000 population will be unlikely to achieve adequate coverage rates for the key primary health care interventions prioritized under the Millennium Development Goals and later on under the Sustainable Development Goals. https://www.who.int/whosis/whostat/EN_WHS09_Table6.pdf 15 CAR’s 2020 wage bill included a total of 255 medical doctors, 306 midwives and nurses, 210 birthing assistants, and 148 health aides. 16 SARA/HeRAMS survey, 2019, MOH; Basic infrastructure such as access to a source of energy (31 percent) or a source of drinking water (48 percent) was also scarce. Among the three regions covered by the Service Availability and Readiness Assessment (SARA) survey (Regions 1, 2 and 7), health facilities were insufficiently equipped for prenatal care and basic obstetric care with about only half of the tracer items available, and much less so for comprehensive obstetric care (7 percent). Page 11 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) tracer items available. Referral systems hardly exist—only 34 percent of health centers and 15 percent of health posts have a means of transport for referral, contributing to delays in emergency care and contributing to a high number of maternal deaths. These challenges lead some patients to seek medical evacuation, which is costly for the Government. For example, in 2019, the evacuation of 316 patients cost the Government approximately US$4.5 million. More than half of these evacuations provided access to treatment of noncommunicable diseases, which, if detected early, could be avoided. • Lack of a functioning national supply chain. Technical and financial partners (TFPs) are largely responsible for the procurement and distribution of drugs and medical supplies on their own account. In 2016, the country’s supply chain collapsed with the near bankruptcy of the central procurement and warehousing agency (Unité de Cession des Médicaments). Implementing partners’ efforts to rapidly respond to humanitarian crises have also contributed to creating a verticalized and fragmentated supply chain. Today, more than 45 TFPs procure, import, store centrally, transport, and distribute their products to health facilities.17 Yet, a large part of drugs and medical supplies do not reach beyond the district centers due to persisting insecurity and insufficient distribution mechanisms. To overcome this issue, the first National Supply Chain Policy (2021–2030) was drafted in August 2021 and is currently pending validation by the Government, after which development of a strategic plan and its operationalization will follow. • Limited coverage of community-based interventions. Globally, there is an extensive evidence base showcasing the potential of community health programs that engage community leaders and deploy community health workers (CHWs) to promote health, raise awareness for women and children to obtain essential health services, and deliver high-impact and cost-effective services.18 A recent situational analysis19 of community health programs in CAR found that most are funded by donors and are fragmented. CAR has a number of CHWs operating in rural areas, but this cadre lacks reference documents outlining their roles and responsibilities, areas of intervention, package of services, and incentives. Overall, CHWs have insufficient equipment and supplies to carry out their roles. In 2019, the Government elaborated a National Community Health Policy for 2020–2030, which aims to empower communities to improve their health and bring health care services closer to the population. The Government is planning to revisit the policy in light of the development of the third National Health Development Plan (NHDP III) and after the publication of new national-level health data. After the re-read, the Government will develop an associated National Community Health Strategy to operationalize the policy, with an aim to harmonize the various community health programs operating in CAR and establish one cadre of multipurpose CHWs who deliver a range of high-quality promotional, preventive, and curative services.20 17 Key partners include the Global Fund for Malaria, Tuberculosis and HIV/AIDS, GAVI, for routine immunization and cold chains; UNICEF for reproductive, maternal, child health supplies, and logistic capacity; UNFPA for reproductive health supplies; the EU for essential medicine purchased and distributed through nongovernmental organizations (NGOs); and the World Food Programme for emergency food distribution. 18 GBVIMS, CAR, 2020 18 Rapport d’enquête menée en 2014 par le ministère des Affaires Sociales avec l’appui de FNUAP sur les VBG en République Centrafricaine. [Report on the 2014 Survey on GBV in CAR carried out by the Ministry of Social Affairs, with support from UNFPA.] 19 Completed with support of UNICEF in August 2021. 20 Envisaged services include both high-impact essential but simple curative interventions to treat key diseases (malaria, diarrhea, pneumonia, malnutrition), preventative interventions (micronutrients, deworming, malarial bed-nets, and so on), and promotional interventions (behavior change communication, demand generation and referrals) through community outreach. Page 12 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) • Inability for households to afford the costs of health services. A large proportion of health financing is comprised of out-of-pocket (OOP) spending, with households responsible for 42 percent of current health expenditure, almost 10 percent higher than the Sub-Saharan African average estimated at 33 percent. This high OOP spending exacerbates widespread poverty by exposing the population to increased risks of catastrophic health expenditures. The Targeted Free Healthcare Policy for all pregnant women, post-partum women, children under five, and survivors of GBV was developed to provide better financial protection to these most vulnerable groups. • Large number of vulnerable populations, particularly survivors of GBV. Despite widespread underreporting, one incident of GBV is reported every hour by the humanitarian alert system which covers less than half the country.21 Humanitarian actors have recorded almost a doubling in the number of GBV cases as a result of COVID-19-related restrictions.22 Sexual and physical violence are prevalent not only in the context of war but also in everyday activities, including at home and in schools.23 Across CAR, children continue to be exposed to risks: one in four families fears for the safety of their children, mainly in regard to sexual violence, forced labor and recruitment by armed groups.24 The Government intends to create an environment of zero tolerance for GBV. The National Strategy to Combat GBV, Harmful Practices, and Child Marriage for 2019–2023 aims to reduce the incidence of GBV. The strategic plan calls on the health sector to strengthen capacity of health workers in the clinical management of GBV survivors and document cases, equip health facilities to accommodate GBV survivors, increase availability of free treatment, train health care staff to provide psychological support, and a community-wide behavior change mobilization to prevent GBV. • Low and inefficient health spending. Current health expenditure was estimated at US$53 per capita in 2018, substantially lower than the Sub-Saharan African average of US$83 per capita.25 Health expenditures are unequally allocated across regions, with Bangui and its suburbs receiving substantially more per capita than the health districts. In addition, the Government’s contribution to the health sector remains low, estimated at US$3.4 per capita, or roughly 10 times lower than the Sub-Saharan African average of US$30 in 2018.26 The share of domestic government health expenditures in the country’s GDP is only 0.7 percent in 2018. The ratio of public financial resources for reproductive, maternal, neonatal, child, and adolescent health and nutrition (RMNCAH-N) as a percentage of GDP has remained constant at 0.5 percent over three years (2017–2019).27 In addition, historical budget execution rates have been muddled by the fact that externally funded public investment execution is not reported through the budget system,28 resulting in artificially low budget 21 UNOCHA, Central African Republic: Situation Report, 5 January 2021; CAR Gender-based violence Information Management System (GBVIMS), 2020 22 2020 rapid COVID-19 Survey: A CAR Perspective (Enquête rapide sur les effets de la COVID-19: Une perspective genre en RCA) jointly published in July 2020 by ICASEES (the CAR National Statistical Office). 23 Rapport d’enquête menée en 2014 par le ministère des Affaires Sociales avec l’appui de FNUAP sur les VBG en République Centrafricaine. [Report on the 2014 Survey on GBV in CAR carried out by the Ministry of Social Affairs, with support from UNFPA.] 24 UNOCHA, Central African Republic: Situation Report, op. cit. 25 World Development Indicators 2021. 26 World Development Indicators 2021. 27 Global Financing Facility (GFF) 2020. 28 With the support of the World Bank-financed Public Expenditure and Investment Management Reform Project (AGIR), budget execution reports that included externally funded public investment have been produced since 2018. Before this time execution was reported through output from the integrated financial management (FM) system, used by the Government, which did not record externally financed transactions. Page 13 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) execution rates (under 50 percent). Interestingly, when data are available, domestically funded execution rates increase and surpass externally funded rates considerably. However, domestic public investment and transfers remain a small proportion of the health budget and have erratic execution rates. 29 This reflects the low capacity in the sector for procurement planning and execution as well as low fiduciary management capacities in the health districts. • High reliance on donor funding. In the national budget, externally financed public investment has overpowered domestic public investment: the roughly US$27 million invested between 2018 and 2020 is equivalent to 3.7 times the domestically financed investments in the sector for the same period. Donor spending was the largest source of funding in the health sector, representing more than half of current health expenditures (51 percent). Major financiers in the health sector comprise a mix of humanitarian and development agencies, with humanitarian agencies accounting for more than one-third of external financing (2018).30 With the absence of a coherent health financing strategy, it is not clear how funds for health are allocated, how they are aligned with government priorities, and how the partners’ multiple interventions align with core sector priorities and performance. • Weak PFM. At the central level, the MOH and its Resource Directorate have faced challenges in providing evidence-based and financially sound arguments that support their budget requests or presenting procurement plans that would accompany their budget in time. Hence, domestic budget allocations for health are made mostly on the basis of previous allocations. There are also considerable challenges of absorption capacity of the health districts. These include practical considerations such as the Government’s inability to make payments outside of Bangui, limiting the suppliers that could service the districts, and causing absenteeism when civil servants are forced to visit areas with banking services to collect their wages as well as a lack of understanding of fiduciary management protocols which inhibits local resource managers to submit the required documentation for local purchases. • Scarce health-related data. In the absence of a functioning health management information system (HMIS), CAR has been more reliant on survey data than other countries. After a gap of almost 10 years without a major population survey, results of the 2018–2019 MICS were released in early 2021. A SARA/HeRAMS survey is planned for 2022 (updating the 2019 survey). While these have provided valuable diagnostic information on the challenges facing the health sector, there is a need to strengthen the HMIS to ensure availability of routine data that can help inform policy decisions based on evidence. The Roadmap for the HMIS was elaborated in June 2019 and is currently being implemented. Existing paper forms and registers have been revised and streamlined and rolled out in 12 districts so far alongside the new District Health Information System ver. 2 (DHIS2) which has been piloted in Bangui. The country’s ambition is to roll out DHIS2 in all areas of the country. However, key challenges persist including poor internet connectivity, low staff capacity for data collection and use, a weak culture of data quality, and insecurity. 9. With the return of peace and stability in some areas of CAR since 2016, the Government has a window of opportunity to rebuild the country’s health system and make progress on reducing maternal 29 These include direct transfers to the health districts. 30 Key external financiers include Global Fund, World Bank, Doctors without Borders (Médecins sans Frontiers, MSF), European Union (EU), UNICEF, GAVI, WHO, and UNFPA. Page 14 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) and child mortality. In 2020, the MOH outlined 10 core domains of action31 to initiate progress toward UHC by 2030. The key domains of reform include bringing health services closer to the population; providing universal access to essential medicines and vaccination; fighting against epidemics and communicable diseases such as HIV/AIDS, tuberculosis, and malaria; and ensuring safe childbirth and equitable access to family planning. Building on these principles, NHDP III, currently being finalized, intends “to make CAR a country where access to quality health services is ensured for all social strata, with full participation of the population within the framework of UHC.” 10. The Government has launched policy initiatives in support of UHC. The 2018 Presidential Decree for Targeted Free Healthcare guaranteeing access to basic care, including drugs, for all pregnant women, post-partum women, children under five, and survivors of GBV constitutes a major step, indicative of the government support to these vulnerable groups. The decree was reinforced with the adoption of Performance-Based Financing (PBF) as a national strategy for service provision. To tackle the persisting challenge of high maternal and child mortality, the MOH, with support from the GFF, drafted the Investment Case for the Rapid Reduction of Maternal and Child Mortality32 to prioritize the sector around key health systems strengthening strategies and a core package of high-impact interventions to be delivered by health facilities and CHWs.33 CAR is making progress, but the transition from emergency relief to a sustainable and domestically funded health system that provides UHC is long. As for sub-sectoral strategies, the Government is keen on collaborative development and adoption of different strategies and plans that will clarify government priorities in each domain, including strategies on national health supply chain, human resources for health, and community health as stated earlier. Box 2. Background on the Global Financing Facility for Women, Children, and Adolescents (GFF) The GFF supports low- and lower-middle income countries to accelerate progress on RMNCAH-N and strengthen financing and health systems for UHC. The GFF supports government-led, multistakeholder platforms to develop and implement a national, prioritized health plan (called an Investment Case) that aims to help mobilize sustainable financing for health and nutrition. The GFF Trust Fund, hosted by the World Bank, links moderate amounts of resources to World Bank financing and supports countries to strengthen their focus on data, quality, equity, results, and domestic resources for health. The GFF currently supports 36 countries and aims to expand to 50 countries with the highest maternal and child mortality burdens by 2023. 11. PBF has a long history in CAR as an approach to strengthen the country’s health system, and it has played a critical role for the Government to purchase a basic package of services for the Targeted Free Healthcare Policy. PBF was initially piloted in CAR in 2009 by the EU through the Bêkou Fund. The World Bank began supporting PBF in 2016 through the Health System Support Project (P119815; US$38.93 million) and then continued financing the model during the Health System Support and Strengthening (SENI) Project (P164953; US$54 million). In 2019, PBF was adopted by the Government as a national strategy in CAR to strengthen the health system by incentivizing the delivery of high-impact health services as well as improved governance and operational management. By the end of 2020, SENI financed a basic 31 The 10 domains of presidential impetus for universal health coverage (UHC) in CAR are to (1) bring health services closer to the population; (2) provide access to essential medicines; (3) provide access to vaccination and to fight against epidemics; (4, 5, and 6) fight against HIV/AIDS, tuberculosis, and malaria; (7) provide access to good child nutrition and clean water and sanitation; (8) enhance girls’ education; (9) ensure safe childbirth and family planning needs; and (10) provide road safety. 32 The Investment Case was launched by the President of the Republic in April 2020 and is being updated with recent data. 33 The Investment Case is currently being updated to incorporate evidence from the latest MICS 2019 and to align with NHDP III as it is developed. Page 15 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) package of health services in 15 health districts or for approximately 40 percent of the country’s target population. The Bêkou Fund currently supports an additional 13 health districts. The introduction of PBF in CAR coincided with expansion of the approach globally, particularly in Sub-Saharan Africa. Historically, governments and donors in CAR had been financing input-based and fee-for-service models. PBF was introduced to serve as a lever to transform the health system toward results-oriented management according to well-established international standards. It focused on outcomes rather than inputs, reimbursing health facilities based on quantity and quality of services provided with a particular emphasis on high-impact maternal and child health interventions. It further introduced mechanisms to address equity concerns by providing higher subsidies to remote health facilities and individuals who are identified as being the most vulnerable by criteria set by their communities. 12. There is now an emerging body of global evidence that assesses the impact of PBF and makes recommendations on how these programs can be adapted to be more efficient and sustainable. A new focus has emerged to simplify the approach without losing the gains made. Globally, initial results suggest that PBF has improved performance of the health sector and resulted in greater health service utilization. However, attributing PBF to improving quality of services or reduction of maternal and child mortality has been more difficult to establish. Experience has also shown considerable challenges of PBF’s high implementation costs mainly due to complex and costly verification mechanisms. In many cases, the PBF approach has also often been heavily donor driven and operating outside of government PFM systems, which results in lack of financial and institutional sustainability in the absence of a clear path for government budget resources to support the approach. Growing evidence from other countries in the region also suggests that merging elements of PBF with other alternatives such as direct facility financing (DFF)34 may be a lower-cost option and include fewer complex arrangements while still ensuring robust systems for fiduciary and performance accountability. Details on differences, similarities, and complementarity between PBF and DFF are described in box 2.1. 13. The PBF model in CAR is being adapted in light of new global evidence and the country-specific context. PBF has not been evaluated in CAR35 due to security challenges, and at this point in time, results are inconclusive regarding its impact on service utilization or health outcomes (see annex 2). This reflects the significant implementation challenges faced in CAR, including external shocks, the recurring conflict, and disruptions to services arising from COVID-19. The PBF approach is however strongly supported by the Government due to its positive impact on the health system, including introducing management and performance tools, strengthening governance and controls with more focus on accountability and transparency, and enhancing measures to improve quality of care through performance assessment at all levels (health center, district hospitals, and district health offices) as well as community feedback. It has also introduced equity considerations through an equity bonus as well as decentralized financing, autonomy, and monitoring. Given both the recent positive trends in PBF outputs and the strong government commitment, there is a good opportunity to continue using PBF to drive sectoral reform and system strengthening, while at the same time drawing on both domestic and global learning to substantially adapt the current model to improve cost efficiency, strengthen sustainability, and evaluate the model’s wider impact on health service utilization and quality. 34DFF is an approach whereby payments are made directly to a health facility and are not conditioned on performance metrics. 35Among the 35 pilot PBF programs financed by the World Bank, 29 were accompanied by rigorous impact evaluations, some of which are not yet complete. In the case of CAR, a baseline study was conducted in 2012 but was discontinued due to disruption during conflict and consequent change of geographical intervention areas. Page 16 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) C. Relevance to Higher Level Objectives 14. The proposed project supports the CAR Country Partnership Framework (CPF) for 2021–2025 (Report no. 150618-CF), the World Bank’s Western and Central Africa Regional Strategy, the Africa Human Capital Plan, and the FCV strategy. Human capital and health are the backbones of the CPF, with the first focus area of the strategy being Human Capital and Connectivity to Boost Stabilization, Inclusion, and Resilience. The Western and Central Africa Regional Strategy places human capital and women empowerment as one of the key objectives, emphasizing the importance of health, education, social protection and other multisectoral interventions that are closely inter-linked. The project’s focus on health service delivery and health system strengthening to develop human capital of all people in CAR is a major priority in the Africa Human Capital Plan. In addition, the project will support the CPF and FCV strategy by rebuilding confidence in government institutions to deliver social services and strengthening social cohesion within communities. Furthermore, by directing the health system’s attention toward frontline service delivery while strengthening health system performance and preparedness, the project will support the resilient recovery phase of the COVID-19 crisis and help build better, in line with the fourth pillar of the World Bank’s COVID-19 Crisis Response approach. Finally, by building human capital and improving the health status of the population, the project will help address key drivers of fragility as identified in the Systematic Country Diagnostic. 15. The project is also aligned with the principles of the Sustainable Development Goals (SDG) and is designed to help CAR achieve its high-level health objectives and support health system reforms. Specifically, the project aligns with SDG 3: Good health and well-being, contributing to targets related to the reduction of maternal mortality, ending all preventable deaths under five years of age, as well as achieving UHC that seeks equitable access of healthcare services to all men and women. The project is also aligned with the Presidential Roadmap for UHC that prioritizes RMNCAH-N and bringing services closer to the population and more generally with the draft NHDP III. The project supports policies and strategies to achieve UHC, notably the Targeted Free Healthcare and PBF, as well as the implementation of the key sub-sectoral plans that are currently under development, including the National Health Workforce Strategy, National Supply Chain Policy, and the National Community Health Strategy, as well as the Roadmap for the HMIS. Similarly, the project is guided by and helps implement the Government’s Investment Case to accelerate progress on RMNCAH-N. 16. This project is the driver of the World Bank’s coordinated engagement in CAR’s health sector. SENI-Plus will build on the lessons learned from the current health sector project (SENI), which supported health service delivery through PBF and piloted comprehensive GBV interventions. Other World Bank projects in the sector were designed to complement SENI and will continue to enhance synergies with SENI-Plus in response to specific health sector needs. The Regional Disease Surveillance System Enhancement Project (REDISSE IV - P167817 - US$15 million) builds national and regional intersectoral capacities for collaborative disease surveillance and epidemic preparedness, while SENI-Plus will support targeted investments to enhance pandemic preparedness by fully integrating it in the health system strengthening. The COVID-19 Strategic Preparedness and Response (COVID-19 Project P173832 - US$7.5 million) and its additional financing (US$25.5 million) directly address the COVID-19 response, including the deployment of vaccines and, in doing so, will invest in the country’s immunization system. The Maïngo Project (P171158 - US$50 million) aims to increase essential health services, education, and employment opportunities that empower women and adolescent girls. It will use a community-based approach to Page 17 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) generate demand for health services, whereas SENI-Plus will primarily focus on improving the supply of health services (for details of ongoing World Bank health sector operations, see annex 2). 17. Beyond health sector operations, the World Bank-executed Programmatic Advisory Services and Analytics (PASA) will be instrumental in supporting the Government in its evidence-based policy decisions for critical reforms and informing the design and implementation of World Bank-financed operations including this project. The PASA will complement the ongoing engagements through (a) exploring innovative approaches to strengthen service delivery at both facility and community levels and (b) supporting the domestic resource mobilization and utilization, improving PFM, and aligning efforts of all partners around government priorities. II. PROJECT DESCRIPTION 18. The proposed project is fully aligned with the strategic priorities of NHDP III and builds on the gains made under SENI while ensuring complementarity with other World Bank health sector engagements and beyond. The project aims to assist the Government in its effort to attain UHC by (a) continuing support to delivery of essential quality health services at health facilities and extending its reach to communities and (b) providing holistic support to GBV survivors. The project will further strengthen the various pillars of the health system through (a) developing a functional national health supply chain; (b) supporting targeted investments to improve hospital capacity especially at subnational levels; and (c) supporting sectoral reforms in the areas of human resources for health, HMIS and performance measurement, and PFM. The project will further help the country prepare for future pandemics and emerging diseases by integrating these activities as part of health system strengthening. A. Project Development Objective PDO Statement 19. To increase utilization of quality essential health services, especially for women and children, in targeted areas in the Central African Republic. PDO-Level Indicators 20. The achievement of the Project Development Objective (PDO) will be measured through the following PDO-level indicators. • Children who receive three doses of Pentavalent vaccine (Penta 3) (number) • Facility deliveries attended by a skilled health personnel (number) • Modern contraceptive services received by women and adolescents (disaggregated by short- and long-term methods) (number) • Availability of tracer drugs at health centers in targeted health facilities (number) • Average quality score of health centers in targeted areas (number) Page 18 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) B. Project Components Table 1. Overview of Project Components and Financing (US$, millions) Project Components IDA GFF Total Component 1. Supporting Essential Health Service Delivery 28.0 8.0 36.0 1.1: Increasing Health Service Utilization and Quality through PBF 19.5 6.5 26.0 1.2: Strengthening Community-Based Health Service Delivery 4.5 1.5 6.0 1.3: Providing Holistic Support to GBV Survivors 4.0 0.0 4.0 Component 2. Strengthening Health System Performance and 28.5 3.5 32.0 Preparedness 2.1: Strengthening the National Health Supply Chain 7.0 0.0 7.0 2.2: Upgrading Hospitals to Improve Domestic Diagnostic and 10.0 0.0 10.0 Treatment Capacity 2.3: Implementation Support for Key Health Sector Reforms 10.5 3.5 14.0 2.4: Integrating Pandemic Preparedness in Health System 1.0 0.0 1.0 Strengthening Component 3. Project Management, Coordination, and 1.5 0.5 2.0 Monitoring and Evaluation Component 4. Contingent Emergency Response Component 0.0 0.0 0.0 (CERC) Total project cost 58.0 12.0 70.0 Component 1: Supporting Essential Health Service Delivery (US$36.0 million equivalent - IDA US$28.0 million and GFF36 US$8.0 million) 21. Component 1 seeks to (a) continue the delivery of essential health services and support the Government’s provision of targeted free health care through use of an adapted PBF delivery model; (b) support the delivery of community-level interventions by financing a basic package of services delivered by CHWs; and (c) provide holistic support to GBV survivors in target districts. Subcomponent 1.1: Increasing Health Services Utilization and Quality through PBF (US$26.0 million - IDA US$19.5 million and GFF US$6.5 million) 22. This subcomponent will continue to support the Government’s provision of essential health services through PBF to strengthen the provision of quality services at health facilities. It will finance (a) performance-based payments of cost-effective RMNCAH-N services at health centers and district hospitals conditional on the quantity and quality of services delivered to the population and (b) PBF implementation and supervision, including costs related to verification and counter-verification, supervision at all levels, and maintenance of the PBF-related information technology system; and (c) technical support and capacity building to adapt the current PBF model based on lessons learned in country and global evidence, including training and consultation workshops, and consultants to provide 36The GFF grant currently has a closing date of June 30, 2025. If in case the grant is not extended beyond this date, the project will be restructured to ensure full disbursement of GFF grant before the said date. Page 19 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) technical assistance as needed. In addition, the project will support procurement of essential drugs through a centralized approach to ensure that the health centers and district hospitals have the critical inputs to provide the necessary services. The project will target the same 15 health districts targeted under SENI to ensure continuation of these services once the SENI project closes.37 23. Initially, in the first year of project implementation, the project will provide payments on the basis of the existing PBF model to ensure there are no disruption in the delivery of services. However, key stakeholders in CAR agree that the current PBF model needs adaptation to better manage its overall cost and improve its integration into the Government’s system. In addition to the technical support under the project, the World Bank-executed PASA, through technical assessments and operational research, will generate evidence for the adaptation of the PBF design and inform decisions on different improvement options. The key aspects of the model that will be targeted for adjustments include the following and changes will be reflected in the revised PBF manual (annex 2): • Strengthen governance and control of how PBF funds are managed. Some possibilities include exploring alternative options for internal control. This includes, in addition to hiring an internal auditor and financial controller for the project, involving MOH inspectors to conduct on spot counter- verification. • Revise the institutional arrangements to better embed the National Technical Unit for PBF (Cellule Technique Nationale du Financement Basé sur la Performance, CTN-FBP), which currently manages the PBF program, into the Government system and decouple it from the World Bank Project Implementation Unit (PIU). This measure, accompanied by others to strengthen national oversight, aims to increase ownership and visibility at the national level to facilitate alignment with other TFPs behind the Government’s PBF strategy. The new structure will be renamed as the National Technical Unit for Health Projects Cellule Technique Nationale Projets Santé (CTN-PS), as it is intended to encompass a broader range of technical expertise than PBF, which will work closely with the PIU for implementation of project-related activities. • Reduce the number of services linked to performance indicators and simplify the service packages. These measures aim to decrease transaction costs by reducing the number of indicators that need to be verified and provide more flexibility to the CTN and MOH to ensure that payments to facilities are within the envelope of available resources. The CTN will lead the process of redefining the service package to be incentivized by PBF. • Revisit the verification strategy with an aim to reduce the cost of verification while maintaining high accountability standards. Options to rely more strongly on national and local organizations, including other para-public institutions such as the School of Public Health for counter-verification activities and community-based organizations (CBOs) rather than contracted international NGOs, and to adopt a data-driven and risk-based approach to verification will be explored. With expected reduction in the number of services to incentivize through an output-based approach, costs for verification may reduce and focus can be shifted to more supportive supervision. • Revise payment mechanisms to explore a good mix of cost-effective services to invest in accordance with the resources available while maintaining strong incentives to deliver results. Possible alternatives that have been explored in other countries are a mix of PBF with DFF, including 37 SENI is expected to close by the end of September 2022. Page 20 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) block grant payments to facilities. Both PBF and DFF can include the transfer of funds directly to health facilities, which increases autonomy and flexibility in how facilities use funds. A mixed approach may provide possibilities of other ‘lighter touch’ alternatives that still incentivize volume of services but with a more simplified implementation modality. • Improve measures to incentivize quality of services by reviewing the effectiveness of current measures and adapting the current quality checklist to better fit the country context. In the first year of project implementation, the evaluation criteria will be revised for (a) district hospitals to include aspects of staff competency in addition to structural and procedural quality and (b) health centers to simplify the measurement criteria. Client satisfaction surveys, which are conducted at community levels, will also be reviewed and adapted to better reflect needs. • Ensure the interoperability of the PBF digital portal with the national HMIS to avoid parallel systems. The idea is to gradually expand DHIS2 and make the PBF portal fully interoperable so that all data can be consolidated in one place. • Devise a strategy to integrate PBF payments into the sector PFM. Ensure that PBF payments are managed through the Government’s budget systems to improve sustainability of the model. The project will also consider direct financing in alignment with the Government’s budget process and associated implications for treasury management. • Seek ways to enhance facility autonomy by strengthening legislative and regulatory provisions to rationalize the management of health facility revenue while considering PFM principles (through ministerial orders, circular notes, and so on) and strengthening fiduciary management of health facilities, including in basic accounting skills and financial reporting. Subcomponent 1.2: Strengthening Community-Based Health Service Delivery (US$6.0 million - IDA US$4.5 million and GFF US$1.5 million) 24. This subcomponent will support delivery of an essential health package at the community level. Activities to be supported under SENI-Plus will include (a) delivery of the essential health package, including the provision of basic equipment and materials, developing and costing of the package, and provision of incentives to CHWs;38 (b) the development of operational plans, tools, and materials to facilitate the rollout of the national strategy; (c) the design and implementation of digital solutions to improve task management and data collection; (d) training and supervision of CHWs; and (e) traditional birth attendants (matronnes accoucheuses) through provision of basic equipment, development of training curricula, and provision of training in limited areas. These activities will be aligned with the Government’s National Community Health Policy and associated strategy once it is developed. 25. This subcomponent will enhance access of services to the most remote or hard-to-reach communities in CAR, in complementarity with Subcomponent 1.1, which focuses on ensuring that free 38Under the current PBF scheme, CHWs have been receiving an incentive payment from the health facilities to which they are attached based on achievement of two performance indicators: (a) the number of clients referred and received by the health facility and (b) loss to follow-up cases referred and received in the health facility, including cases of maternal death declared. The National Community Health Strategy will define and standardize the incentives provided to CHWs throughout CAR. The PBF manual will be updated accordingly in alignment with the strategy. Page 21 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) services are available in facilities. It will also work in close coordination with the Maïngo Project, as presented in box 3. Subcomponent 1.3: Providing Holistic Care to GBV Survivors (IDA US$4.0 million) 26. This subcomponent will support the delivery of a holistic package of GBV services in line with the National Strategy to Combat GBV, Harmful Practices, and Child Marriage. It will sustain and expand efforts that were initiated in five health districts39 under SENI to provide holistic services to GBV survivors. The proposed project will progressively expand support to nine health districts that overlap with the Maïngo Project. Activities to be supported are (a) holistic care at district hospitals and selected health facilities including medical care for the referred and complex cases at the district hospitals; (b) provision and procurement of post-exposure prophylaxis (PEP) kits, including emergency contraception and treatment for sexually transmitted infections (STIs) at health centers and district hospitals; (c) psychosocial care in facilities and communities; and (d) training of health care providers (doctors and health workers) at project-supported health facilities to respond to GBV through screening and medical response including administration of PEP kits to survivors who are referred to the health facility. In the initial stages of the project, SENI-Plus will continue to support the evidence-based community preventive approach (SASA! or Fadeso! in Sangho) through contracting of NGOs that are currently supported under SENI in the five districts. However, once the two projects are fully operational, it is expected that gradual transfer will be made for Maïngo to focus on the community-based approach, while SENI-Plus will focus on provision of holistic care at hospital levels. Box 3. Synergies between SENI-Plus and Maïngo on Community Health and GBV Objective. The Maïngo Project aims to enhance access to essential health services, education, and employment opportunities that empower women and adolescent girls in targeted areas of CAR. It will focus on community engagement and national communication campaigns to change gender norms and generate demand for health services and educational and employment opportunities for women. Geographic coverage. It overlaps with nine of the 15 SENI-Plus target health districts. 39The five health districts supported under SENI for GBV holistic support are Bambari, Alondao, Kaga Bandoro, Sangha Mbaere, and Paoua. Page 22 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Synergies on community health. The Maïngo Project will finance the design of the National Community Health Strategy. Thereafter, both projects will finance its implementation. It is envisioned that specific aspects of operationalizing the strategy—such as financing technical assistance to train, supervise and build capacity of CHWs—will be covered by the Maïngo Project in overlapping health districts, to benefit from cost efficiency and enhance synergies across the two projects. Annex 2 presents three potential scenarios that can be used to delineate activities between the Maïngo and SENI-Plus projects. The final scenario will be selected once the strategy is complete. Synergies on GBV. The Maïngo Project will finance community-based interventions to support survivors of GBV. The project will finance Safe Spaces that deliver integrated programs for adolescent girls and will serve as an opportunity to screen and refer GBV survivors to district hospitals financed by SENI-Plus for specialized medical and psychosocial care. The Safe Spaces will also help reintegrate survivors back into their communities and provide them with cash grants and livelihood training. The Maïngo Project will finance community mobilization to prevent GBV based on effective approaches initiated during SENI and national-level communication campaigns to change gender norms. 27. This subcomponent will focus on bolstering the health system’s response to GBV based on lessons learned from SENI. At least one doctor at targeted district hospitals will be trained to receive survivors and treat physical injuries, including surgery if necessary. Psychosocial specialists will be deployed to care for survivors, and GBV focal points will be hired at targeted health facilities to facilitate coordination and rollout of the holistic model. Targeted district hospitals will be adapted to provide confidentiality for survivors. From the second year of project implementation, the project will support other modalities for the community preventive approach, including integrating approaches in the activity package for CHWs or involving other organizations such as religious organizations or women’s associations. These alternative approaches will allow to progressively sustain the model in the longer term while building on expertise transferred by contracted NGOs. Component 2: Strengthening Health System Performance and Preparedness (US$32.0 million equivalent- IDA US$28.5 million and GFF US$3.5 million) Page 23 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) 28. Component 2 will address critical bottlenecks to a functioning health system in CAR. A first set of investments will directly facilitate the delivery of essential services to women and children by accelerating the development of a functional national health supply chain (2.1) and through targeted investments to equip and conduct minor rehabilitation in priority hospitals outside of the capital region (2.2). The project will also support selected Government reforms that are key to moving toward a stronger and sustainable health system while ensuring that the performance and sustainability of the project’s investment are met. This component will further contribute to building a sustainable and resilient health system (2.3) that is prepared to respond to future pandemics and emerging diseases (2.4). Subcomponent 2.1: Strengthening the National Health Supply Chain (IDA US$7.0 million) 29. The project will support the development of a national health supply chain to store and distribute essential medicines and medical supplies. In line with the vision stipulated in the draft National Supply Chain Policy (2021–2030), this subcomponent will finance the (a) provision of technical assistance to develop the National Supply Chain Strategic Plan in line with the policy; (b) development of an electronic logistics management information system for better forecasting, planning, and management of stocks; (c) establishment and operationalization of the Supply Chain Conducting Unit to improve governance, coordination, and consolidation of efforts by the Government and partners; and (d) support to designing and construction of a central warehouse and its operationalization, pending results of the feasibility assessment as well as final recommendations arising from the audit of Unité de Cession de Medicaments (or Medicines Procurement Unit). 30. Support under SENI-Plus will be provided in close coordination with other partners engaged in rebuilding the national supply chain. Harmonizing donors is an important step to ensure the availability of medicines and medical supplies throughout the country. In-depth consultations among partners are being conducted to coordinate the areas of engagement and explore synergies. Once a National Supply Chain Strategic Plan and a roadmap are developed, the Government intends to optimize available resources from TFPs and ensure their alignment with government priorities. This subcomponent will also build on technical assistance provided through the PASA to develop innovative digital solutions for tracking the delivery of medicines and supplies. Subcomponent 2.2: Upgrading Hospitals to Improve Domestic Diagnostic and Treatment Capacity (IDA US$10.0 million) 31. This subcomponent aims to strengthen the capacity of priority district and regional hospitals to diagnose and treat patients. The project will finance (a) the provision of basic medical equipment and supplies that are critical for early detection and treatment of obstetric care as well as for common diseases that primarily constitute the causes of medical evacuation; (b) improvements of health infrastructure including minor rehabilitation of selected facilities to comply with norms and standards, including improvement of water supply and electricity; and (c) training of local medical staff, including regional and district hospital doctors, laboratory technicians and other laboratory staff, and nurses. Investment will focus on the 15 SENI target districts and will take a phased approach based on an assessment of the status of health infrastructures and human resources before commencement of activities. The first phase will target five hospitals where needs are identified as the greatest based on a defined set of criteria. The second and third phases will progressively expand to cover other district hospitals in SENI target areas. Funds permitting, the project will consider support to tertiary hospitals and health infrastructure in the Page 24 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) capital region of Bangui where other partners are not present. A phased rollout plan will be developed before the start of the activity. Subcomponent 2.3: Implementation Support of Key Health Sector Reforms (US$14.0 million - IDA US$10.5 million and GFF US$3.5 million) 32. This subcomponent will support key reforms that are critical to strengthen the country’s health system and institutionalize project investments. The intervention areas envisaged are (a) human resources for health; (b) HMIS and performance measurement; and (c) health sector PFM. Finally, throughout the project, specific efforts will be deployed to address the perennial concern of poor donor alignment behind the government’s agenda. Human Resources for Health 33. The project will fund targeted measures to ensure that staff are available to effectively deliver services in underserved project areas. More specifically, it will finance (a) technical assistance to finalize the National Health Workforce Strategy; (b) development and implementation of decentralized training programs for nurses and midwives; and (c) the deployment of medical professionals in remote areas. Development of the strategy will be completed in a participatory manner involving key stakeholders from Government, donors, NGOs, health workers and their associations, and beneficiary populations. It will require multisectoral collaboration from the Ministries of Health, Education, and Finance. This is critical as CAR moves out of a state of humanitarian assistance—it will serve to coordinate the various actors who are already training and paying salaries of health workers. 34. The project will explore sustainable solutions to reduce the limited availability of health personnel outside of the capital region. Difficulty in access and insecurity considerably hamper the deployment of centrally recruited staff to remote areas. Two types of measures will be implemented. First, decentralized training programs for nurses and midwives will be developed and implemented. In CAR, a large number of health workers are unqualified despite having received basic training, and some are already employed in health facilities. The project will support the development and piloting of training programs at decentralized levels to enhance the competence of staff in remote and hard-to-reach regions, who could be trained and subsequently retained as health professionals in the areas where they are from. Building on existing models in CAR40 and elsewhere, the training plan and modules will be developed, tested, and rolled out. The project will explore the use of a cascading approach through training of trainers and a practicum-based approach, both of which have been used successful in CAR and in other neighboring countries. Second, SENI-Plus will continue to finance the deployment of midwives and medical doctors to remote areas. The National Health Workforce Strategy will develop a system to incentivize the deployment of staff to rural areas as well as a transitional plan for the Government to gradually take over the cost of deployment of these categories and integrate them into government systems. 40These training programs will build on existing experiences of health human resource training centers in Gamboula, Bambari, and Bouar as well as Catholic church. In addition, NGOs, particularly MSF, the International Federation of the Red Cross, International Medical Corps, Médecins du Monde, and Alina, have used various approaches to support the training and scale-up of the health workforce in CAR. These include leveraging international experts to provide in-service training and mentoring, supporting initiatives to decentralize training for nurses and midwives, and sending health workers to neighboring countries to receive specialized training. Page 25 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Box 4. Synergies between SENI-Plus and the CAR Public Sector Digital Governance (PSDG) Project (P174620) on Human Resource Management The PSDG project will finance mobile payments to civil servants and invest in a human resource management system under the Ministry of Civil Service. It will support payment of salaries through mobile money to deploy more civil servants to areas outside of Bangui. This intervention is expected to minimize the need for civil servants to travel to locations where banking services are available (only three towns in the country) to recover their salaries. In addition, the PSDG Project will support the improvement of recruitment and career management systems for civil servants and their alignment with the wage bill payment systems. PSDG will prioritize sectoral interventions in the health and education sectors. HMIS and Performance Measurement 35. The project will build on the HMIS investments made under SENI and supplement them with new initiatives to strengthen monitoring and evaluation (M&E) and all aspects of data use. The project will finance (a) national rollout of improved HMIS tools and gradual transition into DHIS2 software in all 35 districts; (b) provision of information technology equipment and internet connectivity (including VSAT in areas where Wi-Fi access); (c) technical assistance for the MOH to establish a new integrated M&E system to cover all projects and programs through recruitment of key M&E staff, workshops, training, and communications to foster a culture of data quality and use; and (d) deployment of decentralized data managers to all regions and districts in the country. Deployment of data managers has played a vital role in scaling up DHIS2, particularly at the district level.41 This will be accompanied by the development of a clear transition plan beyond the project to eventually integrate these positions within the government workforce. Further, as and when needs arise, the project will support selected household, health facility, and health financing surveys. This could include the next round of the MICS and/or Demographic and Household Survey, SARA/HeRAMS surveys, resource mapping and expenditure tracking exercises, and surveys to support the monitoring of essential health services. Health Sector PFM 36. The institutionalization of mechanisms such as PBF or DFF will require adjustments in PFM arrangements. A PFM assessment, planned under the PASA and expected to be delivered by the end of 2022, will identify key bottlenecks and propose a phased roadmap to overcome them. Expected activities include (a) PFM capacity building at subnational levels to allow for larger transparency and autonomy, notably training of district and health facility staff on basic accounting and financial reporting; (b) development of tools to increase budget transparency and budget allocation (such as investing a part of the MOH budget to support the PBF); (c) an in-depth analysis on the status of alignment of the PBF approach with the current PFM system; and (d) development of an actionable roadmap in support of PBF better serving the service delivery goals of efficiency, equity, quality, and accountability. Donor Alignment 37. The project will directly support donor alignment efforts, namely, to improve coordination between the Government, donors, and humanitarian actors operating in the country. It will finance (a) 41Under SENI, 55 data managers were recruited who played a vital role in not only HMIS but also in the pandemic response, undertaking surveillance and reporting work as well as supporting contact tracing and patient follow-up. Page 26 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) support to high-level platforms, including meetings and workshops for sectoral committee(s), and capacity building of the members of the platform; (b) monitoring of progress of alignment, using the gap assessment as a baseline; (c) learning exchanges on alignment including south-south knowledge sharing; and (d) technical assistance to support alignment and implementation of the alignment plan. 38. The project will capitalize on the country-led process, as demonstrated in the strong leadership of the Minister of Health on this agenda, to improve partner alignment, including through national planning, financing and budgeting, and monitoring processes. CAR has developed a roadmap for alignment, centered around one plan, one budget, one report.42 The project will build on recent exercises including health sector resource mapping and expenditure tracking supported by GFF to foster better coordination and alignment of the interventions of different actors as well as a better understanding of resource allocation. This analysis will feed into a gap assessment survey that will provide a baseline of the level of alignment of partners. Further, the project will continue to support coordination activities related to the Investment Case, including support to its operationalization through an updated Results Framework, functional platform, resource mapping, and expenditure framework. All these activities will contribute to addressing fragmentation in health financing. Subcomponent 2.4: Integrating Pandemic Preparedness in Health System Strengthening (IDA US$1.0 million) 39. CAR urgently needs to invest in building a resilient health system that can quickly respond to emerging disease outbreaks. The project will help integrate health security and preparedness into all elements of the broader health system and complement activities supported through regional initiatives, other stakeholders (such as WHO), and other World Bank operations, namely the REDISSE IV and the COVID-19 projects. SENI-Plus will finance the following in nine priority at-risk health districts:43 • Strengthening surveillance capacity through (a) improving reporting capacity by developing electronic reporting systems (including HMIS surveillance); (b) providing basic equipment and supplies (such as tablets) to allow timely reporting and installing an epidemic outbreak alert system; and (c) financing costs related to organizing coordination committees at the district level for epidemiological data analysis (including routine monthly surveillance data analysis). • Establishing rapid response district teams through (a) building a network of staff from districts with borders; (b) developing training manuals and reporting tools on topics including service delivery in case of emergency, awareness, and rapid detection of epidemic diseases, among others; (c) carrying out cascade training of the response teams; and (d) equipping them with basic equipment required 42 One plan is NHDP III currently being finalized. One budget will build on this plan and will be supported by the development of a medium-term expenditure framework to reflect the contributions of stakeholders to meet the priorities identified. One report will derive from the use of a set of key indicators developed in the M&E framework, to track progress toward the objectives and outcomes set out in the single plan. Strategic use of existing data to measure alignment at the national level, including recommendations for new data collection efforts, will be considered. 43 In CAR, 24 out of 35 health districts share borders with other countries. To ensure maximum impact with limited funding, activities under this subcomponent will focus on nine districts that are considered as highest risk of transmission and overlap with SENI and REDISSE IV. Of the nine districts, the first phase will focus on three districts where needs are the greatest (Sangha Mbaere, Baboua Abba, and Mobaye Zangba), with progressive expansion to the remaining six districts. Page 27 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) to do their work (such as computers, data analysis and GIS software, mobile phones, and motorbikes). • Surveillance at the community level. In close alignment with Subcomponent 1.2, the project will (a) develop training modules that would enhance CHWs’ capacity in epidemic surveillance and preparedness and (b) support identification of sustainable community engagement strategies to ensure community involvement and ownership in early detection of diseases and management of cases. Component 3: Project Management, Coordination, and Monitoring and Evaluation (US$2.0 million equivalent - IDA US$1.5 million and GFF US$0.5 million) 40. This component will help ensure effective and efficient technical and fiduciary management and implementation of the project. The component will support project implementation through the financing of (a) operating costs, training, and equipment; (b) payment of salaries of international and national consultants; (c) audits and communications; and (d) implementation and monitoring of environmental and social standards as well as project results indicators. The PIU responsible for day-to- day management of the project will be the current PIU of the SENI, REDISSE IV, and COVID-19 projects that will also assume the responsibilities of the implementation of the SENI-Plus project. Component 4: Contingent Emergency Response Component (CERC) (US$0.0) 41. A CERC will be included under the project in accordance with World Bank Investment Project Financing (IPF) Policy paragraphs 12 and 13, for projects in Situations of Urgent Need of Assistance or Capacity Constraints. This will allow for rapid reallocation of project proceeds in the event of a natural or man-made disaster or crisis that has caused, or is likely to imminently cause, a major adverse economic and/or social impact. Gender 42. Gender inequalities are pervasive in CAR and the country’s Gender Equality Index is the second lowest in the world.44 On average, women in CAR have two-thirds of the years of schooling of men. Approximately 70 percent of women (ages 15–24 years) are illiterate compared to 48 percent of men in the same age group. Nearly one-fourth of women in CAR are already married before the age of 15 compared to 5 percent of men. As previously highlighted, women’s health outcomes, especially regarding reproductive health, are among the lowest in the world and their access to care is limited (paragraph 4). While data are scarce, for those that were available, there were gaps between men and women in critical areas: unpaid care and domestic work, key labor market indicators, including unemployment rate, pay gaps, and information and communications technology skills. Further, socioeconomic inequalities in outcomes and access to services are considerable. The latest MICS data revealed significant gaps in access to essential key maternal and reproductive health services (including antenatal care, facility-based 44United Nations Development Programme, Gender Inequality Index (GII) data report, 2019. The GII is an inequality index that reflects how women are disadvantaged in potential human development due to disparity between female and male achievements in reproductive health, empowerment, and the labor market. http://hdr.undp.org/en/content/gender-inequality- index-gii. With a value of 0.680, CAR ranks 188 out of 189 countries. Page 28 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) delivery, and utilization of modern contraceptives, as described in paragraph 6) across geographical locations, rural and urban settings, and income levels. 43. Various studies mentioned by the national strategy to fight GBV in CAR (2018–2020) confirm an exceptionally high level of violence against women and girls. The reports also note that some population groups are more vulnerable or at risk to GBV, including adolescent and elderly women, women and children who are heads of households, and women from religious or ethnic minorities. Overall, it is difficult to assess the full situation with regard to GBV and sexual exploitation and abuse (SEA) in CAR due to the silence of survivors and lack of reporting. 44. The underrepresentation of women among major categories of health services providers is both a likely consequence of their lower access to education and labor markets and a barrier to access to health services for women. Only 20 percent of doctors (generalists and specialists) are women45 and a sex-disaggregated analysis of the same data reveals that some health regions (2, 3, 5, and 6) have no female doctors on the payroll in 2020. Global evidence shows that in more conservative societies, having female health workers facilitates women’s access to health services.46 45. The project will help reduce some of these inequalities by (a) improving women’s access to reproductive and maternal health services and narrowing geographical and socioeconomic differences in access to these services; (b) scaling up the provision of holistic care for GBV survivors; and (c) reducing the gender gap in the supply of health workers: • Improving access to reproductive, maternal, and child health service and narrowing geographical and socioeconomic differences among women. Under Component 1, the project will expand delivery of essential maternal and reproductive health services to the most remote areas of the country. Under Component 2, the project will help improve district and regional hospital capacity to provide obstetric services through provision of medical equipment, facility rehabilitation, and training of medical professionals. Early detection and treatment of complicated pregnancy cases and delivery in appropriately equipped facilities can help reduce maternal and infant mortality. Indicators to track this action include (a) the number of facility deliveries attended by skilled health personnel and (b) the number of pregnant women who attend four antenatal care visits.47 • Provision of holistic care for survivors of GBV. Building on the experience of SENI, the project will support and expand the provision of holistic care to GBV survivors under Subcomponent 1.3. Progress will be monitored based on the increase in the number of district hospitals with integrated holistic GBV Services. • Reducing the gender gap in supply of health workforce. Under Subcomponent 1.2, the project will support female CHWs to deliver essential services to women and children in the poorest 45 2020 Payroll and Pension Data, Ministry of Civil service. 46 In some World Bank-financed projects, employing women from local communities to provide essential health services has resulted in improvement of women’s access to health services. For example, the Community Midwifery Education Program in Afghanistan, where conflict and strong gender-based segregation made it difficult for women to seek health services, resulted in increasing women’s access to health services and reduction in maternal mortality. 47 To measure gaps among women of different geographical locations and socioeconomic backgrounds, the project will assess the percentage point difference of women ages 15–49 years with birth(s) attended by a skilled health professional in urban versus rural areas/highest versus lowest wealth quintile should data be available. Page 29 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) communities and in rural areas as well as training of matronnes acoucheuses or traditional birth attendants, many of whom will be female. Under Subcomponent 2.2, the project will support training program for nurses and midwives as well as the deployment of doctors and midwives to remote areas. Progress will be monitored through the number of health professionals employed full time in health facilities (female disaggregate). Climate Change Risks and Vulnerabilities 46. The project has been screened for short- and long-term climate change and disaster risks and the exposure risk is Moderate. This includes exposure to extreme temperatures, extreme precipitation, and droughts. This exposure risk is assessed at this level for both the current and future timescales. CAR is a landlocked country, which exposes the population to the adverse risks of natural disasters, climate change, and disease outbreaks. The increasing temperatures, changes in rainfall pattern, and desertification in the country are leading to food insecurity and scarcity of resources, which have implications for the nutritional status of the population including the lack of water availability. Moreover, climate change is also exacerbating conflict, deepening poverty, and disrupting traditional means of survival. This project will implement various climate adaptation and mitigation measures to reduce the impact of climate change on the population. Adaptation activities will include (a) guidance on climate- sensitive purchasing for equipment, supplies, and materials; (b) climate-resilient measures which will be included in national strategies and plans; (c) activities to improve climate and health competency levels among specialists, health care workers, and laboratory staff; and (d) activities to improve climate-sensitive disease surveillance. Mitigation activities include the financing of climate-sensitive equipment and supplies and fuel-efficient vehicles. Climate-smart construction will also take place. Annex 3 provides additional details on climate Co-Benefits. Citizen Engagement 47. Citizen engagement activities in the proposed project will build upon experience of the SENI Project and will include stakeholder consultations, targeted outreach and behavior change, and communications as well as multistakeholder engagement to establish and implement a grievance redress mechanism (GRM). SENI-Plus will be based on a model of inclusive, adaptive management of activities and emphasizes beneficiary outreach. SENI-Plus will include public consultations in accordance with the Stakeholder Engagement Plan (SEP) to increase awareness of all stakeholders and collect their feedback throughout the project. The project will ensure that consultative activities are adapted to the sensitives and concerns of the disadvantaged or vulnerable population (indigenous peoples [IPs], returnees, displaced persons, women, elders, and so on) and will ensure that their rights are fully respected. Targeted outreach and behavior change-related activities will be the core of community health interventions (Subcomponent 1.2). Additionally, the project will further enhance the established GRM that was initiated by the SENI project and ensure better operationalization of the 1212 grievance hotline, for identification, registration, assessment, and resolution of complaints. The GRM will be adapted to the needs of IPs. In addition, the GRM will be sensitive to SEA and sexual harassment (SH). C. Project Beneficiaries 48. Subcomponents 1.1 (PBF), 1.2 (community health service delivery), and 2.2 (upgrading hospital capacity) will target 15 health districts that are targeted by SENI (Regions 2, 3, 4, 5, and 6) and correspond Page 30 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) to more than 400 health centers (annex 2) and 15 district hospitals. Depending on the final design of the adapted PBF approach, costs, and budget availability, the geographical scope of the PBF may be progressively expanded to other health districts with poor health outcomes and where no other partners are present. Community health activities under Subcomponent 1.2 will be expanded incrementally to the 15 health districts and in alignment with the geographic phasing that will be employed by the Maïngo Project. Similarly, support to hospitals under Subcomponent 2.2 will take a phased approach to progressively expand it to 15 districts. 49. Subcomponent 1.3 (GBV) will progressively expand beyond the five health districts that are supported under SENI to cover the health facility based GBV activities in nine health districts that overlap with the Maïngo Project. The expansion will occur incrementally in phases in alignment with the Maïngo Project. 50. Subcomponent 2.4 (pandemic preparedness) will target nine health districts that share borders with neighboring countries with the highest risk of transmission and those that overlap between SENI and REDISSE IV projects to ensure maximum impact.48 51. Other activities under Component 2, including support to national health supply chain, support to key sectoral reforms, and deployment of medical doctors, midwives, and data managers will cover nationwide. 48 To be implemented in 12 health districts in the first year (nine districts bordering districts under SENI and three Bangui metropolitan health districts) and the remaining 12 will be covered in the second year. Page 31 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) D. Results Chain Note: HRH = Human resource for health. E. Rationale for World Bank Involvement and Role of Partners 52. The World Bank is one of the main donors of the health sector and has been a reliable partner of the Government and the MOH for decades. The Health Sector Support Project which began in 2014 provided much needed emergency support in the aftermaths of conflicts and later reoriented toward rebuilding the country’s health system through the introduction of PBF and supporting its national implementation. The successor SENI project supported the progressive expansion of the PBF scheme and the country’s Targeted Free Healthcare Policy and contributed to addressing some of the critical bottlenecks of the CAR’s health system. Currently, the Maïngo Project complements these efforts by bringing in a multisectoral approach to generate demand for health services and educational and employment opportunities. The REDISSE IV and COVID-19 projects help address the immediate threat of pandemic and strengthen disease surveillance and preparedness. Given these successful engagements across an array of issues, the value added of the World Bank for this operation includes the capacity to build on these gains and mobilize a wide range of technical expertise to support sectoral coordination, partnerships, resource mobilization, key strategies, and sectoral reforms. Cross-sectoral collaboration such as with the governance sector is also envisaged particularly in PFM and human resources. Page 32 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) 53. The comparative advantage and technical expertise the World Bank bring will support critical health sector reforms and support the Government in ensuring a coordinated and harmonized health system strengthening approach. NHDP III places strong emphasis on partners’ role in the planning processes, strengthening of technical capacity of national structures responsible for implementation of priority interventions, and the mobilization of external resources for achievement of results. In addition, the project will benefit from the GFF’s Essential Health Services Grant which will leverage the IDA funds. Support from the GFF will continue to provide space and process for the MOH to coordinate key partners in health, to address the issue of fragmentation and inefficiency. The additional grant made available through SENI-Plus will provide further opportunity to convene the Government and partners to better coordinate and align their efforts, including for the implementation of package of high-impact interventions identified in the Investment Case. Analytical work conducted under the World Bank- executed PASA will also support the Government in improving its domestic resource utilization and mobilization as well as prioritization of its domestic resource spending through support to a more coherent health financing strategy. F. Lessons Learned and Reflected in the Project Design 54. Moving from SENI to SENI-Plus, it is critical for the Government to leverage the lessons learned from prior engagements and other countries in the region. SENI-Plus will capitalize on and continue to invest in approaches that have succeeded while readapting those that did not. In particular, the following aspects are emphasized in the project design: • Strengthened focus on governance and internal control mechanisms. While SENI has contributed to enhancing health service delivery and performance, some of the weaknesses identified have resulted in the need to increase focus on accountability and transparency through more rigorous internal controls and greater investment in building managerial capacity. An in-depth fiduciary review was conducted under SENI and resulted in recommendations to improve the overall fiduciary arrangement of the PIU, including (a) scaling up staffing for fiduciary functions; (b) reinforcing contract management functions; (c) establishing a quality review team for all procurement documents; (d) creating an internal audit function; and (e) establishing a complaint handling mechanism at health facilities and for others beneficiaries and NGOs (see Financial Management [FM] and Procurement sections in annex 1 for more details). In additional, oversight functions need to be strengthened through the National Health Steering Committee (Comité de Pilotage unique du Ministère de la Santé et Population, COPIL) as well as involvement of general inspection. • Adaptation of the current PBF approach for better sustainability, cost efficiency, simplicity, and integration into government systems. This will include, among others, revisiting the governance structures, tariff and service packages, performance indicators, verification and counter-verification arrangements, exploring better ways to incentivize quality and equity, payment, facility autonomy, and better alignment with PFM. Better links with community-level interventions need to be further examined and embedded into the PBF design. • Harmonization of interventions. Key partners operating in the health sector in CAR include a mix of development and humanitarian agencies. Hence, a more systematic mechanism for partner coordination is critical to avoid vertical approaches and ensure full alignment of all partner support with government priorities. Leveraging coordination platforms created under SENI to develop the Page 33 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Investment Case will enhance synergies and complementarity with other partners and stakeholders, while ensuring full alignment with government priorities. • Addressing GBV. A well-defined package of holistic care has been instrumental in supporting GBV survivors. The project will expand on this experience and further strengthen health facility-based intervention in this area. Further, the health sector projects are developing a portfolio-wide approach to address risks of SEA and SH. This includes developing standardized codes of conduct, GRMs, and a single plan of action for the sector. With support of the World Bank, a GBV services mapping will be conducted by leveraging innovative technologies. • Complementarity with other stakeholders working in areas covered by the project to deliver services in hard-to-reach and insecure areas. The project will seek ways to better coordinate with NGOs/CBOs operating in these areas for enhanced supervision and better reach of services. • Sustainability consideration for acquisition of essential medicines and supplies and deployment of human resources. While this project will finance continued support for critical inputs for service delivery, a clear transition plan for sustainability will be developed as part of the project support. III. IMPLEMENTATION ARRANGEMENTS A. Institutional and Implementation Arrangements 55. The MOH will be the main line ministry for the implementation of the project.49 Under coordination by the Minister of Health and the Cabinet Director, technical activities will be undertaken by the relevant directorates and units within the ministry. Oversight functions of the project will be ensured through (a) the COPIL, presided by the Minister of Health and whose role is to ensure that projects are aligned with the national sectoral policies and they are implemented in a coordinated manner, and (b) the Technical Monitoring Committee (Comité Technique de Suivi) that will oversee the implementation of the project, including validation of the annual work plan and budget (AWPB), and is responsible for providing overall technical oversight of project implementation, performance monitoring, intersectoral coordination and coherence with sector policies and strategies, approval of the AWPB, Procurement Plans, annual audit reports, and progress reports. 56. The CTN-FBP that managed the technical aspects of PBF will be restructured as CTN-PS to provide technical support to the PIU in implementation of World Bank-financed health projects. The CTN-PS will be established within one month after the effective date of the project and will expand its mandate beyond PBF to include other sectoral expertise that are critical for the country to achieve UHC. These include eight technical experts on PBF, quality of care, RMNCAH-N, community health, planning and capacity building, epidemiological surveillance, and governance, among others. The recruitment of CTN-PS staff (already civil servants) will be based on defined terms of reference, and each CTN-PS staff will sign an annual performance contract with the Cabinet. Incentives will be paid to these CTN staff based on quarterly assessment against their agreed terms of reference and performance target, by a committee comprising MOH officials and representative(s) of TFPs. A manual for the performance bonus acceptable and approved by the World Bank will be developed prior to payment of the bonus, which will include: (a) eligibility criteria and procedures for selection of CTN-PS members; (b) the performance assessment 49 These ministries will also be involved in the GBV component as was the case with the SENI Project. Page 34 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) method, payment process and required supporting documents; (c) the amount to be paid under the performance bonus; and (d) the Performance Contract template. 57. Day-to-day implementation of the project will be managed by the PIU that manages World Bank-financed projects in the health sector. The PIU, established under the MOH for SENI, currently serves as the PIU for SENI, REDISSE IV, and COVID-19 projects, including its additional financing for vaccine acquisition and deployment. The PIU is led by a General Coordinator and will be strengthened with the recruitment of additional specialists, including a focal point for SENI-Plus who will be recruited within six months of project effectiveness, a senior accountant, and an internal financial controller. In addition, the PIU comprises an international procurement specialist, a procurement specialist, a national and an international GBV specialist, a communications specialist, an administrative and financial management (FM) specialist, a PBF portal manager, an environmental safeguards specialist, a social safeguard, SEA/SH prevention and response specialist, and an assistant to the coordinator. The renewed organigram of the PIU is provided in annex 1. Learning from implementation challenges experienced under SENI, the project will ensure strong focus on governance with close supervision mechanisms at central and subnational levels, including exploring possibilities to involve the General Health Inspection50 to oversee project implementation through counter-verification activities. These changes will be reflected in the revised Project Operations Manual (POM) which will be updated by no later than one month after project effectiveness. B. Results Monitoring and Evaluation Arrangements 58. Project M&E will align with national M&E frameworks. The Results Framework indicators have been aligned, wherever possible, with national frameworks as set out in both the Investment Case and NHDP III. Core tools for project monitoring will include the national HMIS, the PBF portal, and Geo-Enabled Monitoring and Supervision (GEMS), with the latter extended to cover existing PBF processes such as community satisfaction surveys. The HMIS and PBF portal use many of the same primary data collection tools. However, weaknesses in the national HMIS means that a parallel PBF reporting process has been used during SENI. As the HMIS is progressively strengthened and migrated to DHIS2, SENI-Plus will put in place an interoperability solution to draw PBF data directly from DHIS2, eliminating the need for parallel data entry and ensuring complete integration of HMIS and PBF data. Given the project’s focus on human resources, routine monitoring of staffing levels in facilities will also be strengthened. Where necessary, the M&E arrangements may be adapted to accommodate the security situation in intervention areas. This may include the use of a third-party monitoring agency if project staff are unable to carry out monitoring activities. . C. Legal Operational Policies . Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No . 50The National Public Health Institute may also play a key role in supporting the counter-verification, and details of its roles and engagement will be further discussed during implementation. Page 35 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) D. Sustainability 59. Technical sustainability will be ensured by knowledge transfer throughout the project. The CTN- FBP in CAR has built enough capacity that can be leveraged to further refine and reorient the PBF approach so that it is more sustainable. The project’s investment to align the PBF program with the country’s PFM will help provide stronger autonomy to decentralized levels of the health system and gradually build country capacity to manage funds. The project will also place strong emphasis on health personnel training, mainly through initiatives to decentralize capacity building of CHWs, nurses, and midwives as well as deployment of skilled medical experts to transfer knowledge to doctors and nurses in the regions and health districts. While deployment of key personnel (including medical doctors, midwives, and data managers) will continue from SENI to address the perennial issue of staff shortage, transitional plans will be prepared to gradually integrate these functions into government systems. 60. As for financial sustainability, the project will contribute to improving the efficiency of health spending through continued use of a performance-based mechanism. The Targeted Free Health Care Policy will be maintained through provision of services using the adapted PBF mechanism as a way to improve financial protection and prevent catastrophic health expenditures. CAR’s fiscal constraints also mean that domestic resources will not be able to finance the sector` in the short or medium term. Therefore, a robust national health financing strategy that outlines the long-term vision for the country is needed. These clear national directions will also help reduce fragmentation and misalignment of partner interventions. E. Technical, Economic, and Financial Analysis 61. Project investments will contribute to strengthening health system performance. They will do so by refining PBF to improve upon the model that has delivered health services to 40 percent of the country’s population. It will help address critical health systems’ bottlenecks, a major one being the challenge of distributing high-quality drugs to health centers. Operationalization of the National Community Health Strategy will also result in a significant number of lives saved. The project will invest in strengthening the health system to provide comprehensive services for GBV survivors using a tried and tested approach under SENI. It will build diagnostic and treatment capacity at regional hubs, which will enable these centers to serve as centers of excellence and treat more complex causes of mortality, including providing safe emergency obstetric care for mothers. Finally, the project will invest in key health sector reforms that are needed to better coordinate the sector and better sustain project investments. Overall, the project will use project resources to improve equity of access for women, children, and the country’s most vulnerable groups. 62. The project will foster value for money by investing in high-impact health services. Increasing access to high-impact health services translates into better health outcomes, resulting in higher economic growth. In low-income countries, reductions in mortality are estimated to account for 11 percent of economic growth.51 Improved health outcomes translate into economic growth through many pathways, including increased labor productivity; increased school attendance and greater cognitive capacity for 51Jamison, J. T., et al. 2013. “Global Health 2035: A World Converging within a Generation.” The Lancet 382 (9908): 1898–1955 doi:0.1016/S0140-6736(13)62105-4. Page 36 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) learning; greater investment due to longer life expectancy; and the opportunity to leverage the demographic dividend which is supported by lower child mortality and fertility rates. Ex Ante Cost-Benefit Analysis 63. An ex-ante cost-benefit analysis was conducted to understand the economic viability of the proposed project. The cost-benefit analysis focuses expansion of four health services (antenatal care, institutional deliveries, long term family planning, and pentavalent vaccination) through Component 1. By modeling just these four services, the project is estimated to have a net present value (NPV) of US$18.45 million. Furthermore, the cost-benefit ratio is 1.31, meaning that every dollar invested in the proposed intervention will yield an estimated benefit of US$1.31. These conclusions stand after a sensitivity analysis is completed, with key assumptions of the model being altered. The methodology for this analysis is presented in annex 4. 64. Existing evidence highlights the economic benefits of project interventions under Subcomponent 1.3. The provision of holistic care to GBV survivors is a cost-effective strategy, yielding high economic benefits. The World Bank estimated that the economic costs of lost productivity due to domestic violence range from 1.2 to 2 percent of GDP.52 Hence, interventions aimed at reducing the incidence of GBV could substantially drive GDP growth. 65. Supporting the development and implementation of key health sector reforms under Component 2 is an efficient way to drive economic growth. Global evidence suggests that strengthening the national supply chain could improve the health sector margins by tens of billions of dollars and improve patients’ safety. More specifically, improved supply chain performance could substantially reduce costs by increasing inventory levels across the value chain and cutting product obsolescence.53 An increase in the health sector budget share combined with improvements of health status of the population leads to higher GDP growth rates and more employment and reduces the number of people living below the poverty line. In addition, upgrading hospitals to improve domestic diagnostic and treatment capacity has also been documented as a highly cost-effective interventions with the potential to drive growth through reduced mortality and improvement in health outcomes. Finally, integrating preparedness into health system strengthening will also lead to higher economic benefits. The COVID-19 pandemic is a clear indication of the importance of pandemic preparedness with estimates showing that there is 47–57 percent chance of another global pandemic as deadly as COVID-19 occurring in the next 25 years.54 Financial Analysis 66. Investments funded through the project are to strengthen health and nutrition services delivery through essential service delivery and system strengthening contributing to UHC. World Bank financing and public sector engagement are critical to ensure the health and well-being of the population and more broadly to promote economic and social goals. The public sector is also key to providing and promoting preventive health services (including health security) and supporting equity improvements to access 52 https://www.worldbank.org/en/topic/gender/publication/engender-impact-addressing-gender-based- violence#:~:text=Gender%2Dbased%20violence%20is%20a,primary%20education%20in%20developing%20countries . 53 Ebel et al. 2013. 54 Center for Global Development 2021. Page 37 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) quality essential health services. Moreover, these interventions have positive externalities, including societal returns of investing in women and children’s health for economic growth. F. Fiduciary (i) Financial Management (FM) 67. The PIU is already implementing the ongoing SENI, REDISSE IV, and COVID-19 projects. Recent FM supervision missions of these projects have identified some weaknesses in contract management and concluded that there is a need to strengthen the overall fiduciary arrangement. This will be done through (a) creating an internal audit function with a staff to be recruited in a transparent manner (the recruitment process is underway under SENI Project and selected candidate will be trained in the use of international audit procedures and standards); (b) developing an audit charter, code of ethics, audit manual to strengthen the governance of the PIU as a whole; (c) recruiting an additional international FM specialist and an accountant who will be working exclusively on this project; (d) establishing a complaint handling mechanism at the level of health facilities and other beneficiaries as well as NGOs; and (e) carrying out independent contract management audits of key contracts or involving third-party monitoring agencies. 68. The PIU is familiar with World Bank fiduciary procedures. However, fiduciary risks will involve (a) multiple implementing entities at the central level with weak capacity, which can lead to delay in implementation, reporting, and disbursement; (b) risks of mismanagement of contracts with NGOs, including absence or inadequate supporting documents of proof of services; (c) weak management of operating costs, including staffing costs, as well as inadequate procedures related to travel costs; (d) inadequate reporting from the implementing entities; and (e) weaknesses of the internal control system particularly for the PBF components related to the funds disbursed to the health districts, health facilities, and hospitals. To better mitigate the risks, the following actions will need to be implemented: (a) the Internal Audit Unit will be organized in such a way as to ensure overall fiduciary oversight of the project, and the internal audit reports will be made available for review by World Bank staff during supervision missions; (b) a detailed mapping of risks and controls should be performed quarterly to assess internal audit efforts and performance, and collaboration between internal and external auditors should be enhanced; (c) clear deadlines and requirements for budget preparation, frequency, and criteria of fund transfer to beneficiaries should be well established and documented; (d) the FM section of the PBF manual of procedures should be revised and enhanced; (e) a simplified reporting template will be developed to be used by implementing entities such as health facilities supported under the project; and (f) interim financial report (IFR) frequency and format will be well explained to implementing entities. Close supervision and timely support will be provided by World Bank fiduciary team in Bangui. 69. The PIU will be responsible for preparing and consolidating the AWPB in consultation with all implementing entities. The AWPB and the disbursement forecast will be consolidated into a single document by the PIU, which will be submitted to the Technical Monitoring Committee for approval and thereafter to the World Bank for ‘no objection’. Its execution will be monitored using suitable accounting software in accordance with the budgeting procedures specified in the manual of procedures and report on variances along with the quarterly IFR. The PIU will need to improve the level of details relating to AWPB and annexes and increase the use of accounting software, Tom2 Pro, for recording the AWPB. Page 38 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) 70. Transaction-based disbursements will be used. A Designated Account will be opened in a commercial bank on terms and conditions acceptable to IDA. It will be under the fiduciary responsibility of the PIU. An initial advance representing a six-month forecast of expenditures will be made into the Designated Account. Subsequent disbursements will be made against the submission of a Statement of Expenditures or records, as specified in the Disbursement Letter. Other methods of disbursing funds (reimbursement, direct payment, and special commitment) will also be made available to the project if necessary. The PIU should monitor on a quarterly basis the alignment of disbursement schedules with AWPBs to enhance the flow of funds. It should also explore the use of technology for making payments to beneficiaries, particularly digitized payments using mobile money which could be facilitated by the new digital governance project also financed by the World Bank. 71. A service agreement will be signed between the Government and implementing entities, particularly NGOs, for the implementation of the PBF and GBV components. The agreement will provide all fiduciary procedures governing the implementation of these activities. An initial advance will be released to these implementing entities and replenishments will be made based on the status of implementation of works and activities as evidenced in quarterly activity reports. The appointment of the internal controller who will oversee, among others, the implementation of this project will help ensure better fiduciary management. The internal controller will conduct supervisions on a quarterly basis and prepare the internal audit report along with findings and recommendation in coordination with the KOBO Toolbox monitoring team. The new fiduciary guidelines between the World Bank and United Nations agencies will be used for the preparation and fiduciary execution of this project. 72. A qualified, experienced, and independent external auditor will be recruited on approved terms of reference within six months of effectiveness. The external audit will be carried out according to International Standards on Auditing and will cover all aspects of project activities implemented and include verification of expenditures eligibility and physical verification of goods and services acquired. The audit period will be on an annual basis and the reports including the project financial statements should be submitted to IDA no later than six months after the end of each fiscal year before June 30. The PIU should ensure that the terms of references for the external audit reflect an adequate scope to cover all project activities (see annex 1 for details on FM arrangements). (ii) Procurement 73. Applicable procurement rules and procedures in the ‘World Bank Procurement Regulations for IPF Borrowers,’ dated November 2020, will be applied to the proposed project. The project is subject to the World Bank’s Anticorruption Guidelines, revised on July 1, 2016. The procuring entity as well as bidders and service providers, that is, suppliers, contractors, and consultants, shall observe the highest standard of ethics during the procurement and execution of contracts financed under the project in accordance with paragraph 3.32 and Annex IV of the Procurement Regulations. 74. Institutional arrangements for procurement. While the PIU has experience in managing complex procurement activities, particularly related to selection of consultants (firms and individual), recent findings under SENI revealed weakness in contract management and reinforced the need for strengthened capacity. Currently, the PIU is staffed with an international procurement specialist with relevant skills and experience dealing with procurement matters and managing Systematic Tracking of Exchanges in Procurement (STEP). The procurement specialist is assisted by two local procurement specialists and a Page 39 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) second international procurement specialist is being recruited to complete the procurement staffing given the increased workload associated with the new projects. The procurement team will be trained on different aspects of the new procurement framework including procurement of goods, works, and consultant services as well as the use of STEP. 75. An in-depth fiduciary review was conducted for the SENI and the previous project. Recommendations included, among others, (a) establishing a quality review team of all procurement documents including bidding documents, bid evaluation reports, and contracts; (b) clarifying the role of the CTN-FBP, which is now restructured as CTN-PS encompassing other technical areas beyond PBF, in preparation and review of terms of reference and evaluation of proposals and review of reports submitted by NGOs/consultants; (c) ensuring that all procurement activities are included in the Procurement Plan and cleared in STEP; (d) establishing a contract management team to ensure that procurement activities are carried out as planned and contracts properly managed and monitored; (e) updating the manual of procedures to include a complete description of the terms of reference for key positions; and (f) collaborating between the project coordination and other actors/structures involved in the implementation. 76. Project Procurement Strategy for Development (PPSD). During the project preparation phase, the Recipient prepared and submitted a simplified version of the PPSD, which was approved by the World Bank The document will be updated and finalized during the early implementation of the project. The PPSD provides the basis and justification for procurement decisions, including the approach to market and selection methods. The PPSD will be recorded into STEP. 77. Procurement Plan. Based on the outcome of the PPSD, the Recipient has prepared a Procurement Plan for the first 18 months. The plan sets out the procurement selection method as well as prior and post review thresholds to be followed and include the key contracts. The Procurement Plan will be recorded in STEP. 78. General Procurement Notice (GPN). A GPN will be prepared and published in at least one local newspapers, in the United Nations Development Business (UNDB) online, and on the World Bank’s external website (see annex 1 for details on procurement). G. Environmental and Social 79. The project is being implemented under the Environmental and Social Framework (ESF) and is rated Substantial for environmental risks, Substantial for social risks, and Substantial for SEA and SH risks. Therefore, the environmental and social (E&S) risk of the project is classified as Substantial. The relevant Environmental and Social Standards (ESS) are as follows: ESS1 (Assessment and Management of Environmental and Social Risks and Impacts, ESS2 (Labor and Working Conditions), ESS3 (Resource Efficiency and Pollution Prevention and Management), ESS4 (Community Health and Safety, ESS5 (Land Acquisition, Restrictions on Land Use and Involuntary Resettlement), ESS7 (Indigenous Peoples [IPs]/Sub- Saharan African Historically Underserved Traditional Local Communities), ESS8 (Cultural Heritage), and ESS10 (Stakeholder Engagement and Information Disclosure). The following ESS are not relevant for this project: ESS6 (Biodiversity Conservation and Sustainable Management of Living Natural Resources) and ESS9 (Financial Intermediaries). Page 40 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) 80. Environmental risks. Key environmental risks are (a) the improvement in the provision of services in health facilities that will lead to increased biomedical waste as well as increased health and safety risks for staff and, to a lesser extent, to communities, especially if the waste is not properly managed; (b) activities under Subcomponent 2.1. related to the possible construction of a national supply warehouse; and (c) minor rehabilitation supported under Subcomponent 2.2. The civil works will generate negative impacts such as construction waste, noise pollution, space conversion, destruction of vegetation cover, increase in aerosols and engine fumes, risks of transmission of STIs and HIV/AIDS due to the arrival of working personnel, and community and occupational health and safety (OHS) risks (including the risk of spreading COVID-19). 81. Social risks. Key social risks are (a) the risks of discrimination and exclusion of vulnerable groups (women, GBV survivors, IDPs) and poor households; (b) the risks related to the expansion of transmissible diseases (STI, HIV/AIDS, and COVID-19) given that through activities, the project will be able to reach a wide range of people; (c) risks of GBV/SEA/SH in capacity building, training initiatives, and constructions; (d) risks of exclusion and marginalization of vulnerable groups (IPs, young people) in the recruitment of community workers related to the possible construction of a central warehouse under Subcomponent 2.1; (e) the risk of attacks on project workers, beneficiaries, and health personnel in relation to the presence of non-state armed groups in the project areas; (f) Recipient’s relative low capacity to manage project-related E&S risks and impacts in a manner consistent with the ESS; and (g) limited familiarity of the PIU with the overall ESF. 82. SEA/SH risks. There is a substantial risk of SEA and SH. Due to the nature of the activities (especially construction/rehabilitation, technical assistance, and training) that will involve communities, especially vulnerable groups, to mitigate the risk, instruments such as an SEA and SH assessment and action plan, including an accountability and response framework, have been developed. In addition, a code of conduct and awareness of SEA, especially among all service providers, has also been developed. Furthermore, as one of the focus areas of this project is support to GBV survivors, the project will support a holistic response (medical and psychosocial) and training of health workers in nine of the 15 target districts. Synergies will be ensured with the Maïngo Project and its Safe Spaces to ensure that within the holistic approach the local GBV counselors living with communities in intervention zones are recruited and fully involved in the process to better assist in the identification and orientation of GBV survivors. 83. Risks of exclusion, discrimination, and marginalization of vulnerable social groups. As some activities of this project (for example, support to provision of targeted free health care) will involve the selection of beneficiaries, strategic approaches have been developed in the SEP to ensure that there is no exclusion or discrimination/marginalization of vulnerable groups (women, GBV survivors, and IDPs) and poor households. These strategic approaches will also be applied to the recruiting of people to ensure that certain qualified vulnerable people including among IDPs, IPs, ethnic minorities, youth, and women are not excluded during project activities. Therefore, the project will continue to ensure inclusion of vulnerable social groups through its all-inclusive SEP. 84. Security risks for project workers and other stakeholders. For certain activities, the project will be implemented nationwide including in areas where non-state armed groups are present. Thus, the risk of attacks on project workers and beneficiaries should be considered. The Recipient has developed a summary version of the Security Risks Assessment and a Security Management Plan consistent with the requirements of ESS4 and in a manner acceptable to the World Bank and publicly disclosed in country on Page 41 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) February 19, 2022, and on World Bank website on February 21, 2022. A full version specific to the project will be developed, approved and disclosed prior to project effectiveness. The Security Management Plan includes appropriate security risk mitigation measures to protect project workers and beneficiaries. In addition, the security screening of sites shall be done before the commencement of project activities (events, works, trainings, and so on) in all project areas, and all bidding documents need to include Security Management Plan requirements for contractors. 85. COVID-19-related risks. Current COVID-19-related risks of dissemination and uncertainties on new outbreaks will contribute to increased health risks especially in relation to community moblization activities. To mitigate likely risks emanating from COVID-19 or other infectious diseases, the Recipient included mitigations measures in the Environmental and Social Management Framework (ESMF), disclosed in country on March 15, 2022, and on World Bank website on March 17, 2022. These measures aim at ensuring that direct and indirect workers and all stakeholder involved in the project are safe. 86. Community and worker risks related to HIV/AIDS transmission. Project activities (including civil works, training, and supervisions) which may create arrival of working personnel and face-to-face interaction in different cities may lead to the spreading of communicable diseases and a number of other safety and health risks to communities, especially risk of transmission of STI and HIV/AIDS. The Recipient will incorporate awareness raising sessions and preventive materials into the workers' health and safety plan and the ESMP. 87. An Environmental and Social Commitment Plan (ESCP)55 was prepared and publicly disclosed in- country on March 1, 2022, and on World Bank website on March 27, 2022, which includes measures and actions to which the Recipient is committed, for the preparation and implementation of the other E&S plans or instruments during project implementation, including their timeline. The SEP was also prepared and disclosed on February 23, 2022, in country, and March 27, 2022, on World Bank website. Through the preparation and implementation of the ESCP, the project will address the gaps through targeted training and support for the E&S specialists to be recruited. Other relevant instruments to be prepared and their timelines are included in the ESCP: • Security Risk Assessment and Security Management Plan – a preliminary version has been prepared and disclosed prior to appraisal, and the full version is due by project effectiveness. • SEA/SH risk assessment and action plan, including the code of conduct and accountability and response framework – a preliminary version has been prepared and publicly disclosed on February 21, 2022 both in-country and on World Bank website, but the full version is due by project effectiveness. • Labor Management Procedures, including a GRM for workers and OHS measures, as an annex to the ESMF has been prepared, but a full version is due within two months of effectiveness. • Ressetlement Action Plan (including the Livelihood Restoration Plan), to be developed and implemented prior to initiating construction activities that involve land acquisition, compensation or involuntary resettlement (including physical or economic displacement). 55 https://imagebank2.worldbank.org/search/33773315 Page 42 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) • Biomedical waste management plan, a preliminay draft has been prepared and the full version is due by project effectiveness. • Indigenous Peoples Plan, a preliminary draft has been prepared and the full version is due by project effectiveness. • Site specific E&S instruments, such as Environmental and Social Impact Assessment/ESMP will be done during implementation, prior to initiating civil works activities as per the ESMF screening and requirement. 88. GRM. The project will set up a project-specific GRM, sensitive to SEA/SH issues, for the ethical treatment and resolution of such complaints that is proportionate to the potential risks and impacts of the project. The Grievance Redressal Committee will include women, young people, and other vulnerable groups when present (IPs, IDPs, returnees, and persons with disability) to make it more inclusive. The GRM would also be used for overall project-related issues, including social and environment safeguards related. The GRM will also serve as a platform for continuous feedback from project-affected communities, other interested stakeholders, and implementing partners. The project-specific GRM will be outlined in the SEP for people to report concerns or complaints. Elements will include (a) the development of a comprehensive communication strategy for each project target area as well as the preparation of all communication materials in accessible form to people with low literacy and disabilities and specially targeted to women to create awareness and disseminate project information; (b) civil society organization and citizen forums to disclose and receive feedback on projects’ semiannual reports; (c) ensuring that the GRM will also be sensitive to receive and manage project-related GBV complaints in a confidential manner; and (d) beneficiary surveys. 89. Institutional capacity. These ministries will also be involved in the GBV component as is the case with the SENI Project. The project will work with some service providers, including the United Nations Office for Project Services and various NGOs, which have some experience in the implementation and monitoring of safeguard instruments but limited experience with the ESF. 90. The PIU’s current E&S team includes one environmental specialist, one social specialist, two GBV/SEA/SH specialists (one international and one national), and two E&S assistants. This team will be strengthened by adding one more specialist to manage the E&S risks and impacts of all World Bank- financed projects that the PIU manages. In addition, the PIU’s E&S team will receive regular training and technical assistance throughout the implementation of the project. Given that SENI is being implemented under safeguards policies, while the COVID-19 and REDISSE IV projects are under the ESF, the MOH has not yet fully mastered the application of the ESF instruments. Thus, the E&S capacity of the MOH, as well as that of other relevant institutions (ministries and agencies) involved in the project, will be strengthened at all levels. IV. GRIEVANCE REDRESS SERVICES 91. Communities and individuals who believe that they are adversely affected by a World Bank supported project may submit complaints to existing project-level grievance redress mechanisms or the World Bank’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 World Bank’s independent Inspection Panel which determines whether Page 43 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) harm occurred, or could occur, as a result of World Bank 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. V. KEY RISKS 92. The overall risk is rated ‘Substantial.’ Macroeconomic, sectoral strategies, technical design of project, institutional capacity for implementation and sustainability, fiduciary, and E&S risks are rated ‘Substantial.’ Political and governance risk is rated ‘High.’ Stakeholder risk is rated ‘Moderate.’ 93. Political and governance risk is ‘High’. CAR’s political and governance context remains extremely fragile. The December 2020 presidential election was marked by violence following the creation of a rebel coalition and the subsequent government counter-offensive. The Government had regained control over most of its territory by end 2021. While the country has recently seen important gains in terms of consolidation, fighting continues in some areas of strategic interest. Armed groups, government troops and their allies are accused of human rights violations. The Government has set up an investigation commission to shed light on those accusations and is committed, should the accusations be proven, to take proper measures to end those practices, by referring each case to the competent jurisdiction. Furthermore, the choice of bilateral partnerships in the security sector is creating tensions with some of CAR’s traditional partners. Political instability could weaken accountability measures and increase security risks that would prevent the project activities from reaching the intended beneficiaries and exacerbate the challenges in the sector. However, the Government’s commitment to post-conflict economic recovery, with strong support from development partners through critical reforms to improve governance and institutional capacity, helps mitigate this risk. 94. Macroeconomic risk is ‘Substantial.’ The country faces two specific risks to the growth and macroeconomic outlook. The first risk pertains to the growth projections that have been revised downward with renewed insecurity and prolonged effects of COVID-19. The dynamism of exports is conditional on strong international demand, which is likely to be affected by the global economic slowdown and insecurity on the Bangui-Douala corridor. A potential decline in key export goods could reduce government revenues and weaken the macroeconomic outlook. Second, CAR faces a high risk of debt distress, limiting its ability to finance investment programs, social spending, and the growing needs of the population, leaving the economy highly dependent on foreign aid. These risks could delay the implementation and achievement of the objectives of the project as they can weaken government capacities and key administrations involved in the project. A debt management and transparency strategy will be pursued under the World Bank Sustainable Development Finance Policy as risk management measures. Also, critical structural reforms supported by development partners, including the International Monetary Fund and World Bank, to improve PFM, increase domestic resource mobilization, and improve the business environment will minimize these macroeconomic risks. 95. Sectoral strategy risk is rated ‘Substantial’. There is clear political support by the current Minister of Health especially on the reforms to be supported under the project, including the national PBF strategy, Page 44 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) National Supply Chain Strategy, and National Community Health Strategy. However, most of these strategies are currently at different stages of development and may face potential delays in finalization and adoption, which may affect project implementation. The ongoing dialogue and increased attention for more coordinated efforts among partners to align their engagement with the government’s strategies will also help mitigate this risk. 96. Technical design is rated ‘Substantial’. Three elements of the project pose the greatest technical risk. First are the adaptations that will be made to the PBF model, which will be defined during the first year of the project based on a large body of evidence that is emerging from multiple impact evaluations of PBF in the region. The project will mitigate risks by introducing a phased approach and evaluating adaptations to the model. Second is the National Community Health Policy, which was finalized in 2019 but has not yet translated into an operational strategy. SENI-Plus will mitigate the risk associated with having a delay in the development of the strategy by initially incentivizing CHWs as defined in the current PBF manual until the strategy is in place to improve links between communities and health facilities. Third are investments to develop a functioning supply chain in an FCV setting, which requires a high level of donor coordination and development of logistical networks in remote and insecure areas. To mitigate this risk, the project will work with technical experts and firms that have experience developing supply chains in FCV settings. 97. Institutional capacity for implementation and sustainability is ‘Substantial’. The constrained capacity of the MOH at the central level and severe shortage of health workers at frontline levels could pose substantial risk for project implementation. The PIU has experience in managing several World Bank- financed health sector projects and its knowledge of World Bank procedures and guidelines will help mitigate this risk. The PIU will be significantly strengthened with a renewed setup and additional staff included to support the four World Bank-financed projects in the sector. In addition to fiduciary and E&S specialists, the World Bank task team now has two senior health specialists based in Bangui who will continue to provide intensified day-to-day support in all areas of project implementation. 98. Fiduciary risk is rated ‘Substantial’ for the following reasons: (a) weaknesses related to timeliness and accuracy of the AWPB; (b) lack of access to bank accounts at the subnational and health facility levels to receive, manage, and account for the funds transferred from the central level; (c) weaknesses in the contract management to ensure that procurement of goods and services is carried out as planned; and (d) lack of financial reporting with poor timeliness and completeness as well as inadequate reporting format. The following mitigating measures will help address these risks: (a) improving the AWPB by developing detailed estimates of costs and financing needs for all beneficiaries including health facilities; (b) exploring the use of technology for making payment to beneficiaries using mobile money; (c) carrying out independent contract management audits of key contracts; (d) establishing a complaint handling mechanism at the NGO and health facility levels; and (e) developing a detailed mapping of risks and controls to regularly assess the internal audit performance. Risks will be mitigated through two levels of verification: verification and counter-verification by an independent and external evaluation agency. To ensure that there is a clear separation of functions and appropriate regulatory frameworks are in place, the MOH, particularly the CTN-PS, will play a key role in the validation of results declared (for both PBF and non-PBF activities), payment to providers, validity of the counter-verification of results, and estimation of performance indicators. However, their fiduciary performance still needs to be strengthened. The GEMS system, which was put in place with the support of SENI, enables improved accountability for the central-level staff to bring cash and supplies to the health facilities. Page 45 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) 99. Environmental risk is rated ‘Substantial’. Implementation of project activities will generate risks and potentially irreversible impacts on the environment. Improved provision of essential services in health facilities and communities under Component 1 will lead some beneficiary hospitals and health facilities to carry out small-scale rehabilitation of delivery rooms, laboratories, and treatment rooms, in addition to enabling a private consultation space for GBV survivors to access services. These potential risks and impacts have been assessed in detail in the ESMF. 100. Social risk is rated ‘Substantial’. Component 1 activities include PBF interventions in support of targeted free health care. The criteria for selection of beneficiaries under the free healthcare policy should be clearly developed, agreed upon, and publicly disclosed in a transparent way. An inappropriate or flawed selection process could create social tension among communities and result in risks of discrimination and exclusion. The same attention should be paid under Component 2 concerning the recruitment of community workers (IPs and young people) in the possible construction of a national warehouse. In addition, measures need to be taken to mitigate risks related to the expansion of transmissible diseases (STI, HIV/AIDS, and COVID-19) given that through these activities, the project will be able to reach a wide range of people and disseminate training and information. However, while the overall social benefits are expected to be positive, the anticipated social risks and impacts include security risks. . Page 46 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Results Framework COUNTRY: Central African Republic CAR Health Service Delivery and System Strengthening Project (SENI-Plus) Project Development Objectives(s) To increase utilization of quality essential health services, especially for women and children, in targeted areas in the Central African Republic. Project Development Objective Indicators RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Supporting Essential Health Service Delivery Children who have received 3 doses of Pentavalent vaccine 43,059.00 46,071.00 49,083.00 52,096.00 55,108.00 58,120.00 (Penta3) (Number) Facility deliveries attended by skilled health personnel 82,373.00 83,856.00 85,365.00 86,902.00 88,466.00 90,060.00 (Number) Modern contraceptive services received by women and 104,053.00 105,926.00 107,833.00 113,573.00 119,347.00 125,128.00 adolescents (Number) Modern contraceptive services received by women 102,112.00 103,950.00 105,821.00 107,726.00 109,665.00 111,640.00 and adolescents – short- term (Number) Modern contraceptive services received by women 1,941.00 1,976.00 2,012.00 5,847.00 9,682.00 13,518.00 and adolescents – long-term and permanent (Number) Strengthening Health System Performance and Preparedness Page 47 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Availability of tracer drugs at health centers in targeted 76.00 77.00 79.00 81.00 83.00 85.00 districts (Percentage) Average quality score of health centers in targeted districts 55.00 60.00 65.00 70.00 75.00 80.00 (Percentage) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 1. SUPPORTING ESSENTIAL HEALTH SERVICE DELIVERY People who have received essential health, nutrition, and 231,158.00 235,319.00 474,874.00 718,740.00 966,996.00 1,219,720.00 population (HNP) services (CRI, Number) People who have received essential health, nutrition, and population (HNP) 155,724.00 158,530.00 319,920.00 484,210.00 651,460.00 821,720.00 services - Female (RMS requirement) (CRI, Number) Number of deliveries attended by skilled health 82,373.00 83,856.00 169,221.00 256,123.00 344,588.00 434,650.00 personnel (CRI, Number) Number of children 66,449.00 67,645.00 136,508.00 206,610.00 277,974.00 350,620.00 immunized (CRI, Number) Number of women and children who have received 82,336.00 83,818.00 169,145.00 256,007.00 344,434.00 434,450.00 basic nutrition services (CRI, Page 48 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Number) 1.1: Increasing Health Service Utilization and Quality through PBF Pregnant women who have attended 4 antenatal care visits 38,907.00 44,468.00 50,028.00 55,589.00 61,149.00 66,710.00 (Number) Patients under the Free Health Services (Gratuité Ciblé) scheme who report receiving 81.00 83.00 85.00 87.00 89.00 90.00 their service and medication at no charge (Percentage) Facilities receiving performance payments on 60.00 67.00 73.00 80.00 80.00 80.00 time (Percentage) Quality satisfaction score of beneficiaries for health 60.00 64.00 68.00 72.00 76.00 80.00 services in district hospitals (Percentage) 1.2 Strengthening community-based essential health service delivery People referred to health facilities by community 76,496.00 80,707.00 84,918.00 89,128.00 93,339.00 97,550.00 workers (Number) 1.3: Providing Holistic Support to GBV Survivors District hospitals with integrated GBV services 5.00 7.00 9.00 11.00 13.00 15.00 (Number) 2. STRENGTHENING HEALTH SYSTEM PERFORMANCE AND PREPAREDNESS NHDP/Investment Case performance reports discussed at quarterly meetings of the 0.00 3.00 6.00 9.00 12.00 15.00 Comite de Pilotage Unique (Number) 2.2: Upgrading Hospitals to Improve Domestic Diagnostic and Treatment Capacity Page 49 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Number of hospitals scoring 80% or higher on the 'diagnostic capacity' 0.00 3.00 6.00 8.00 10.00 12.00 components of the PBF quality assurance checklist (Number) 2.3: Implementation Support for Key Health Sector Reforms Number of additional health professionals employed full- 0.00 65.00 130.00 196.00 261.00 326.00 time in health facilities (Number) Number of additional health professionals employed full- time in health facilities in 0.00 39.00 78.00 117.00 156.00 190.00 targeted districts - female (disaggregation) (Number) 2.4: Integrating Pandemic Preparedness in Health System Strengthening CHWs trained on epidemic surveillance and preparedness 0.00 0.00 413.00 825.00 1,238.00 1,650.00 (Number) IO Table SPACE UL Table SPACE Monitoring & Evaluation Plan: PDO Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Number of children who Routine HMIS data PBF National Technical Children who have received 3 doses of have received a third doses Quarterly PBF Database collection Unit Pentavalent vaccine (Penta3) of Pentavalent vaccine from staff of facilities targeted by Page 50 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) the Project in the previous 4 quarters. Number of deliveries attended by skilled health Routine HMIS data PBF National Technical Facility deliveries attended by skilled Quarterly PBF database personnel in facilities collection Unit health personnel targeted by the project in the previous 4 quarters. Number of contraceptive PBF services delivered in the Database Routine HMIS data PBF National Technical Modern contraceptive services received Quarterly previous 4 quarters by staff collection Unit by women and adolescents of facilities targeted by the Project. Number of short-term Modern contraceptive services contraceptive services received by women and adolescents – delivered in the previous 4 short-term quarters by staff of facilities targeted by the Project. Number of long-term or permanent contraceptive Modern contraceptive services services delivered in the received by women and adolescents – previous 4 quarters by staff long-term and permanent of facilities targeted by the Project. Average of the percentage of tracer drugs (as defined in the PBF quality assurance PBF National Technical Availability of tracer drugs at health tool) available in each Quarterly PBF Database Quality assurance visits Unit centers in targeted districts health centre for the previous four quarters (districts targeted by the Project). Average quality score of health centers in Average of PBF quality Quarterly PBF Database Quality assurance visits PBF National Technical targeted districts scores for the previous four Page 51 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) quarters for health centers Unit in districts targeted by the Project ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection People who have received essential health, nutrition, and population (HNP) services People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) Routine HMIS data PBF National Technical Number of deliveries attended by Quarterly PBF Database collection Unit skilled health personnel PBF/Immuniz Routine HMIS data National Immunization Quarterly ation Number of children immunized collection Program database Routine HMIS data PBF National Technical Number of women and children who Quarterly PBF Database collection Unit have received basic nutrition services Number of pregnant women who have attended a fourth Routine HMIS data PBF National Technical Pregnant women who have attended 4 antenatal care visit in Quarterly PBF database collection Unit antenatal care visits facilities targeted by the project in the previous 4 quarters. Page 52 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Average across the last four quarters of the percentage Patients under the Free Health Services of eligible patients in the Patient satisfaction PBF National Technical (Gratuité Ciblé) scheme who report Quarterly PBF Database PBF community survey who surveys Unit receiving their service and medication at report not having paid any no charge charges for services or medication. Average across the last four quarters of the percentage of facilities eligible for PBF National Technical Facilities receiving performance payments performance payments that Quarterly PBF Database PBF Payment records Unit on time received them in accordance with the timelines set out in the PBF Manual. Average of patient satisfaction scores for the Patient satisfaction PBF National Technical Quality satisfaction score of beneficiaries Quarterly PBF Database previous four quarters for surveys Unit for health services in district hospitals district hospitals targeted by the Project. Number of patient referrals by community health PBF National Technical People referred to health facilities by workers to facilities (with Quarterly PBF Database Routine data collection Unit community workers proof of receipt at the facility) in the previous 4 quarters.. Number of hospitals supported by the Project Administrativ PBF National Technical District hospitals with integrated GBV Quarterly MOH Report that have a psychosocial e data Unit services agent and staff trained in GBV services. NHDP/Investment Case performance Cumulative number of Quarterly Administrativ Meeting minutes Directorate of Research, reports discussed at quarterly meetings of quarters in which PNDS e data Page 53 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) the Comite de Pilotage Unique and/or Investment Case Studies and Planning performance reports were presented and discussed at a meeting of the country platform (Comité de Pilotage Unique). Number of hospitals scoring an average of 80% or higher Number of hospitals scoring 80% or over the past four quarters higher on the 'diagnostic capacity' Quarterly for the new 'diagnostic components of the PBF quality assurance capacity' sub-score of the checklist PBF quality checklist for hospitals. Number of health professionals employed in Directorate of Human Number of additional health professionals facilities targeted by the Quarterly PBF Database Routine data collection Resources employed full-time in health facilities Project as reported in the latest quarterly PBF submissions. Number of health professionals employed in Number of additional health facilities targeted by the Directorate of Human professionals employed full-time in Project as reported in the Quarterly PBF database Routine data collection Resources health facilities in targeted districts - latest quarterly PBF female (disaggregation) submissions who are female. Cumulative number of community health workers Administrativ Directorate of Research, CHWs trained on epidemic surveillance (CHWs) trained on epidemic Quarterly Meeting minutes e data Studies and Planning and preparedness surveillance and preparedness with support from the project. Page 54 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) ME IO Table SPACE Page 55 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) ANNEX 1: IMPLEMENTATION ARRANGEMENT AND SUPPORT PLAN Overall Institutional Arrangements 1. The PIU established by SENI under the MOH currently serves as the PIU for the SENI, REDISSE IV, and COVID-19 projects and will also serve as the PIU for SENI-Plus. The PIU will continue to assume, among others, fiduciary management responsibilities, overall planning, internal audit, and M&E. In addition to additional staff recruited at start of project, further staffing needs will be determined during project implementation on the basis of fiduciary assessments, a review of E&S aspects, and other technical needs. These aspects will be reflected in the revised POM. Figure 1.1. PIU Organigram Financial Management 2. The CTN-FBP, which will be restructured as CTN-PS under the MOH, will continue to oversee the technical aspects of the project while the overall day-to-day fiduciary management will be handled through the existing PIU under the same ministry. Recent FM supervision missions of these projects have concluded that the PIU has sound FM arrangement to accommodate the new project with an experienced FM specialist and well-functioning software. There is no overdue external audit nor IFRs from this unit. Page 56 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) However, submission of audit reports for the last years was delayed and there have been concerns regarding the overall fiduciary management of contracts with some NGOs including CORDAID. 3. An in-depth procurement and FM review was conducted for the ongoing SENI Project in December 2021 as it relates to the contract awarded to CORDAID. Several non-compliance and violations of the procurement and FM procedures were identified, and the following recommendations were made to ensure more efficient implementation during the SENI-Plus Project. The PIU is working to ensure that all these recommendations are followed prior to the start of SENI-Plus. • Establish a quality review team to ensure that procurement documents are prepared in accordance with the agreed procedures. • Use STEP for all procurement transactions including post review contracts and amendments. • Enforce the complaints mechanism for all implementing entities including the PIU, health facilities, and NGOs to improve transparency by fair treatment of grievances. • Recruit adequate staff for fiduciary functions. • Create an efficient archiving system (electronic archiving may be more appropriate given the large volume of document). • Establish a contract management team within the PIU which will have the main responsibility of the contracts monitoring and advanced risk management among other roles. 4. The PIU is familiar with World Bank fiduciary procedures, there are significant fiduciary risks for the implementation of this project, and the overall FM risk is rated Substantial. FM-related risks and their proposed mitigation measures are described in Section III.F(i) and in table 1.1. Table 1.1. Risk Assessment and Mitigation Conditions Risk Risk Mitigating Measures Incorporated into Residual Risk for Rating Project Design Risk Effectiveness Inherent risk Country level: As a post- S The Government is committed to a reform N S conflict country, CAR is a program that includes strengthening of the substantial-risk country public FM through the ongoing Public from the fiduciary Expenditure and Investment Management perspective. Reform Project (P161730) which was closed on June 30, 2021, as well as the new PSDG Project (P174620). Entity level: Project S The fiduciary responsibility of the project N S resources may not be used will be managed by current SENI team; for intended purposes and additional staff will be recruited in a lack of clarification of the transparent manner. The POM should role between the PIU and clearly define the roles and responsibilities implementing entities may of the teams. affect smooth implementation of the project. Page 57 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Conditions Risk Risk Mitigating Measures Incorporated into Residual Risk for Rating Project Design Risk Effectiveness Project level: Project design S Team will include an accountant to ensure N M is relatively complex since it the effectiveness of the accounting system. involves multiple sectors The PIU will prepare an Accounting, and stakeholders who are Financial, and Administrative Procedures not familiar with World Manual, along with the adoption of a POM Bank FM procedures. including adequate fiduciary procedures. Training on fiduciary policies and procedures will be conducted for all the FM staff including the new FM specialist to be recruited prior to effectiveness and the new accountant. Control risk S M Budgeting: The AWPB will S An accounting software will be set and N M be prepared by the PIU and generate the IFR and other relevant data to approved by the COPIL. enable monitoring of the budget. Lack of capacity and Recruitment of an accountant is underway availability of appropriate under SENI who will support the team tools to prepare and preparing and monitoring the budget. monitor the execution of the budget could pose a risk. Accounting: The project S The accounting procedures will be N M accounting function may documented in the Procedures Manual. The not be properly discharged FM functions will be carried out by an due to capacity issues, experienced FM staff including the software-related issues, and additional FM specialist to be recruited prior lack of clear procedures. to effectiveness; a multi-project software will be acquired. Additional training will be provided to the FM staff for a better use of the accounting software. Internal control: Lack of S Elaboration of an FM Procedures Manual N M clarification of role of the and training on the use of the manual by the PIU and implementing financial expert. entities may affect the The scope of work and control process is internal control processes. defined through the CAR generic manual. The POM should clearly define the roles and responsibilities of the teams. Fund’s flow: Delays in S A Designated Account will be opened where N M payment of suppliers and in an advance will be deposited for timely replenishment of the payment of suppliers; request for Designated Account. replenishment of the Designated Account Security threat in the should be sent to the World Bank at least country may pose a serious every month. risk to payments to beneficiaries across the country. Financial reporting: S (a) A computerized accounting system will N M Inadequacy of the be used. Page 58 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Conditions Risk Risk Mitigating Measures Incorporated into Residual Risk for Rating Project Design Risk Effectiveness accounting system may (b) IFR and financial statement formats was result in inaccurate IFRs and agreed. The PIU will oversee overall financial statements as well reporting. The IFRs will be submitted to the as other financial-related World Bank no later than 45 days after the reports. end of the quarter. Auditing: The risks are the S The project will recruit acceptable external N S following: auditors (independent auditors). (a) Audit not carried out in The World Bank will review the audit terms compliance with acceptable of reference and the short list of proposed audit standards audit firms to be consulted. (b) Delays in submission of audit reports and in the implementation of audit report recommendations. Governance and S (a) The terms of reference of the external N S accountability: Possibility of auditor will include a specific chapter on circumventing the internal corruption auditing. The review performed control system with by the internal auditor will be an additional colluding practices such as mitigation tool. bribes, abuse of (b) The FM Procedures Manual will be administrative positions, incorporated in the POM and will be mis-procurement, and so on approved within one month of is a critical issue. effectiveness. (c) Quarterly IFRs including budget execution and monitoring will be prepared. (d) Measures to improve transparency such as providing information on the project status to the public and encourage participation of civil society and other stakeholders are built into the project design. Overall FM risk S M 5. Information and accounting system. CAR is a member of the Organization pour l’Harmonisation en Afrique du Droit des Affaires (Organization for the Harmonization of Corporate Law in Africa). Thus, the country adheres to its accounting standards, in line with the international accounting standards, and Syscohada accounting standards will apply. An integrated financial and accounting system is in place and will be updated to accommodate this project. The project code and chart of accounts will be developed to meet the specific needs of the project and documented in the manual of procedures. The charter of account should be prepared according to the wording used in tables for sources and uses of funds for the accepted eligible expenditures. These diaries and records should be maintained with the support of FM software that should be operational no later than three months after project effectiveness. FM staff at the PIU should also be trained in the use of the software by the same date. 6. Internal control system. The PIU will ensure that internal control systems and procedures of the project as well as roles and responsibilities will be documented in the project FM manual. Alternative Page 59 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) measures such as regular supervision through desk reviews and field visits (that include expenditures and asset reviews) will be carried out by the World Bank to ensure that the implementing agency is maintaining adequate systems of internal controls and key procedures are complied with. The external auditor will also ensure the effectiveness of the internal controls. 7. Interim financial reporting. The PIU will prepare the unaudited IFRs on a quarterly basis. These reports will be submitted to IDA within 45 days following the end of each quarter. The reports will include (a) a table with sources and use of funds; (b) a table with use of funds per activity; (c) a table regarding use of funds according to procurement methods and threshold, and (d) a table with M&E or physical advance of activities. Financial statements will be prepared for each financial exercise covering in general 12 months. Interim financial statements will also be prepared considering certified status of expenditures. The format of such reports has been discussed and agreed. 8. Disbursement arrangements (disbursement methods). Given the Substantial risk environment, the report-based disbursement will not be applicable by default. Therefore, upon project effectiveness, transaction-based disbursements will be used. An initial advance up to the ceiling of the Designated Account (CFAF 2.5 billion, approximately US$4.3 million) will be made into the Designated Account, and subsequent disbursements will be made monthly against submission of a Statement of Expenditures or records as specified in the Disbursement Letter. The other methods of disbursing the funds (reimbursement, direct payment, and special commitment) will also be available to the project. The minimum value of applications for these methods is 20 percent of the Designated Account ceiling. The project will have the option to sign and submit withdrawal applications electronically using the e- Signatures module accessible from the World Bank’s Client Connection website. The proposed funds flow diagram for the Designated Account is presented in Figure 1.2. Page 60 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Figure 1.2. Funds Flow Diagram Transactions based IDA Direct payment SENI-Plus Designated Account in a commercial bank Supplier / Service Providers Transfers of funds Flow of documents (invoices, good receipt notes, purchase order, contract) 9. External audit. A qualified, experienced, and independent external auditor will be recruited on approved terms of reference three months after effectiveness. The external audit will be carried out according to International Standards on Auditing and will cover all aspects of project activities implemented and include verification of expenditures eligibility and physical verification of goods and services acquired. The report will also include specific controls such as compliance with procurement procedures and financial reporting requirements and consistency between financial statements and management reports and field visits (for example, physical verification). The audit’s scope will cover funds released to the NGOs and other implementing entities. The audit will be on an annual basis, and the reports including the project financial statements will be submitted to IDA six months after the end of each fiscal year. 10. The project will comply with the World Bank disclosure policy of audit reports, for example, make publicly available, promptly after receipt of all final financial audit reports (including qualified audit reports), and place the information on its official website within one month of the report being accepted as final by the team. 11. Governance and accountability. The risk of fraud and corruption within project activities is high given the country context and inherent risks of activities. However, the proposed fiduciary arrangements will help mitigate such risks. Page 61 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Table 1.2. FM Implementation Support Plan FM Activity Frequency Desk reviews IFR review Quarterly Audit report review of the program Annually Review of other relevant information such as interim internal control Continuous as they become available systems reports On-site visits Review of overall operation of the FM system (Implementation At least twice in the year Support Mission) Monitoring of actions taken on issues highlighted in audit reports, As needed auditors’ Management Letters, internal audits, and other reports Transaction reviews As needed Capacity-building support FM training sessions During implementation and as and when needed FM Action Plan 12. The FM Action Plan described in table 1.3 has been developed to mitigate the overall FM risks. Table 1.3. FM Action Plan Responsible FM Issue Remedial Action Recommended Completion Date entity Conditions Accounting Upgrading the accounting software and PIU Three months No software training the fiduciary staff on the use of after effectiveness that software FM Updating the project procedures manual PIU Within one month No procedures as part of the POM, which will include of effectiveness manual FM and accounting aspects Reporting Agree on the format and content of PIU Three months No (IFRs) unaudited IFRs after effectiveness External Selection of an external auditor on terms PIU Six months after No auditing of reference (project accounts) effectiveness Procurement The CAR Public Procurement Institutional Setup 13. Important actions have been taken during the last 10 years to improve the quality and efficiency of the public procurement system in CAR. A new procurement law No. 08.017 was adopted and enacted on June 6, 2008. The new law enshrines the principle of separation of functions between contracting, control, and regulation. The three functions are devoted to the following entities: the Procuring Entities, the General Directorate of Public Procurement (Direction Générale des Marchés Publics, DGMP), and the Public Procurement Regulatory Authority (Autorité de Régulation des Marchés Publics, ARMP). Page 62 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) 14. The last assessment conducted by the consultant under the Public Expenditure and Investment Management Reform Project (P161730) showed that the level of compliance with the provisions of the Procurement Law is low. About 45 of 64 procurement plans are received and most of the reasons for using single source is ‘emergency’. The World Bank supports the Government and DGMP to better play its role of control and apply the conditions for use of direct selection as provided in section 42 of the Procurement Law. Emergency due to bad planning will not be considered as a reason for using direct selection. 15. Publication of contracts award and procurement plans is mandatory in the Procurement Law, but implementation is not yet effective. Publications need to be completed as per section 29 of the Procurement Law through wide newspaper circulation. About 40 percent of the publications are done as per the Procurement Law’s provision, and the objective is to reach 60 percent. The World Bank will support CAR in the reforms of its procurement system and policies. The methodology for assessing procurement systems is not planned to date, but an assessment will be carried out. 16. The imbroglio noted in the role and functions of the DGMP and ARMP will be clarified. A decree will be published to better clarify the function of control devoted to the DGMP and the regulations dedicated to the ARMP. Relation between the World Bank-Financed Projects and the ARMP/DGMP 17. Procurement activities under World Bank-financed projects are not submitted to the review of the DGMP. However, discussions have been opened with the two national entities to involve them in the project procurement. This is subject to several reforms/measures that are currently discussed under the Development Policy Operation and the PSDG Project (P174620). Some of the measures are related to the transparency of the national procurement procedures, the limitation of the procurement using direct selection, and the preparation of capacity-building programs for DGMP and ARMP staff. The revision of the Procurement Law is envisaged in the next years. 18. Applicable procurement rules and procedures. The Procurement Regulations will be applied to the proposed project. The project is subject to the World Bank’s Anticorruption Guidelines.56 19. The procuring entity as well as bidders and service providers, that is, suppliers, contractors, and consultants, will observe the highest standard of ethics during the procurement and execution of contracts financed under the project in accordance with paragraph 3.32 and Annex IV of the Procurement Regulations. Institutional Arrangements for Procurement 20. The PIU has a good track record in managing complex procurement activities, particularly under selection of consultant firms and individuals. The PIU is staffed with an international procurement specialist with relevant skills and experience dealing with procurement matters and managing STEP. The procurement specialist is assisted by two local procurement specialists, and a process for the recruitment of a new international procurement specialist has been launched. The procurement team will be trained 56Anti-Corruption Guidelines” means, for purposes of paragraph 5 of the Appendix to the General Conditions, 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. Page 63 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) on different aspects of the new procurement framework including procurement of goods, works, and consultant services as well as the use of STEP. 21. PPSD. During the project preparation phase, the Recipient prepared and submitted to the World Bank for review a simplified version of the PPSD. The document will be updated and finalized during the early implementation of the project. The PPSD provides the basis and justification for procurement decisions, including the approach to market and selection methods, especially considering the limitations of in-country capacity and therefore the need for international or regional competitive selections. Further the PPSD emphasizes the need to build procurement capacity and strengthen contract management. The PPSD will be recorded into STEP. 22. Procurement Plan. Based on the outcome of the PPSD, the Recipient has prepared a detailed Procurement Plan. The plan sets out the procurement selection method as well as prior and post review thresholds to be followed for the first 18 months and include the key contracts. The Procurement Plan will be recorded into STEP. 23. General Procurement Notice (GPN). A GPN will be prepared and published in at least one local newspapers, in the UNDB online, and on the World Bank’s external website. 24. Project Operations Manual (POM). The POM of SENI will be updated no later than one month after project effectiveness to reflect the specificity of SENI-Plus. The POM will clarify the relation between the different key actors of the project. 25. Recruitment of PIU staff. Recruitment of PIU staff will be done as per clause 7.32 of the Procurement Regulations. The PIU staff will be selected by the Recipient according to its personnel hiring procedures for such activities, as reviewed and found acceptable by the World Bank. However, the hiring procedures should be acceptable by the World Bank. These recruitments are not ‘procurement’ activities and shall not go into the Procurement Plan in STEP, but the World Bank task team leader shall agree with the Recipient on review of terms of reference, short list of candidates, résumés, and final selection of PIU staff. 26. The risk associated with procurement is rated Substantial. Details of the risks and mitigation measures are presented in table 1.4. Table 1.4. Procurement Risks and Mitigation Measures Risks Mitigation Measures Lack of qualified and experienced • The PS of the SENI will used for the project. The PS has been trained on PSs within the country the new procurement framework and contract management. His capacity will continue to be strengthened during project implementation and an additional PS will be recruitment under the new project. Delays in the update of information • A close follow-up will be done by the PS of the World Bank for a regular in STEP update of procurement transactions in STEP including post review activities. Delays in the implementation of • The POM will be updated to reflect the specificities of the new project. procurement activities • Action plans will be developed for complex procurement activities. Limited capacity of the private • A simplified PPSD has been prepared by the Recipient. The PPSD sector including consultants describes how fit-for-purpose procurement activities will support Page 64 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Risks Mitigation Measures project operations for the achievement of PDOs and deliver value for money. • International Open Procurement Approaches will be applied for complex activities. Managing fraud and corruption and • Ex ante due diligence of firms being selected will be attempted using noncompliance databases available in country and externally. • PPRs will be conducted for post review activities. Weak preparation of procurement • Establish a quality review team to ensure that all procurement documents including bidding documents are well prepared and procurement process well documents, evaluation reports, and documented. contracts Absence of contract management • Establish a contract management team including multidisciplinary profiles and clarify the role of the CTN-FBP in review of reports. Note: PS = Procurement specialist. Page 65 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) ANNEX 2: DETAILED PROJECT DESCRIPTION Table 2.1. Comparative Analysis of Changes in Key Health Indicators between MICS 2010 and MICS 2018–2019 MICS 2010 MICS 2018–2019 Difference Health status of the population Neonatal mortality — 28 Infant mortality 116 65 −51 Under-five mortality 179 99 −80 Moderate or severe stunting (%) 40.7 39.8 −0.9 Moderate or severe wasting (%) 7.4 5.4 −2.0 Low birth weight (%) 13.7 13.0 −0.7 Diarrhea in the last two weeks (children) (%) 23.7 24.1 +0.4 ARI symptoms (children) (%) 6.9 5.9 −1.0 Fever episodes (children) (%) 32.2 30.8 −1.4 Total fertility rate 6.2 6.4 0.2 Adolescent fertility rate 229 184 −45 Early pregnancy (%) 45.3 42.8 −2.5 Coverage of preventive interventions Use of improved water source (%) 54.1 58.7 +4.6 Use of improved toilets (%) 22.3 21.8 −0.5 Children under 5 years of age sleeping under ITNs (%) 36.4 50.6 +14.2 Pregnant women sleeping under ITNs (%) 40.4 55.1 +14.7 IPT for pregnant women (%) 34.6 30.2 −4.4 Exclusive breastfeeding under 6 months (%) 34.3 36.2 +1.9 Vitamin A for children under 5 years of age (%) 78.0 60.8 −17.2 DTP / Penta vaccine (%) 30.9 34.4 +3.5 Measles vaccine (%) 49.8 45.0 −4.8 Neonatal tetanus vaccine (mothers) (%) 53.3 59.0 +5.7 ANC1 (qualified personnel) (%) 68.2 51.8 −16.4 ANC4 (any provider) (%) 38.1 41.4 +3.3 Contraceptive prevalence rate (%) 15.2 17.8 +2.6 Coverage of curative interventions ORT and continuous feed (%) 37.5 35.6 −1.9 ORS (%) 15.6 23.4 +7.8 Treatment-seeking for ARI (%) 29.8 34.7 +4.9 Antibiotic therapy for ARI (%) 31.3 29.8 −1.5 Antimalarial treatment for children under 5 years of age (%) 34.1 29.9 −4.2 Delivery attended by qualified personnel (%) 53.8 42.9 −10.9 Institutional deliveries (%) 52.5 58.3 +5.8 Caesarean section rate (%) 4.5 2.2 −2.3 Table 2.2. SENI-Plus Targeted Districts and Population Targets Population Pregnant Children Region Prefecture Health Districts 2021 Women under Five REGION 2 NANA MAMBERE BABOUA-ABBA 163,387 6,388 28,266 REGION 2 NANA MAMBERE BOUAR-BAORO 349,389 13,661 60,444 Page 66 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Population Pregnant Children Region Prefecture Health Districts 2021 Women under Five REGION 2 MAMBERE KADEI BERBERATI 123,737 4,838 21,407 REGION 2 MAMBERE KADEI CARNOT-GADZI 79,327 3,102 13,723 REGION 2 SANGHA MBAERE SANGHA-MBAERE 142,075 5,555 24,579 BOZOUM- 158,578 6,200 27,434 REGION 3 OUHAM PENDE BOSSEMPTELE REGION 3 OUHAM PENDE PAOUA 211,728 8,279 36,629 REGION 4 KEMO KEMO 166,458 6,508 28,797 REGION 4 NANA GRIBIZI NANA-GRIBIZI 165,609 6,475 28,650 REGION 4 OUAKA BAMBARI 221,191 8,649 38,266 REGION 4 OUAKA KOUANGO-GRIMARI 167,767 6,560 29,024 BAMINGUI BAMINGUI- 60,765 2,376 10,512 REGION 5 BANGORAN BANGORAN REGION 6 BASSE KOTTO ALINDAO-MINGALA 144,038 5,632 24,919 REGION 6 BASSE KOTTO KEMBE-SATEMA 83,437 3,262 14,435 REGION 6 BASSE KOTTO MOBAYE-ZANGBA 122,743 4,799 21,235 Note: 15 districts with estimated population of 2.36 million (2021). Estimations: 1 District ~ 30 health centers 1 Health center catchment area ~ 10 villages or communities 1 Village/community ~ 500 inhabitants. Subcomponent 1.1: Increasing Health Service Utilization and Quality through PBF 1. PBF has played a critical role in strengthening the country’s health system and implementing the Targeted Free Healthcare Policy. The World Bank began supporting PBF in 2016 through the Health System Support Project and then continued financing the model during the SENI project. In 2019, PBF was adopted by the Government as a national strategy in CAR to strengthen the health system by incentivizing the delivery of high-impact health services as well as improved governance and operational management. By the end of 2020, SENI financed a basic package of health services in 15 health districts or for approximately 40 percent of the country’s target population. 2. The current PBF model in CAR reimburses payments to facilities based on the quantity and quality of preventive, promotion, and curative package of services57 in the form of a ‘fee for service.’ It also supports targeted free health care for pregnant and lactating women, children under five, and poor and marginalized households as well as GBV survivors. PBF also aims to strengthen health systems, focusing on the pillars of the health system to support high-impact interventions including immunization and maternal and child health. Further, PBF supports the provision of care at the community level through facilities providing incentive payments to CHWs who are operating within their geographical area of responsibility, based on the number of patients referred and loss to follow-up cases referred to facilities. In addition, essential generic drugs and other health inputs are provided to health facilities to support the targeted free services as well as medical equipment and supplies. 57Current PBF in CAR includes 55 indicators: 30 for minimum package of activities (MPA) at health centers and 25 for the complementary package of activities (CPA) at the district hospital. The majority of indicators refer to maternal and child health care services. Page 67 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) 3. Separation of functions of financing, regulation, service delivery, contracting, and payment is the cornerstone of the current PBF model in CAR. The CTN-FBP participates in the preparation and evaluation of contract management and evaluates the technical aspects of the contracting and auditing agencies (Agence de Contractualisation et de Vérification, ACVs), regional health directorates, and district health teams. The PIU proceeds with quarterly payment of subsidies to health facilities after validation of the quantitative and qualitative invoices issued by the CTN-FBP following validation by each district committee and entry on the PBF portal. The ACVs verify the quantity of essential health services delivered to the target population, the regional health directions verify the quality of health services in hospitals, and the district health teams verify quality in health centers. Within the regulatory framework, the regions and health districts receive subsidies for implementation of their activities. 4. Payments to facilities are made on a quarterly basis calculated based on multiple factors. These factors include (a) quantity of services provided by the facilities (reported on a monthly basis, verified and validated); (b) an equity adjustment payment to the health facility depending on remoteness, security, and working conditions of the facility; (c) quality score obtained through a quantified quality checklist which is in place for each level of the service package to introduce measures of quality;58 and (d) monthly advance, if received, to strengthen the voices of communities and beneficiaries. Results of the community surveys are also considered in the calculation and payment of the overall quality adjustment for health facilities. 5. Data collection, validation, and payment cycles are linked. The ACVs are responsible for entering data that they verify quarterly. Next, data validation takes place by data managers at health districts. Since verified data are reported on the PBF portal, it is possible to follow up on the evolution of indicators as they go through the rounds of initial reporting, verification, and then validation. At the start of the quarter, health facilities receive an advance payment of 50 percent, representing their average mean consumption of last three months. The remaining 50 percent is transferred after the verification and validation of the PBF invoice. The compilation of payment requests and synthesis is realized by the CTN-FBP. The transfer of subsidy to the health facility accounts is ensured by the fiduciary unit of the PIU. 58The quality scorecard consists of elements including management and governance of health facilities, staff availability and competence, hygiene practices, availability of equipment and diagnostics to treat priority conditions, drug stock management, FM. Page 68 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Figure 2.1. Health Districts Covered by the PBF Scheme in CAR Source: SENI-REDISSE IV- COVID-19 PIU Page 69 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Table 2.3. Adaptation of the PBF Model in CAR - Preliminary Findings and Possible Options Priority Dimensions for Findings In CAR Possible Options for Adaptation Adaptation Institutional The PIU was merged with the CTN-FBP as one entity. While this Review current PBF institutional arrangement and clarify the arrangement arrangement facilitated implementation of PBF activities, having the relations between different levels and entities/rethink the CTN- CTN-FBP operate under a World Bank-financed structure that FBP position for other partners’ buy-in with a view to fully oversees multiple World Bank-financed projects may limit integrating the PBF approach in the Government. Consider the ownership of the national strategy and discourage other partners creation of a CTN-PS with all the experts in charge of PBF as well as from aligning their support to the PBF model. other experts required for all health projects. Governance and A current control mechanism is weak, leading to possible fraud and Explore alternative options, including hiring an internal auditor control corruption. involving MOH inspectors to conduct on-the-spot internal control. Other possibilities include engaging para-public institutions such as the School of Public Health to ensure the counter-verification of all the actors. Explore leveraging innovative technology, including mobile money, for facility direct payment. Verification Verification has been conducted by NGOs (also called ACVs). There Possible options include (a) using an integrated mixed approach of are increasing concerns around the high cost and efficiency of this general inspection involved in external counter-verification arrangement. On the other hand, recent evidence from SENI together with organizations such as the Public Health Institute of highlighted the importance of having a rigorous verification in place Bangui; (b) recruiting individual auditors at the regional level in to ensure strict financial control. In this regard, an in-depth review collaboration with members of the health district management of the current organization and effectiveness of verification will be teams; or (c) contracting local institutions or CBOs to perform the carried out during project preparation to propose possible (counter)-verification role (or to contribute to verification). adjustments drawing from global experiences and then adapted to Further, to reduce the burden of verification, a risk-based the CAR context. approach may be introduced. The approach(es) will then be tested in one or two regions in the first year of project implementation. The project will also explore the possibility of transferring some responsibilities to decentralized entities at local levels as part of cost containment measures while ensuring management and verification standards are enhanced for better governance. Facility Facilities are not autonomous. Elaborate regulatory texts and performance policy to improve autonomy facility leadership and autonomy. Strengthen legislative and regulatory provisions to rationalize the management of the facility’s revenue while considering PFM principles (through ministerial orders, circular notes, and so on). A status report on FM Page 70 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Priority Dimensions for Findings In CAR Possible Options for Adaptation Adaptation and accounting will be considered to have a clear roadmap to facilitate the autonomy of health facilities. Service packages PBF payments are currently based on 55 indicators, comprising 25 Review relevance of indicators and costs; propose reduction in the for CPA at district hospitals and 30 for MPA at health centers. While number of indicators, especially for those that are already paid for these indicators for CPA and MPA are all targeting the high-impact through an input-based approach; explore what is a good mix of RMNCH-N interventions, there is a need to review the relevance of cost-effective services to invest in accordance with the resources indicators and their associated costs. Reduction in the number of available; explore other 'lighter touch' options that will still indicators is proposed to determine the optimal mix of cost-effective incentivize volume of services but with more simplified services to invest in accordance with the resources available. implementation modality (for example, mixed approach with DFF including use of block grants). Review and adapt PBF fundamental principles, particularly related to the purchase of MPA in health centers and CPA indicators in hospitals (revision of the manual and HF mapping with catchment areas). A detailed costing will be carried out to further inform the revised packages for hospitals and health centers. Better costing data could also help (a) harmonize purchasing practices across various partners and (b) adjust the list of indicators based on specific circumstances (for instance, if a partner is funding a specific activity or facility, the payment could be adjusted to avoid duplication and maintain fairness). Costing The current model is based on international good practices (US$6 Map out per capita spending (of both donors and Government) per capita), but real cost is unknown and could be substantially across districts with a view to achieving a more equitable lower/disproportionate. distribution. Consider possibility of applying a district-specific per capita investment cost depending on a high level of concentration of partners with heavy investment in inputs. Quality of No sufficient evidence on how the quality consideration in the Revisit the quality checklist and simplify/adapt to the CAR context. services current PBF model is influencing quality improvement. The quality Review the effectiveness of current quality measures. Equity checklist is too ambitious for the CAR context. adjustment (currently used for health facility upgrade) will be reviewed and modalities revisited. At the district hospital level, the project will support significant investments in medical equipment, infrastructure improvement, and training of human resources (Subcomponent 2.2). Page 71 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Priority Dimensions for Findings In CAR Possible Options for Adaptation Adaptation Payment Available data do not confirm that in the case of CAR, the part that Explore a mixed approach learning from other countries (Nigeria, mechanism was paid through fee for service drove the impact of PBF schemes. Cameroon, Burkina Faso, Zambia) where impact evaluation In this respect, a possible alternative that has been explored in other findings confirmed that DFF may be a lower cost and less complex countries is a mix of PBF with DFF, that is, lump-sum payments to intervention that can achieve similar results as PBF when it comes facilities. There are frequent delays in payment of subsidies. For to increasing health service coverage. Both PBF and DFF can facilities without bank accounts, subsidies are paid in cash, raising include the transfer of funds directly to health facility bank accountability issues. accounts, increasing autonomy in how facilities used funds, integrating community representatives in facility management, increasing the frequency of supervision visits by the central level, and introducing a quantified quality checklist. The project will support strengthening of fiduciary capacity of districts and health centers, including basic accounting skills, will be particularly relevant considering the direct financing’s alignment with the budget process (PFM) and its implications for treasury management. Pooling and Current PBF is funded by the World Bank and EU only, with no other Conduct a thorough mapping of what other partners are investing alignment of partner participation, while other partners could be interested to in and how that should affect the PBF design. Explore possibilities partners fund the Government using the same approach. of actual or virtual common basket whereby partners can pool funds to support PBF. If resource pooling is not possible, explore ways to harmonize/coordinate the type of services to provide, mechanisms to assess quality, and so on in a joint manner by advocating flexibility. Alignment of The PBF approach has mostly been outside of government Alignment would require simplified and flexible fiduciary protocols PBF with PFM budgetary processes, which makes the model less sustainable. adapted to the CAR PBF model that bring PBF into the budgetary Transition requires systematically considering the extent to which process and its accountability mechanisms but still remain the the current PBF approach is aligned with government PFM systems performance orientation of the system. A PFM bottleneck analysis and where there may be opportunities to improve. This will require will be conducted through World Bank-executed funds (PASA) assessing whether the government PFM system recognizes facilities which will inform the way forward. Capacity building on PFM and as spending entities and later how or whether it could provide them development of an FM manual to improve alignment of PBF with authority and autonomy to use funds in a flexible manner and make PFM are also required. The PFM principles must be respected with output-oriented payments to providers while maintaining sound the possibility of control by the agents in charge of the Treasury of levels of financial accountability. the Ministry of Finance. Data integration The PBF portal operates in parallel to the national HMIS. DHIS2 will Support strengthening of HMIS/DHI2 implementation and scale up Page 72 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Priority Dimensions for Findings In CAR Possible Options for Adaptation Adaptation of PBF database gradually replace the current HMIS, but the rollout of DHIS2 is still while ensuring interoperability with the PBF portal. Recruit with DHIS2 only in five districts in Bangui and around and is yet to be expanded. additional IT staff in the PIU. Resource Low buy-in of other partners and lack of sufficient evidence to make Conduct assessments to document the contribution of PBF on the mobilization a strong case of PBF’s contribution to reduction of maternal, reduction of maternal, neonatal, and infant mortality in the project neonatal, and infant mortality. intervention areas. Pursue opportunities for an impact evaluation. Strengthen advocacy for the mobilization of domestic resources as well as partner contributions to support PBF financing scheme. Procurement Frequent stock-out of drugs that are controlled by the central level Diversify drug supply and distribution mechanism to ensure and decreases the credibility of PBF and does not allow facilities to efficiency, including the current options being explored (UNICEF, management of perform. direct purchase with international suppliers, and so on); need to drugs strengthen and enforce the pharmacy accreditation system for facilities to buy drugs at authorized local suppliers (instead of informal sectors). Human Lack of sufficient and quality human resources to support delivery of Redesign the PBF scheme to better leverage recruitment, resources services. Involvement of CHWs for facilities to conduct outreach is retention, training, and deployment. Equity bonus to be adapted not formalized. to better incentivize deployment to address the issue of unequal geographical distribution of health personnel. Once the Community Health Strategy is in place, revisit the CHW incentive structure that is currently supported under PBF. Page 73 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Box 2.1. Differences, Similarities, and Complementarity between PBF and DFF PBF is a health system strengthening approach that makes payments to health facilities based on the quantity and quantity of services delivered and is often modified by equity weights. In many low-income countries, PBF has been the primary mechanism to finance recurrent costs at primary health care facilities and increase staff salaries. It has been an appealing approach for donors given the link between investments and results. However, PBF relies on strict verification systems, which can increase the cost of health services. In some countries, it has resulted in the development of parallel information and public FM systems. DFF is also a health system strengthening approach. It involves a purchaser making payments directly to health facilities, usually using a prospective approach (that is, capitation) or based on a facility budget. At its core, DFF requires that facilities have both legal and operational autonomy to receive, manage, and account for funds. It requires that the purchaser clearly defines the benefit package, or services outputs, on which health facilities can spend funds. Finally, it requires that facilities have sound FM to document their purchases. DFF relies on routine reporting and auditing systems, which may be less costly and simpler to implement than PBF verification mechanisms. PBF and DFF have many similarities—both approaches require reinforcing health facility management, supervision, and information systems. Both decentralize funding to the health facility level and require that facilities have their own bank accounts to receive payments. Existing evaluations of PBF in comparison with DFF suggest that both approaches have resulted in similar impacts on service utilization and quality. Moving forward, PBF and DFF should be used as complementary health system strengthening approaches. DFF can be used to provide predictable base payments that are aligned with population needs, whereas PBF can add a performance element to incentivize utilization and quality for specific services. Verification remains critical but should be conducted based on risk analysis and be embedded within national auditing systems. Sources: Witter, Sophie, Maria Paola Bertone, Karin Diaconu, and Olga Bornemisza. 2021. “Performance-Based Financing versus “Unconditional” Direct Facility Financing - False Dichotomy?” Health Systems & Reform 7 (1): e2006121; WHO. 2022. Direct Facility Financing: Concept and Role for UHC. Geneva: WHO. Subcomponent 1.2: Strengthening Community-Based Health Service Delivery 6. Rationale for support to the National Community Health Policy and Strategy by multiple World Bank projects. The policy and associated strategy have the potential to transform the epidemiological profile of CAR by generating demand for health services, changing health-related behaviors that promote health and prevent disease, increasing access to basic services that prevent and treat the leading causes of death among children, and expanding access to family planning commodities. Community health strategies have been successfully rolled out in other fragile and conflict-affected settings. Given the magnitude of the task, the Maïngo and SENI-Plus projects and the PASA will support the design and implementation of the policy and associated strategy. The Government is working to finalize the strategy by December 31, 2022. 7. Design of the strategy. The Maïngo Project will finance costs related to supporting the design of the strategy, including (a) study tours; (b) technical assistance from national and international experts; (c) workshop costs to convene partners; and (d) development of training materials and operational tools. 8. Strategy implementation. Once the policy and the strategy are finalized, both projects will finance its implementation. The health districts covered by each project and the activities financed by each will be determined once the strategy is finalized and costed. However, the approach will be aligned with one of the following three scenarios: Page 74 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) • Scenario 1: Delineation by geographic area. Each project covers implementation costs in specific geographic regions. SENI-Plus pays for implementation in the six health districts it covers independently. Maïngo pays for implementation in the nine health districts it covers independently. The nine overlapping health districts are split between the projects. • Scenario 2: Delineation by activity. Each project finances specified activities across the 24 health districts. For example, SENI-Plus would finance (a) the cost of delivering the essential health package, including procuring commodities and provision of basic equipment and materials; (ii) incentives for CHWs; and (c) implementation of an M&E system. Maïngo would finance (a) initial training for CHWs, (b) supportive supervision, and (c) in-service training for CHWs. • Scenario 3: Delineation by activity and geographic area. Each project finances specific activities in the nine overlapping health districts. SENI-Plus then covers all implementation cost in the six health districts it covers independently, and Maïngo covers all implementation costs in the nine health districts it covers independently. Subcomponent 1.3: Providing Holistic Care to GBC Survivors 9. SENI-Plus will finance health facility-based GBV activities: (a) holistic care at district hospitals and selected health facilities including medical care for the referred and complex cases at the district hospitals; (b) provision and procurement of PEP kits, including emergency contraception and treatment for STIs at both health centers and district hospitals; (c) psychosocial care in facilities and communities; and (d) training of health care providers (doctors and health workers) at project-supported health facilities to respond to GBV through screening and medical response including administration of PEP kits to survivors who are referred to the health facility. SENI-Plus will finance health facility-based activities initially in the five health districts where SENI is supporting, to be progressively expanded in all 15 health districts using a phased approach. 10. SENI-Plus and the Maïngo Project will jointly finance community-based GBV activities: rollout, monitoring, and supervision of the community GBV prevention and social mobilization. The Maïngo Project will finance community-based activities in areas where the two projects overlap, starting in 2023 and 2024 (shaded in light and dark blue, respectively). SENI-Plus will finance community-based activities in areas where the Maïngo Project does not operate. Table 2.4. World Bank-Financed Health Sector Operations Project Key Interventions Geographic Regions SENI-Plus project • Strengthen supply of health services in hospitals, health 15 health districts; facilities, and posts. for selected • Strengthen supply chain for essential medicines. activities covers • Improve quality of health services. nationwide • Increase access to holistic care for GBV survivors. • Support implementation of the Community Health Strategy, focusing on supplying inputs and incentives for CHWs. REDISSE IV • Strengthen surveillance and laboratory capacity to rapidly Nationwide project detect outbreaks. • Strengthen emergency planning and management capacity to rapidly respond to outbreaks. Page 75 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Project Key Interventions Geographic Regions • Support recruitment, training, and retention of qualified staff for routine and emergency public health functions. COVID-19 project • Prevent, detect, and respond to the threat posed by COVID-19. Nationwide • Ensure equitable distribution of COVID-19 vaccines. Human Capital • Generate demand for family planning and essential health 18 health districts, 9 and Women and services. of which overlap Girls’ • Strengthen referrals from communities to health facilities. with SENI-Plus Empowerment • Increase screening and referral for GBV survivors. Project • Support implementation of the Community Health Strategy, focusing on strengthening training and supervision systems for CHWs. Page 76 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) ANNEX 3: CLIMATE CHANGE RISK AND VULNERABILITIES 1. The project has been screened for short and long-term climate change and disaster risks and the exposure risk is Moderate. This includes exposure to extreme temperatures, extreme precipitation, and droughts. This exposure risk is assessed at this level for both the current and future timescales. CAR is a landlocked country, which exposes the population to the adverse risks of natural disasters, climate change, and disease outbreaks. The increasing temperatures, changes in rainfall pattern, and desertification in the country are leading to food insecurity and scarcity of resources, which have implications for the nutritional status of the population including the lack of water availability. Moreover, climate change is also exacerbating conflict, deepening poverty, and disrupting traditional means of survival (that is, subsistence agriculture and livestock production). CAR deals with seasonal movement of herders from neighboring countries into the country causing competition for water and grazing land. Floods are recurring, which may increase vector- and waterborne diseases among the population, affect water supply and quality, and can affect the structural integrity of health facilities and other critical infrastructure. The lack of water, sanitation, and hygiene in the country accounts for the second risk factor that drives the most deaths and disability in the country, and climate change, particularly extreme weather events, can further increase the risk.59 The dry season and droughts may increase the vulnerability of the population as they create favorable conditions for diseases such as typhoid, respiratory infections, acute meningitis (CAR lies within meningitis belt), and diarrheal diseases. Therefore, it is critical to put sustainable and climate-resilient measures in place to reduce the impact of climate change on the population. The Government has submitted its updated Nationally Determined Contributions in January 2022 with a vision for a climate-resilient and low-carbon development. 2. This project will further enhance the Government’s strategy to reduce the impact of climate change through various climate adaptation and mitigation measures. In terms of climate adaptation, under Subcomponent 1.1 (PBF), several activities, including research and technical assistance, will be implemented to ensure effective operationalization of the PBF model. This will include guidance for health facilities that participate in the PBF schemes to purchase climate-sensitive equipment, supplies, or construction materials if available. This will be incentivized through the quality checklists that will be developed for PBF where higher points will be given to health facilities that purchase energy-efficient and other climate-sensitive equipment/supplies/materials (materials that will ensure proper adaptation to climate disasters such as flooding and could ensure continuous electric generation such as solar panels). Under Subcomponent 1.2 (community health), the National Community Health Strategy will be developed, which will include climate-resilient measures including critical information for vulnerable groups to adapt to climate change and examples of training modules that integrate a climate change lens that can be deployed to CHWs. This will include coping strategies for heat stress and exhaustion during hotter days. This strategy will also be used to update the PBF manual, which will enable more adaptation measures to be included to improve health care workers interactions with patients as well as ensure that equipment and supplies purchased by health facilities and rehabilitation of health facilities’ designs are climate friendly. Under Subcomponent 1.3 (GBV), psychosocial support will be provided to GBV survivors in health facilities and communities. Psychosocial specialists, GBV focal points, doctors, health care workers, and Safe Space Club Mentors will participate in capacity-building sessions that will increase their 59 Institute for Health Metrics and Evaluation (IHME), 2019, https://www.healthdata.org/central-african-republic Page 77 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) competency levels on climate change and health promotion/prevention activities to enable awareness raising in the communities as well as improve their coping strategies. 3. Under Subcomponent 2.1 (supply chain), a National Supply Chain Strategic Plan will be developed, which will include measures and guidelines to ensure availability of enough medicines during emergencies as well as consistent, climate-sensitive refrigeration or heat-stable alternatives to reduce medication and vaccine wastage. A central warehouse will be constructed and therefore special attention will be given to ensure that climate change does not cause widespread loss of power that would threaten the supply chain as medication conservation standards would be affected. Therefore, as an adaptation measure, some of the equipment/supplies will ensure that warehouses provide reliable 24/7 power and efficient cooling and battery-powered coolers will be procured. Moreover, solar panels will be procured and installed. Training will be provided to warehouse managers on preventive as well as response measures during extreme weather events. Under Subcomponent 2.3 (key health sector reforms), the project will finance the development of a National Health Workforce Strategy, which will help coordinate actors and provide training options for health care workers that plan to move to remote regions. The decentralized training will include specific modules and reporting tools on climate-related public health emergencies and coping strategies to improve doctors’ and midwives’ capacity for climate resilience, surveillance, and disaster response. In terms of climate-resilient water systems under Subcomponent 2.2, the project will support the development of protocols during emergencies for safe water access and storage, the procurement of well-sealed containers to harvest rainwater during the rainy season to store it for use during drier periods, and training of health care workers to monitor and assess water leaks/drips in bathrooms, exam rooms, laundry facilities, and kitchens. Under Subcomponent 2.4 (pandemic preparedness), strengthened case management capabilities, disease surveillance system, and early warning system will enhance the ability of health services to better respond to future climate-related health impacts from extreme weather events. This will include the integration of weather surveillance to improve the use of information for detecting, investigating, and responding to public health threats. 4. In terms of climate mitigation, under Subcomponent 1.1 and Subcomponent 1.2, the WHO Performance, Quality, and Safety-certified solar and off-the-grid fridges/freezers, waste management equipment (that is, proper waste segregation, equipment such as autoclaving, microwaving, and steam treatment), and other low global warming potential below 125 for regions will be procured, which will reduce the impact of the project on the country's greenhouse gas emissions. Energy-efficient lighting (that is, LED lights) and light control measures (such as diming and occupancy sensors) will also be procured. Under Subcomponent 2.1, climate-sensitive equipment such as those under Subcomponents 1.1 and 1.2 will also be procured. Climate-smart construction will be financed to ensure improved insulation of the central warehouse against extreme heat such as thermal insulation and solar reflective roofs. Fuel- efficient refrigerated and non-refrigerated vehicles (electric) will also be procured, and route optimization will be considered for vaccine transportation by adjusting routes for vehicles depending on weather and road conditions. This will improve fuel mileage and fuel efficiency of the vehicles. Under Subcomponent 2.3, energy-efficient biomedical equipment such as energy-efficient exam lights, medical imaging devices, and low-carbon medical waste management equipment will be considered. To ensure sustainable and less energy-intensive infrastructure, climate-smart rehabilitation such as those described in Subcomponent 2.1 will be financed. Moreover, climate-resilient and energy-efficient water supply and storage infrastructure, such as well-sealed containers, solar water heaters, and toilets that can safely use harvested rainwater or grey water, will be procured, and infrastructure such as handwashing stations will be rehabilitated to reduce water waste. These investments will improve water access and water use efficiency and improve hygiene and reduce the risk of infection. Page 78 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) ANNEX 4. ECONOMIC ANALYSIS 1. The analysis assesses whether the dollar benefit of the SENI-Plus Project in CAR outweighs the dollar cost. The economic analysis takes into consideration the deaths adverted as a result of the SENI plus project financing of four high impact services: (i) four antenatal care visits; (ii) institutional deliveries; (iii) long-term family planning; and (iv) pentavalent vaccines. Table 4.1. Estimated Numbers of Maternal and Children’s Deaths Adverted Year Neonatal deaths adverted Child deaths adverted Maternal deaths adverted 2023 (Yr 1) 1,366 177 117 2024 (Yr 2) 1,464 186 119 2025 (Yr 3) 1,562 314 133 2026 (Yr 4) 1,660 442 147 2027 (Yr 5) 1,759 571 160 TOTAL 7,812 1,691 677 Source: World Bank calculations – estimation methods detailed in separate file available upon request. 2. To convert maternal lives saved into monetary values as the result of SENI-Plus, the GDP per capita (current US$)60 is multiplied by the percentage of women employed (66 percent).61 This method allows to estimate the average loss of future earnings of an individual by assuming the proportion of income from wages at 52 percent following Lübker (2007)62 and similar to the hypothesis made by Walters et al. (2018)63 in their economic analysis for an investment framework for nutrition in Afghanistan. It is also assumed that unlike people working in the formal sector with a predefined retirement age, beneficiaries of the SENI-Plus interventions are likely to continue working their entire lives. Life expectancy at birth in 2018 in CAR was estimated at 53 years for the general population and 55 years for women. It is assumed that children would start earning at age 18 years and continue doing so until 53 years. It is assumed that pregnant women would have stopped earnings or die at the age of 23, that is, the median age at first birth (20 years64) plus half the fertility rate (6.4 children65), implying that the benefits of the SENI-Plus project for pregnant mothers reflect lost earnings from the age of 23 till the age of 55.66 The average annual GDP per capita growth in CAR over 2021–2025 is projected at 1.6 percent. It is assumed the same average annual growth rate will apply for 2022–2027. 3. Under these assumptions, the project is expected to contribute to saving the life of 677 mothers and 9,503 children. Overall, the project will contribute to saving 346,801 years of productive life, amounting to US$91.68 million based on the CAR GDP per capita and the share of wages in income. 60 There is still a debate in the literature on whether the GDP per capita truly reflects future earnings of the poorest people targeted by development interventions, but there is no better indicator identified to date. 61 World Development Indicators 2019 estimates of the labor force participation rate, female (% of female population ages 15 – 64) (modeled International Labour Organization estimate). 62 Lübker, M. 2007. “Labour Shares.” Policy Brief, Policy Integration Department, International Labour Office, Geneva 63 Walters, Dylan; Dayton Eberwein, Julia; Schultz, Linda Brooke; Kakietek, Jakub; Ahmadzai, Habibullah; Mustaphi, Piyali; Saeed, Khwaja Mir Ahad; Zawoli, Mohammad Yonus; Shekar, Meera. 2018. “An Investment Framework for Nutrition in Afghanistan: Estimating the Costs, Impacts, and Cost-Effectiveness of Expanding High-Impact Nutrition Interventions to Reduce Stunting in the Early Years.” World Bank HNP Discussion Paper. 64 The latest Demographic and Household Survey in CAR established it at 19.4 years. 65 2018–2019 MICS. 66 Life expectancy at birth for female in 2018 in CAR, World Development Indicators. Page 79 of 80 The World Bank CAR Health Service Delivery and System Strengthening Project (SENI-Plus) (P177003) Table 4.2. Economic Benefits of the Project Additional Additional Maternal Years of Productive Year Children deaths Total Benefits deaths adverted Lives Saved adverted 2023 (Yr 1) 1,544 117 56,484 14,413,590 2024 (Yr 2) 1,650 Table 4.2. Economic 60,266 15,624,619 Benefits of the Project 119 2025 (Yr 3) 1,877 133 68,475 18,036,897 2026 (Yr 4) 2,103 147 76,684 20,522,368 2027 (Yr 5) 2,329 160 84,892 23,082,756 TOTAL 9,503 677 346,801 91,680,229 Source: World Bank computations. 4. Project costs were calculated using a discount rate of 5 percent and a sensitivity analysis was performed for lower and higher discount rates, namely 3 percent and 10 percent. Table 4.3 presents the disbursement projections from 2023 through the close of the Project in 2027, as well as the discounted cash flows. Table 4.3. Cost-Benefit Analysis of the Project (US$) Year Costsa Benefits Net Benefits Net Benefits (discounted) at 5% 2023 (Yr 1) 13,000,000 14,413,590 1,413,590 1,282,168 2024 (Yr 2) 13,000,000 15,624,619 2,624,619 2,267,245 2025 (Yr 3) 11,000,000 18,036,897 7,036,897 5,789,272 2026 (Yr 4) 12,000,000 20,522,368 8,522,368 6,677,498 2027 (Yr 5) 21,000,000 23,082,756 2,082,756 1,554,185 Source: World Bank computations. 5. Based on this analysis and at a 5 percent discount rate, the main components of the proposed project (PBF and CHW) are cost-effective with a positive NPV of US$18.45 million. Furthermore, the cost-benefit ratio is 1.31, meaning that every dollar invested in the proposed intervention will yield an estimated benefit of US$1.31. These positive ratios indicate that the investment in the SENI-Plus project is worthwhile. These findings are aligned with recently estimated cost-effectiveness ratios for similar interventions in the region, namely the cost-benefit ratio of the KOBIKISA Health System Strengthening project (P167890)67 project in the Republic of Congo. A sensitivity analysis68 was performed to evaluate the performance of the project under different assumptions and the project remains cost-effective under these two scenarios. Under scenario 1, the NPV of the project remains positive at US$ 19.65 million with a cost-benefit ratio of 1.31 and under scenario 2, the NPV of the project remains positive at US$ 15.86 million with a cost-benefit ratio of 1.30. 67 The KOBIKISA Project is the main health systems strengthening support project in the Republic of Congo with the main objective of increasing the level of utilization and quality of reproductive, maternal and child services in targeted areas, especially among the poorest households. 68 The sensitivity analysis includes the following two scenarios: Scenario 1 uses a higher discount rate (10 percent) for the project costs and benefits; and Scenario 2 assumes a lower discount rate (3 percent) for the project costs and benefits. The project remains economically viable in those two scenarios. Page 80 of 80