the world bank for official use only€¦ · imci integrated management of childhood illnesses ine...

Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No: 47537-AO

PROJECT APPRAISAL DOCUMENT

ON A

PROPOSED CREDIT

IN THE AMOUNT OF SDR 46.7 MILLION

(US$70.8 MILLION EQUIVALENT)

TO THE

REPUBLIC OF ANGOLA

FOR A

MUNICIPAL HEALTH SERVICE STRENGTHENING PROJECT (MHSS)

(REVITALIZAÇÃO)

May 12, 2010

Human Development 1

Southern Africa Country Cluster 2

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.

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i

CURRENCY EQUIVALENTS

Exchange Rate Effective January 17, 2010

Currency Unit = Kwanza

Kwanza 89.8 = US$1

US$1.56 = SDR 1

FISCAL YEAR

January 1 – December 31

ABBREVIATIONS AND ACRONYMS

ACT Artemisin-based Combination Therapy

AMDD Averting Maternal Death and Disability Program

ANC Antenatal Care

ARI Acute Respiratory Infection

BCC Behavior Change Communication

CCU Central Coordinating Unit

CEmONC Comprehensive Emergency Obstetric and Neonatal Care

CHW Community Health Worker

CPAR Country Procurement Assessment Review

CQS Consultants Qualification Selection

DA Designated Account

DDM Data for Decision Making

DMS Departamento Municipal de Saúde, Municipal Health Department

DNSP Direcção Nacional de Saúde Pública, National Department of Public Health

DPT Diphtheria, Pertussis, and Tetanus

EA Environmental Assessment

EmONC Emergency Obstetric and Neonatal Care

EMRP Emergency Multi-sectoral and Rehabilitation Program

EMTA Economic Management Technical Assistance

ESW Economic and Sector Work

EU European Union

FM Financial Management

GAAP Governance and Accountability Action Plan

GDP Gross Domestic Product

GEPE Gabinete de Estudos, Planificação e Estadisticas, Planning Department of MOH

HAMSET HIV/AIDS, Malaria, and Tuberculosis Control Project

HMIS Health Management Information System

HRDP Human Resources Development Plan

HRH Human Resources for Health

HWMD Hospital Waste Management Disposal

IBRD International Bank for Reconstruction and Development

IC Individual consultants

ICB International Competitive Bidding

ICR Implementation Completion Report

http://en.wikipedia.org/wiki/Diphtheria

http://en.wikipedia.org/wiki/Pertussis

http://en.wikipedia.org/wiki/Tetanus

ii

IDA International Development Agency

IEC Information, Education, and Communication

IEG Independent Evaluation Group

IFR Interim Financial Reports

IMCI Integrated Management of Childhood Illnesses

INE Instituto Nacional de Estadisticas, National Statistics Institute

ISN Interim Strategy Note

KAP Knowledge, Attitude, and Practice

LCS Least-Cost Selection

M&E Monitoring and Evaluation

MAT Ministerio de Administração Territorial, Ministry of Territorial Administration

MBB Marginal Budgeting for Bottlenecks

MDG Millennium Development Goal

MHSS Municipal Health Service Strengthening

MICS Multiple Indicator Cluster Survey

MTEF Medium-Term Expenditure Framework

MOH Ministry of Health

NCB National Competitive Bidding

NGO Non-Government Organization

ObGyn Obstetrics and Gynecology

OPEC Organization of Petroleum Exporting Countries

PCU Project Coordinating Unit

PEMFAR Public Expenditure Management and Country Financial Accountability Review

PER Public Expenditure Review

PMI (US) President‘s Malaria Initiative

QBS Quality-Based Selection

QCBS Quality and Cost-Based Selection

SBD Standard Bidding Document

SIGFE Sistema Integrado de Gestão das Finanças do Estado, Integrated Financial

Management Information System

SIL Sector Investment Loan

SOE Statement of Expenditures

SSS Single-Source Selection

TB Tuberculosis

TBA Traditional Birth Attendant

TH Traditional Healer

TOR Terms of Reference

TOT Training of Trainers

UNFPA United Nations Fund for Population Activities

UNICEF United Nations Children‘s Fund

UNITA União Nacional da Independência Total de Angola, National Union for the Total

Independence of Angola

WHO World Health Organization

iii

Vice President: Obiageli K. Ezekwesili

Country Director: Olivier Godron (Acting)

Sector Manager: Eva Jarawan

Task Team Leader: Jean J. De St Antoine

iv

ANGOLA

Municipal Health Service Strengthening Project (MHSS)

CONTENTS

Page

I. STRATEGIC CONTEXT AND RATIONALE ...................................................................... 1

A. Country and sector issues. ................................................................................................... 1

B. Rationale for Bank involvement. ........................................................................................ 7

C. Higher-level objectives to which the Project contributes. ................................................... 7

II. PROJECT DESCRIPTION ..................................................................................................... 7

A. Lending instrument. .................................................................................................................. 7

B. Project development objectives. ............................................................................................... 8

C. Project description. ................................................................................................................... 8

D. Lessons learned and reflected in the project design. ............................................................... 12

E. Alternatives considered and reasons for rejection. .................................................................. 14

III. IMPLEMENTATION ........................................................................................................... 14

A. Partnership arrangements. ....................................................................................................... 14

B. Institutional and implementation arrangements. ..................................................................... 15

D. Sustainability. .......................................................................................................................... 17

F. Credit conditions and covenants .............................................................................................. 19

IV. APPRAISAL SUMMARY ............................................................................................... 20

A. Economic and financial analyses. ........................................................................................... 20

B. Technical. ................................................................................................................................ 21

C. Fiduciary. ................................................................................................................................ 21

D. Social. ..................................................................................................................................... 22

G. Policy Exceptions and Readiness. ........................................................................................... 25

Annex 1: Country and Sector Background ................................................................................... 26

Annex 2: Major Related Projects Financed by the Bank and other Agencies .............................. 33

Annex 3: Results Framework and Monitoring .............................................................................. 35

Annex 4: Detailed Project Description .......................................................................................... 46

Annex 5: Project Costs .................................................................................................................. 51

v

Annex 6: Implementation Arrangements ...................................................................................... 54

Annex 7: Financial Management and Disbursement Arrangements ............................................. 67

Annex 8: Procurement Arrangements ........................................................................................... 79

Annex 9: Economic and Financial Analysis ................................................................................. 88

Annex 10: Safeguard Policy Issues ............................................................................................... 95

Annex 11: Project Preparation and Supervision ........................................................................... 98

Annex 13: Statement of Loans and Credits ................................................................................. 101

Annex 14: Country at a Glance ................................................................................................... 102

Annex 15: Key High-Impact Health Interventions by Service Delivery Level .......................... 104

Annex 16: Terms of Reference for the Development of a Human Resources Development Plan105

Annex 17: Terms of Reference for the Development of a Health Infrastructure Development Plan

..................................................................................................................................................... 110

Annex 18: Voucher Scheme to Encourage Institutional Deliveries ........................................... 113

Annex 19: Governance and Accountability Action Plan ........................................................... 119

Annex 20: Availability of Health Workers in the Five Targeted Provinces .............................. 125

Annex 21: Availability of Obstetric Care in the Five Targeted Provinces ................................ 128

Annex 22: Supervision Plan ....................................................................................................... 132

FIGURES

Figure 1:Trends in under-5 mortality rate ....................................................................................... 1 Figure 2: MHSS Institutional Arrangements ................................................................................ 16

Figure 3: Trends in under-5 mortality rate ................................................................................... 26 Figure 4: MHSS Institutional Arrangements ................................................................................ 56 Figure 5: Funds Flow Arrangements ............................................................................................. 76

Figure 6: IMR in Angola and Sub-Saharan Africa ....................................................................... 89 Figure 7: Under-five mortality rates in Angola and Sub-Saharan Africa ..................................... 90 Figure 8: Arrangements for Vouchers ......................................................................................... 115 Figure 9: Angola‘s progress on governance, 2002 to 2006 ......................................................... 121

Figure 10: Angola‘s governance in relation to the Sub-Saharan Africa average (2007) ............ 122

vi

TABLES

Table 1: Key health indicators for the MHSS provinces ..................................................................... 5 Table 2: Risks ..................................................................................................................................... 18 Table 3: Impact on Under-Five and Maternal Mortality Reduction and Additional Cost Per Capita

of Five Health Service Delivery Steps in Angola .............................................................................. 21 Table 4: Observations from Social Assessment ................................................................................. 22

Table 5: Key health outcome indicators ............................................................................................. 27 Table 6: Key health indicators for the MHSS provinces ................................................................... 31 Table 7: Major related projects financed by the Bank ....................................................................... 33 Table 8: Organizations Present in the Five Provinces ........................................................................ 33 Table 9: Project Development Objectives and Outcome Indicators .................................................. 35

Table 10: Monitoring Framework ...................................................................................................... 37

Table 11: Indicators and data source .................................................................................................. 43

Table 12: Detailed Project costs ......................................................................................................... 51

Table 13: Project Costs By Component ............................................................................................. 53 Table 14: Municipalities covered by the MHSS ................................................................................ 54 Table 15: Training Program ............................................................................................................... 58

Table 16 - Location of Delivery Rooms to be Built/Rehabilitated .................................................... 60 Table 17: MHSS Implementation Schedule ....................................................................................... 62

Table 18: Summary Risk Table .......................................................................................................... 70 Table 19: Procurement Management Action Plan to Mitigate Procurement Risk ............................. 82 Table 20: Procurement Thresholds .................................................................................................... 84

Table 21: Key health outcome indicators ........................................................................................... 89 Table 22: Selected health indicators in the five MHSS provinces compared to national average ..... 91

Table 23: Impact on Under-Five and Maternal Mortality Reduction and Additional Cost Per Capita

of Four Health Service Delivery Steps in Angola .............................................................................. 93

Table 24 : Key High-Impact Health Interventions ........................................................................... 104 Table 25: HRH data in Angola and selected SADC countries per 10,000 persons ......................... 105

Table 26: Health staff in facilities providing obstetric and neonatal care. ...................................... 106 Table 27: Cost of Vouchers .............................................................................................................. 113

Table 28: Governance and Accountability Action Plan ................................................................... 123 Table 29: Minimum number of professionals per category per health facility ................................ 125 Table 30: Availability of doctors and nurses in three selected municipalities ................................. 127 Table 31: Percentage of health units with at least one person who can perform selected procedures

.......................................................................................................................................................... 130

Table 32: Percentage of health units with selected equipment ........................................................ 130 Table 33: Percentage of health units with selected drugs ................................................................ 131

vii

ANGOLA

MUNICIPAL HEALTH SERVICE STRENGTHENING PROJECT (MHSS)

PROJECT APPRAISAL DOCUMENT

AFRICA REGIONAL OFFICE

AFTH1

Date: May 12, 2010

Country Director: Olivier Godron (Acting)

Sector Manager: Eva Jarawan

Project ID: P111840

Lending Instrument: Sector Investment Credit

Team Leader: Jean-Jacques de St. Antoine

Sectors: Health (JA)

Themes: Health system performance (67),

child health (63), other communicable diseases

(64), population and reproductive health (69)

Environmental Screening Category: B

Project Financing Data

[] Loan [X ] Credit [ ] Grant [ ] Guarantee [ ] Other:

For Loans/Credits/Others:

Total Project Cost (US$m.): 91.8

Government 16.5

Cofinancier 4.5

IDA (US$m.): 70.8

Proposed terms: Standard, with 20 years maturity including a grace period of 10 years

Financing Plan (US$m)

Source Local Foreign Total

Government 1.0 15.5 16.5

IDA 41.6 29.2 70.8

Total E&P Angola 3.8 0.7 4.5

Total Financing 46.4 45.4 91.8

Borrower: Republic of Angola

Responsible Agency: Ministry of Health

Contact Person: Dr. José Vieira Dias Van-Dunem, Minister of Health

Project Implementation Period: 5 years

Start: September 30, 2010 End: December 31, 2015

Estimated Disbursements (Bank FY/US$ million)

FY 2011 2012 2013 2014 2015 2016

Annual 2.0 7.0 13.0 16.0 20.0 12.8

Cumulative 2.0 9.0 22.0 38.0 58.0 70.8

Project implementation period: 5 years

Expected effectiveness date: September 30, 2010 Expected closing date: December 31, 2015

viii

Does the project depart from the CAS in context or other significant

respects

[ ] Yes [X ] No

Ref. PAD I.B.

Does the project require any exception from Bank policies

Ref. PAD IV.G.

[ ] Yes [X] No

Have these been approved by Bank management? [ ] Yes [ ] No

Is approval for any policy exception sought for the Board? [ ] Yes [X] No

Does the project include any critical risks rated ―substantial‖ or ―high‖

Ref. PAD III. E.

[X] Yes [ ] No

Does the project meet the Regional criteria for readiness for

implementation?

Ref. PAD IV.D.

[X] Yes [ ] No

Project development objective:

Ref. PAD II.B; Annex 3.

The development objective of the project is to improve the population‘s access to and quality of

maternal and child health care services.

Project description:

Ref. PAD II.C and Annex 4.

The project will have three components:

(i) Improvement of Health Service Delivery.

(ii) Voucher Scheme Pilot

(iii) Project Management and Monitoring and Evaluation

Which safeguard policies are triggered, if any? Ref. PAD IV.F.

Environmental Assessment (OP/BP 4.01)

Significant, non-standard conditions, if any, for:

Credit effectiveness:

(i) The Total E&P Co-financing Agreement has been executed and delivered and all

conditions precedent to its effectiveness or to the right of the Borrower to make

withdrawals under it (other than the effectiveness of the Financing Agreement)

have been fulfilled;

(ii) The MOH will have recruited qualified staff for the CCU, satisfactory to IDA,

including international specialists for financial and procurement management, a

public health specialist, and a training specialist with qualifications and experience,

and pursuant to terms of reference, satisfactory to IDA; and

(iii) The MOH has adopted an Operational Manual, including financial management

and accounting procedures annexes, in form and substance satisfactory to IDA.

Disbursement condition.

No disbursement will be made under component 2 (Piloting demand-side incentives to

encourage institutional deliveries) until no later than two years following the effective date: (i)

the Recipient will have adopted the Voucher Scheme Manual in a manner and substance

satisfactory to IDA; and (ii) the Recipient has issued an internal decree, satisfactory to IDA,

regulating the voucher system.

http://www.worldbank.org/environmentalassessment

http://intranet.worldbank.org/WBSITE/INTRANET/OPSMANUAL/0,,contentMDK:20064724~pagePK:60001255~piPK:60000911~theSitePK:210385,00.html


ix

Other conditions:

(i) The Recipient will implement the project in accordance with the Operational Manual

and any substantial change in the Manual would require prior IDA approval;

(ii) The Recipient will maintain the project management arrangements in form, substance,

resources, and with functions satisfactory to IDA;

(iii) The Recipient will conduct a mid-term review no later than December 31, 2012;

(iv) The Recipient will build houses for medical staff on Government land designated for

such purpose; the land acquisition and resettlement assessment will be documented;

and no resettlement will occur.

(v) The Recipient will cause the Project‘s external auditors to perform an audit of the

procurement for all goods, works, consultants‘ services, payments for grants under the

Voucher Scheme and Operating Costs required for the Project. Each audit will cover

two calendar years, commencing with the calendar year in which the first withdrawal

under the Project was made. The audit reports will be furnished to IDA not later than

forty-five days after the end of each period and include action plans to improve

performance and correct shortcomings.

(vi) The Recipient shall ensure that under each yearly budget proposal to its legislature,

adequate arrangements are made by the Recipient to assume such portion of the costs

related to Recipient's in kind contribution, required to achieve the objectives of the

Project.

(vii) The Recipient shall, not later than three months following the Effective Date appoint

the Project‘s internal auditors under terms of reference, qualifications and experience

satisfactory to the Association.

(viii) The Recipient shall, not later than six months following the Effective Date appoint the

procurement auditors for the Project under terms of reference, qualifications and

experience satisfactory to the Association.

1

I. STRATEGIC CONTEXT AND RATIONALE

A. Country and sector issues.

1. At 260 deaths per 1,000 live births, the under-five child mortality rate is the second worst in

the world after Sierra Leone (270). As shown on the chart, if the present trend continues, Angola

has little chance of reaching that Millennium Development Goal (MDG). Maternal mortality,

estimated at 1,750 per 100,000 live births, is also among the highest in the world. Key

epidemiological indicators are presented in Annex 1.

Figure 1:Trends in under-5 mortality rate

2. The long-running war severely damaged the

country‘s infrastructure, weakening its public

administration network and social fabric. Angola has the

highest concentration of landmines globally with 6-7

million mines spread over 35 percent of the country.

The ruined infrastructure, diminished public and social

network, and the presence of landmines make public

service delivery difficult. The war resulted in 65 percent

of health facilities being destroyed, while many health

staff took refuge in Luanda where 70% of doctors and

30% of nurses were estimated to be living in 2004. However, during the last 2-3 years, the situation

completely turned around. According to the results of a national survey of health facilities that

provide obstetric and neonatal care, 70% of doctors now work at the provincial level1.

3. Even though the government is currently rehabilitating the health network, a high percentage

of facilities are still not functional, especially the bottom tier of the health network (health centers

and health posts), and yet this is the main vehicle to deliver primary health care to the population.

Angola has only 8 doctors per 100,000 people, much lower than the average for African countries.

The result is that 60 percent of the population does not have reasonable access to health care. Most

people still have to walk more than one hour to reach a health facility.

4. Child mortality is mainly caused by malaria, acute diarrheal diseases, acute respiratory

infections, measles and neonatal tetanus, which account for 60 percent of child deaths. These can

be easily prevented or treated at the primary health care level, and through healthy practices and

care at the household level. Child malnutrition, the main associated cause of child mortality, is

alarmingly high. UNICEF estimates that 45 percent of children are underweight. This makes

children vulnerable to diseases and health problems, and has enormous social and economic

implications for the future. There are an estimated 6 million malaria cases per year, i.e. more than

one-third of the population of 18 million2 is affected. Malaria represents the major cause of

mortality (of which 40 percent is perinatal3 and 25 percent is maternal mortality), illness, and

absence from work and school. It has the direct effect of increasing poverty.

1 Situation of Obstetric Care in Angola, UNICEF, 2007.

2 Based on a population estimate of 18,685,639, used by the DNSP of the MOH

3 Deaths occurring during late pregnancy, during childbirth and up to seven completed days of life.

http://en.wikipedia.org/wiki/Childbirth

2

5. Maternal mortality. The main causes of death for pregnant women are malaria, hemorrhage,

eclampsia, abortion complications, and prolonged labor. Only 25 percent of births are assisted by

skilled birth attendants. Complications occur in 15 percent of all pregnancies. Many of the causes

of mortality are directly associated to poverty: lack of information at the household level about

pregnancy complications and the risk of maternal death, delays in seeking care, lack of rapid

access to transport, and insufficient reproductive health services. Yet, with emergency obstetric

care in health facilities, skilled staff, proper surgical equipment, a safe blood supply and sufficient

drugs, maternal mortality can be greatly reduced.

6. Obstetric Care. One of the most effective means of preventing maternal mortality is to

encourage mothers to give birth in hospitals where they can have access to 24-hour emergency

obstetric care. However, in Angola there are both supply and demand side constraints to increasing

institutional deliveries.

7. In 2007, the government commissioned a national survey of obstetric and neo-natal care in

Angola. The survey was carried out by the Averting Maternal Death and Disability Program

(AMDD) of Columbia University, in partnership with the Angolan National Institute of Statistics

(INE). Angola has a total of 83 units providing emergency obstetric care. Based on international

norms and population ratios, the study found that Angola has a good supply of Comprehensive

Emergency Obstetric and Neonatal Care (CEmONC) facilities with 37 units. However, Angola is

deficient in basic Emergency Obstetric and Neonatal Care (EmONC) with only 46 EmONC units,

when a reasonable number would be 146. The demand for obstetric care is also low. Only 28

percent of women deliver in a health unit and only 15 percent in an EmONC facility. The quality

of care is sub-optimal as there is a lack of qualified staff4, equipment and drugs, as shown in Annex

21. Less than 50 percent of hospitals and 33 percent of maternity units have ambulances.

8. The AMDD report, with which the Bank agrees, recommends that the MOH:

(i) Increase the proportion of women delivering institutionally and increase the number of

EmONC facilities.

(ii) Create links with the community to encourage women to give birth in health facilities.

(iii) Provide support to reduce transport costs for pregnant women.

(iv) Increase the number of maternity units in health centers so as to improve access.

(v) Improve the quality of existing services.

(vi) Scale up the training of doctors and nurses in obstetric care.

(vii) Provide kits for normal deliveries and C-sections, as well as basic equipment.

(viii) Provide ambulances.

(ix) Ensure the availability of electricity and water.

(x) Improve waste disposal.

(xi) Provide safe blood for transfusion; and

(xii) Conduct maternal death audits.

9. Essential drugs. Essential drugs are generally available in health care centers and posts.

During the last 10 years, the MOH has received technical support for pharmaceutical work from

Sweden, UNICEF and IDA. As a result, it has developed capacity in planning, procurement, and

4 There is a lack of neonatologists and anesthetists which the government is addressing through the contracting of

Cuban doctors. Also a lack of nurse midwives that the project will address through training.

3

distribution. Over the last few years, drug purchases were made in a ―grouped manner‖, with

hospitals receiving their own requirements as well as essential drugs to be deployed to associated

lower-level facilities. In cases when this redistribution was not optimal, provinces have purchased

drugs from their own budgets to complement the requirements for health centers and posts. The

government will ensure that under each yearly budget proposal to its legislature, adequate

arrangements are made by the government to assume such portion of the costs related to

government‘s in kind contribution, required to achieve the objectives of the project. In addition, to

smooth out distribution flows, the project will finance a buffer stock of US$5.2 million.

10. Health infrastructure. With peace in 2002, the government started an ambitious

reconstruction program to rebuild the country‘s infrastructure and expand the health network. The

program is financed by the government, with significant funding from China, the European Union

(EU), as well as IDA through the Emergency Multisectoral and Rehabilitation Program (EMRP),

which covers the provinces of Bié, Kwanza Norte, Malange and Moxico. It was initially essential

to move fast with the reconstruction of facilities, so as to increase the supply of health services, but

it is now important for the government to ensure that the existing and new infrastructure fit within

a medium-term vision.

11. In 2008, supported by the EU, the MOH completed the first step of a mapping of the

country‘s health infrastructure, covering five provinces: Benguela, Bié, Huambo, Huíla and

Luanda. It provided detailed information about the physical status of every facility in each of the

five provinces and allowed the planning of investments to rebuild the health facilities and other

related infrastructure in accordance with government plans. The next step for the MOH is to

complete this exercise in the rest of the country and develop a comprehensive and costed health

infrastructure development plan for the period 2010-2020. This planning work will be supported

under component 3 of the project. Terms of reference are presented in Annex 17.

12. Government spending has been increasing, but its impact is insufficient. The government

recognizes the important role of the health sector in economic growth. The budget for the health

sector significantly increased over the last five years, and even doubled between 2005 and 2006. In

2006, the health budget was US$71 per capita, representing 3.4 percent of GDP. This spending,

although high by Sub-Saharan standards, is not having the expected impact on health outcomes,

principally because of the low coverage, the poor targeting and quality of services5, and too much

reliance on the provision of health services through fixed-based facilities, i.e. hospitals, health

centers, and health posts.

13. Donors’ support. The main donors in the health sector are the EU, the Global Fund, the U.S.

President‘s Malaria Initiative (PMI), and the Bank, which together provide about US$75-80

million annually. This represents about 14 percent of total public health expenditures. More

recently, China has been financing the rehabilitation of health facilities.

14. The government has made positive achievements in the health sector. The government has

made commendable efforts to control the HIV/AIDS epidemic and has been successful so far, with

prevalence remaining at a low 2.5 percent. It is also scaling up its malaria control efforts, notably

through the distribution of bed nets in all provinces and the replacement of chloroquine, to which

5 A detailed analysis of health sector issues and the financing of the sector is available in the report ―Angola – Public

Expenditure in the Health Sector‖ by the EU and the World Bank (2007).

4

the malaria parasites have developed resistance, by an artemisin-based combination therapy

(ACT). This will make an important contribution to child and maternal mortality reduction, which

the government is now tackling directly through the Revitalização Program (Paras. 17-18).

15. Angola has a great opportunity to make a difference in health outcomes. First, since 2002,

the country has been enjoying peace for the first time in more than 40 years. Second, Angola‘s

economic outlook is promising. After a 0.6% contraction of GDP in 2009 as a result of the world

economic crisis, OPEC production cuts and the drop in the price of oil, GDP is expected to grow at

6.5% per annum over the next three years. Economic growth is expected to resume in 2010. Third,

the problems causing high child and maternal mortality are solvable. In fact, there is a large well-

established body of knowledge about the efficacy and effectiveness of different health

interventions, as well as the technologies to tackle these health problems. If the country can use

this knowledge and spend money efficiently on the right interventions, the health status of the

Angolan population will improve in a relatively short time.

16. Support for the government health strategy. The government health strategy is presented in a

number of key documents: (i) The Government Program 2009-2012 (with a section on health); (ii)

the Health Sector Development Plan; (iii) the Revival of Municipal Health Services Plan6; and (iv)

the Plan for the Accelerated Reduction of Maternal and Child Mortality in Angola.

17. To improve the health status of the population, especially maternal and child health, the

Ministry of Health (MOH) has started to introduce an integrated model of health service delivery

consisting of: (i) health facilities providing a complete package of basic health care services; (ii)

outreach teams that will start from health facilities and visit municipalities according to a regular

schedule, bringing preventive and simple curative services to the population; and (iii) community

health workers, supervised by outreach teams, who will mobilize communities, promote healthy

behavior in the population, help recognize early signs of illness, and encourage the population to

seek care from mobile outreach teams or health facilities when possible.

18. This approach is at the heart of the government‘s Revitalização Program. This program aims

to cover 79 percent of the total population, i.e. about 14.8 million. It will cover 80 municipalities

(out of a total 147) selected according to seven criteria: (i) population; (ii) health status: (iii)

accessibility, including low risk of mines; (iv) availability of infrastructure; (v) inclusion in the

decentralization program of the Ministry of Territorial Administration (to the extent possible); (vi)

availability of staff, drugs, and supplies; and (vii) presence of UNICEF and WHO. The

Revitalização program will improve the supply and quality of health services, increase access, and

thus equity. It will improve the planning of health services at the municipal level through better

meeting the needs of the population, providing adequate resources for staffing, equipment, and

drugs; and strengthening the management of health services.

19. In 2006, the MOH started to implement the Revitalização program in five provinces: Huila,

Bié, Cunene, Luanda, and Moxico. These five provinces and their 16 municipalities have prepared

health maps, operational plans, budgets, and received training in the use of these instruments. The

MOH has started to develop a Health Management Information System (HMIS), but results are

limited. Much more work needs to be done to develop the instruments and train staff in recording

the data and using it for decision-making. The MOH has also started to develop a community

6 Revitalização dos Serviços Municipais de Saúde

5

health workers (CHWs) program: 1,671 community health workers were trained in Huila and 948

in Luanda. This experience has led the government to determine that CHWs should be contracted

by municipalities and not by the MOH -- because eventually their functions will be broadened to

also cover other sectors such as agriculture, nutrition, and sanitation. The outreach program has

been initiated: 130 outreach teams were created and provided with 117 motorcycles and 17

vehicles, and their visit routes planned.

20. To improve the program and expand the geographic coverage of Revitalização to the

provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige, the government has asked for

support from the World Bank and Total E&P Angola. The population of the selected municipalities

in these five provinces is 1.9 million. Because of difficulties of access (e.g. landmines) that cannot

be solved in the near term, the project will effectively cover a population of 1.5 million.

21. The five provinces were selected in close collaboration with the government, based on the

seven Revitalização criteria mentioned earlier. Key health indicators for these provinces, presented

in Table 1 below, show that they generally fare worse than the Angolan average. Also, in terms of

total spending per province, these five provinces are in the lower 50 percent of all provinces7.

Table 1: Key health indicators for the MHSS provinces

Bengo Malanje Lunda

Norte

Moxico Uige Angola

% prevalence of fever 61.1 55.9 42.3 25.1 38.8 40.0

% prevalence of diarrhea 35.3 33.7 32.4 19.5 26.3 26.2

% prevalence of ARI8 18.3 4.8 1.7 4.8 3.9 7.0

% exclusive breastfeeding 16.2 17.0 14.9 10.4 37.0 63.9

% women receiving ANC9 80.1 67.7 67.7 71.4 67.7 79.8

% assisted deliveries 36.4 33.5 33.5 35.0 33.5 47.3

22. The framework for local governance in Angola has accelerated rapidly since 2007,

especially with the Local Administration Law of January 2007 which: (i) clarifies the

responsibilities for services delivered at provincial, municipal and communal levels; (ii) allows for

municipalities to become independent budget units; and (iii) gives municipalities a direct

connection with the center, through the Ministry of Finance and the Ministry of Territorial

Administration (Ministerio de Administração Territorial, MAT). In August 2007, the Cabinet

approved the ―Plano de Melhoria da Gestão Municipal‖ (Plan to Improve Municipal Management),

later transformed into the Fund to Support Municipal Management (Fundo de Apoio a Gestão

Municipal, FUGEM). Its aim is to address the financial, human resource and infrastructure

challenges that municipal administrations are facing. It identified 68 pilot municipalities that were

to receive US$5 million in fiscal transfers for investment during 2008 and 2009.

23. The MHSS will benefit from Angola‘s ongoing municipal decentralization program. In the

case of the health sector, municipalities will become responsible for the management and planning

of health services in addition to being responsible for other social sectors. They also have

resources that allow them to complement provinces‘ spending in staffing and essential drugs and

supplies.

7 EU and World Bank, Angola – Public Expenditure in the Health Sector (September 5, 2008)

8 ARI = Acute Respiratory Infection

9 ANC – Ante-Natal Care

6

24. Human resources strategy. The MOH employs about 62,500 health workers, of which

2,500 are doctors (1,200 Angolans and 1,300 from Cuba, Vietnam, and other countries), about

36,000 nurses, 20,000 support personnel, and 4,000 technicians. In the case of doctors, all the

municipalities included in the project will be sufficiently staffed with specialists and generalists as

they will receive, or have already received, a Cuban or other expatriate doctor team. The

movement of Cuban doctors to the municipalities is expected to continue during 2009, and they

will be renewed every three years. In the case of nurses, as a result of a significant training

program during the conflict years, the MOH currently has a greater than sufficient number of

nurses on its payroll.

25. However, the personnel are poorly distributed, some facilities having too many staff and

others lacking them. A detailed analysis of personnel in the five targeted provinces is provided in

Annex 20. To address this problem, the government is offering improved career prospects to

encourage staff to work in rural areas and is considering a system of temporary rotation of staff

from urban to rural areas. Finally, the MOH will provide houses as another incentive for qualified

staff to go to rural areas.

26. The MOH‘s policy is also to upgrade the quality and productivity of its personnel. The

MOH provides specialized courses allowing health personnel to improve their skills, progress to a

higher category (e.g. from basic nurse to nurse midwife), and increase their salary and motivation.

In-service training allows health workers to refresh their knowledge and improve their

performance. These initial steps and ongoing discussions with the government show promise for

addressing the challenge in a systematic and comprehensive manner. The project will support

government efforts by supporting a significant amount of training (see II.C).

27. The MOH has taken the first steps towards developing a Medium-Term Human Resources

Development Plan. The main strategic directions have been outlined, but the plan must be further

developed and its cost estimated, under different scenarios. The project includes support to the

MOH for the development of this plan, under component 3. Terms of reference to that effect are

presented in Annex 16.

28. HAMSET project experience. The MHSS will build upon the strong track record of the

HAMSET project. The HAMSET Project Coordinating Unit (PCU) team has gained substantial

experience in implementing Bank projects including a significant grasp of Bank procedures. The

HAMSET PCU is located within the MOH, and the staff already have a good relationship with

health personnel working on the HIV, TB and malaria programs, as well as with partners and

donors. The PCU has played a strong role in developing strategic action plans for various public

sector ministries as well as private companies, and could likewise work with the National

Department of Public Health (DNSP) of the MOH to assist municipalities in developing their

annual action plans. The PCU staff is a strong and cohesive team that has successfully overcome

staff rotation issues and remained dedicated to its work, including taking over the financial and

procurement management functions when a private company, contracted to that effect, canceled its

contract. The HAMSET PCU‘s growing experience in procurement will be useful for the MOH in

implementing the MHSS and disbursing funds.

7

B. Rationale for Bank involvement.

29. The Bank and Total E&P Angola will support an integrated model of health service delivery

to be implemented under the Revitalização Program, which the government ultimately plans to

scale up throughout the country using its own resources. The large infusion of global resources

towards HIV/AIDS, tuberculosis, and malaria in recent years has left a large unmet financing gap

for maternal and child health services, which the project will help fill. By using its technical

expertise and experience from other countries, the Bank will help the government develop outreach

and community health services and introduce demand-side incentives in the health sector, an

innovative concept in Angola, which the government could scale up, and consider adapting to other

sectors. The Bank‘s proposed contribution has helped to leverage funds from other donors. It will

help strengthen Angola‘s health system, both in the short and medium term.

30. The Bank has been involved in the health sector through the HAMSET project (US$21

million) and the health component (US$8 million) of the Emergency Multi-Sector Rehabilitation

Project (EMRP), HAMSET with a moderately satisfactory rating for implementation and EMRP

with a satisfactory rating. The Bank also conducted two pieces of analytical work: (i) ―Capacity

Assessment of the Ministry of Health (2006)‖; and (ii) jointly with the EU, ―Public Expenditure in

the Health Sector (2007)‖, both used in designing the proposed project.

31. Angola‘s governance indicators are below the African average on most indices. But, the

trend is improving over time, albeit from a very low base. The project includes a Governance and

Accountability Action Plan (GAAP) whose objective is to strengthen governance around the

project and as a result eliminate corruptive practices so that the full potential impact of the project

is attained. The GAAP is presented in Annex 19.

C. Higher-level objectives to which the Project contributes.

32. The project is directly in line with the Bank‘s Interim Strategy Note (ISN) for 2007-2009,

whose second pillar is ―supporting the rebuilding of critical infrastructure and the improvement of

service delivery for poverty reduction‖. It is also aligned with one of the key focus areas of the

World Bank‘s Africa Action Plan: ―Strengthen national health systems and combat malaria and

HIV/AIDS‖. The operation supports the Millennium Development Goals (MDGs) as follows: Goal

4: Reduce child mortality; Goal 5: Reduce maternal mortality; and Goal 6: Combat HIV, malaria

and other diseases. Finally it is directly in line with the following objectives of the Bank‘s HNP

Strategy: (i) improve the level and distribution of key HNP outcomes (e.g. MDGs), outputs, and

system performance to improve living conditions, particularly for the poor and the vulnerable; (ii)

improve financial sustainability in the HNP sector; and (iii) improve governance, accountability,

and transparency in the health sector.

II. PROJECT DESCRIPTION

A. Lending instrument.

33. The project will be financed through a Sector Investment Loan (SIL). The total project cost

is US$91.8 million and will be financed as follows: (i) IDA: US$70.8 million; (ii) Total E&P

Angola: US$4.5 million; and (iii) government: US16.5 million. Total E&P Angola will finance

part of the training program, solar kits and the rehabilitation/construction of four delivery rooms in

8

Malange and will channel its funds through a cofinancing arrangement with the Bank through a

Trust Fund. Total E&P Angola relies on the Bank‘s appraisal and the next step is the signature by

Total E&P Angola of a Trust Fund Agreement with IDA. A detailed project cost table is presented

in Annex 5.

B. Project development objectives.

The development objective of the project is to improve the population‘s access to and quality of

maternal and child health care services.

C. Project description.

34. The project has three components: (i) improvement of service delivery (US$56.3 million);

(ii) voucher scheme pilot10

(US$0.8 million); and (iii) project management and monitoring and

evaluation11

(US$18.2 million). The project will be implemented in the five provinces of Bengo,

Malange, Lunda Norte, Moxico, and Uige in 18 municipalities12

. It will have a life of five years.

35. The MHSS project supports an integrated model of health service delivery with a minimum

package of interventions (see Annex 15) aimed at reducing child and maternal mortality. By

bringing health services to the population through outreach and community health workers, the

project will help municipalities deliver a higher volume of cost-effective preventive and curative

services to a population that may not have sought these services in the first place. This is because

people face trade-offs on the use of their time between walking long distances to reach health

centers and employing it for productive or other family activities. Better planning and management

will help increase the volume of services in both urban and rural areas. Details on the functioning

of outreach teams and community health workers and their relationship with the rest of the system

are provided in Annex 4. The provision of demand-side incentives and the improvement of the

supply and quality of obstetric care should increase the number of institutional deliveries and help

reduce maternal mortality. To increase access to obstetric care, the project will have a dual

strategy: (i) it will provide equipment to existing municipal health centers, to help improve the

quality of care; and (ii) it will expand the supply of obstetric care by building 36 new delivery

rooms in health centers and posts, bringing the services closer to the population.

36. Finally, the project supports the training of midwives and nurses to provide better obstetric

care in these facilities. Nurses trained in EmONC and pre-natal care will be part of the integrated

primary care outreach teams that will visit the most distant communities. The training will focus on

the improvement of practical skills rather than on theoretical concepts.

37. Why are the proposed project interventions appropriate? They are the right ones for four

reasons. First, they are technically sound and consistent with a series of Lancet articles which

recommended interventions to reduce child and maternal mortality, prioritized on the available

evidence (see IV. B). Second, the project supports the development of a delivery system that can

be put in place relatively quickly as it involves the training and redeployment of existing staff, thus

improving the quality and efficiency of service delivery. The pre-service training of CHWs takes

10

Piloting of demand-side incentives to encourage institutional deliveries 11

Includes significant activities to strengthen the capacity of the MOH and municipalities 12

The list of municipalities covered is in Annex 6.

9

45 days. In-service training for outreach team nurses lasts only 1-2 weeks. Taking into

consideration the time it takes to organize the courses, the project will take 12-18 months to train

the required staff. By contrast, it would take a decade and perhaps more to train new doctors and

nurses, as well as build the fixed-base infrastructure. Long-term investment in training and

infrastructure is also necessary and is being undertaken by the government. What the Revitalização

program does is to put in place a short-term strategy to reach the MDGs more quickly. Third,

project interventions make economic sense. The per capita costs of outreach and community

services are estimated to be 33 and 80 percent respectively of those of fixed-base facilities. Finally,

significant experience from Brazil, South Asia, and African countries such as Ethiopia, Eritrea, and

Mauritania indicate that outreach and community health services have been major contributors to

the reduction of maternal and child mortality. Details are provided in Annex 6.

38. Component 1 - Improvement of health service delivery (US$56.3 million). Component 1

will help strengthen the Angola health system in the five targeted provinces through training of

health personnel, scaling up of outreach and community health services, strengthening of obstetric

care, and improvement of hospital waste management, The training subcomponents (1a and 1b) are

substantial. Their organization and feasibility are described in Para. 74 and Annex 6. There will be

six subcomponents as described below.

39. Subcomponent 1a - Strengthening of municipal health services at the primary level13

,

entirely financed by Total E&P Angola, would finance the following training activities:

(i) Training of 20 trainers in Emergency Obstetric and Neonatal Care (EmONC);

(ii) Training of 180 general nurses in EmONC;

(iii) Pre-service training of about 80 nurse midwives;

(iv) Training of 22 trainers in the Integrated Management of Childhood Illnesses (IMCI); and

(v) Initial in-service training of about 345 general nurses in IMCI.

40. Subcomponent 1b - Strengthening of municipal health services at the primary level will

finance goods, consultants, and training for the following activities:

(i) Pre-service training of about 75 general nurses;

(ii) Training of about 92 staff in health service management and planning;

(iii) A specialization course (public health, management of common diseases, and selected

surgical procedures) for about 20 general physicians;

(iv) Printing and distribution of manuals and information, education, and communication

(IEC) posters;

(v) Teaching and learning materials, and library books;

(vi) Introduction of telemedicine in five provincial hospitals;

(vii) A study of drugs planning, budgeting, acquisition and logistics;

(viii) Provision of drugs and supplies in kind by the MOH and provinces; and

(ix) An 18-month buffer stock of essential drugs and supplies.

41. Subcomponent 2 – Scaling up of outreach services will finance training and goods for the

following activities:

13

This subcomponent is split into 1a and 1b to allow Total to finance a discrete number of activities totaling US$3.3

million equivalent under 1a.

10

(i) A refresher course for about 300 nurses in common disease management;

(ii) Integrated outreach activities by mobile teams (per diem and fuel);

(iii) Vehicles (4x4s, ambulances) and maintenance;

(iv) Quad vehicles and maintenance kits;

(v) Motorcycles and maintenance kits;

(vi) Solar kits and camping kits for outreach teams.

42. To simplify accounting and reporting, operating costs for outreach activities by mobile

teams (per diem and fuel) are included with all other operating costs under component 3.

43. Subcomponent 3 – Improving community interventions will finance training and goods for

the following activities:

(i) Training of about 28 trainers for community health;

(ii) Training of about 1,080 community health workers (CHWs);

(iii) Yearly refresher courses for CHWs;

(iv) Mobilization and education training meetings with traditional birth attendants (TBAs);

(v) Kits (T-shirts, caps etc.) for CHWs, TBAs, and traditional healers (THs);

(vi) Clean delivery kits for TBAs; and

(vii) Kits for THs.

44. Subcomponent 4 (a) – Improving obstetric care will finance works, goods, and consultants

for the following activities:

(i) Rehabilitation and construction of about 32 delivery rooms (for pre and post delivery,

and child care) in health centers and posts14

;

(ii) Construction of about 24 houses for health professionals at provincial and municipal

levels15

;

(iii) Management and supervision of civil works;

(iv) Goods and equipment for pre-natal care, family planning, delivery and IMCI rooms, and

maternities;

(v) Radios for ambulances;

(vi) Review of norms for delivery kits (normal and C-sections); and

(vii) Delivery kits.

45. Subcomponent 4 (b) – Improving obstetric care, entirely financed by Total E&P Angola,

would finance works and goods for rehabilitation and construction of 4 delivery rooms (for pre and

post delivery, and child care) in health centers and posts in Malange.

46. Subcomponent 4 (c) – Improving obstetric care, entirely financed by Total E&P Angola,

would finance goods for solar kits for maternal and child health care16

.

47. Subcomponent 5 – Improving hospital waste management disposal (HWMD) will finance

goods, consultants, and training for the following activities:

14

The location of delivery rooms to be built or rehabilitated is provided in Annex 6. 15

Houses will be provided with access to water, electricity, and telecommunications. 16

Not to be procured from Total E&P Angola because of conflict of interest.

11

(i) Materials and equipment for HWMD by municipal hospitals, health centers, and health

posts;

(ii) Training in HWMD for provincial supervisors and municipal-level personnel;

(iii) Training in biosafety and universal protection; and

(iv) Supervision and quality control of HWMD.

48. Component 2 – Voucher Scheme Pilot (US$0.8 million). This component will finance

provision by the government of : (i) cash transfers to beneficiaries residing in the municipalities of

Negage and Caculama to facilitate access to child delivery services and pre-natal care, all in

accordance with the provisions of the Voucher Scheme Manual; and (ii) technical assistance to

manage these activities.

49. The project will pilot vouchers to encourage pregnant women to deliver in a health facility.

These consist of: (i) transport voucher subsidies; and (ii) direct subsidies for pregnant women. The

pilot will start in the second year. Vouchers will be available to pregnant women living within the

selected municipalities. The municipalities chosen, Negage in Uige province, and Caculama in

Malange province, already have a reasonable supply of obstetric care which will be further

strengthened during year 1 of the project (see Annex 20).

50. Communities and hospitals will be sensitized about the scheme to ensure the support of the

male and local community leaders within the target areas. The ability of women to redeem their

vouchers may be in the hands of other household members, therefore the target segments for the

marketing campaign includes: (i) women between the age of 15-45 years; (ii) transport providers;

(iii) health workers; and (iv) other critical community members such as fathers and community

leaders. The social assessment suggests that men, especially husbands of pregnant women, must be

targeted with advocacy and health education activities to make them more involved in the early

stages of preparing for the birth.

51. Health facilities will be prepared about the mechanics of the scheme (e.g. the need to

provide copies of a delivery certificate to each woman who delivers), but will also be encouraged

to increase their productivity and at least maintain the quality of their services so as to meet the

increased demand. These hospitals will also receive support (goods and equipment, training, etc.)

through component 1 of the project.

52. At community level, CHWs and TBAs will be informed about the scheme and encouraged

to accompany pregnant women to the hospital. Partnerships with local NGOs, Faith-based

organizations, village committees, or women‘s groups where they exist, will help ensure the

availability of transport.

53. The Recipient will issue an internal decree (Decreto Executivo) at Ministry level, regulating

the voucher scheme through a pilot approach. A Voucher Scheme Manual will establish the system

and procedures for the pilot. Both will be conditions of disbursement for component 2 whose

implementation will start in year 2.

54. The overall management of the scheme will be contracted to an NGO. M&E will also be

contracted out. Details on the voucher scheme are provided in Annex 18. A manual of procedures

governing the administration and monitoring of the vouchers is under preparation. The adoption of

12

the manual establishing the system for the vouchers, satisfactory to IDA, is a condition of

disbursement for this component.

55. This component will finance consultants.

56. Component 3 – Project Management and Monitoring and Evaluation (US$18.2 million). This

component will have three subcomponents: (i) strengthening program management; (ii)

strengthening the capacity of the Department of Planning of the MOH; and (iii) strengthening of

monitoring and evaluation.

57. Subcomponent 1- Strengthening Program Management. This subcomponent will finance

consultants and operating costs for the following activities:

(i) Strengthening the staffing of the Central Coordinating Unit;

(ii) Strengthening the capacity of Provincial Departments of Health through the contracting

of two specialists (health service management and M&E) for each of the five provinces;

(iii) Supervision of provinces (per diem and transport);

(iv) Outreach activities by mobile teams (per diem and fuel)

(v) Participation in international conferences and training;

(vi) Coordinating meetings for implementation planning and monitoring;

(vii) Financial and procurement audits; and

(viii) Preparation of detailed provincial and municipal health plans.

58. Subcomponent 2 - Strengthening the Capacity of the Department of Planning of the MOH.

This subcomponent will finance consultants to support the preparation of: (i) a Medium-Term

Human Resources Development Plan; (ii) a Health Infrastructure Investment Plan and (iii) a

Medium-Term Expenditure Framework (MTEF).

59. Subcomponent 3 - Strengthening of Monitoring and Evaluation (M&E). This subcomponent

will finance goods, consultants, and training for the following activities:

(i) Strengthening the M&E capacity of the MOH in the use of the current HMIS;

(ii) Capacity building in data for decision-making at central, provincial, and municipal level;

(iii) Preparation and conducting of access and quality surveys;

(iv) Mid-term and final evaluations of the project; and

(v) Computers, training manuals, and stationery for M&E.

D. Lessons learned and reflected in the project design.

60. This review of experience draws lessons from Bank projects in Angola in health and other

sectors, and similar health projects in other African countries and elsewhere. It also draws from the

World Bank publication: ―Improving Effectiveness and Outcomes for the Poor: An IEG Evaluation

of World Bank Group Support for HNP Since 1997.‖ The main lessons are presented below.

61. Project design should adopt successful local interventions in the sector. With support from

HAMSET as well as from the Global Fund and the President‘s Malaria Initiative, the government

started reducing mortality and morbidity rates for malaria, through an IEC-based prevention

strategy using community workers and outreach by local and international NGOs. This project will

13

utilize the lessons learned from this approach to implement IEC programs targeting institutional

deliveries through the CHWs and outreach teams.

62. Experience in demand-side incentive programs. A number of demand-side subsidy programs

around the world have been successful in increasing demand for underutilized health services.

India‘s Universal Institutional Program introduced in 2006 provides monetary incentives to women

to deliver in a government hospital as well as a transport subsidy for her or the accompanying

community health worker. The program has not been evaluated yet, but early indications are that it

has resulted in a tremendous increase in institutional deliveries, although it has faced some

difficulties as it put pressure on the supply of services and their quality. Using these lessons, the

project will upgrade the facilities and train the personnel in year 1 before the voucher system is

initiated in year 2.

63. Linkages with the water sector are important. Adequate water and sanitation services are an

essential ingredient to supporting good health. For example, the Morocco Rural Water Supply and

Sanitation Project (1998-2003) showed a 24 percent reduction in diarrheal diseases in young

children between 1995 and 2000. The MHSS will benefit from and develop linkages with the

Bank-financed Angola Water Sector Institutional Development Project approved in July 2008.

64. Project design should be built on solid economic and sector work (ESW). Before designing

the MHSS, the Bank undertook two pieces of analytical work: (i) Capacity Assessment of The

Ministry of Health (2006); and (ii) Public Expenditure Review (PER) of the Health Sector

(2007)17

. Both reports were extensively discussed with the government and donors, and their

analysis and conclusions, particularly those of the second one, have been instrumental in the design

of the MHSS.

65. The Bank and governments need to focus more on monitoring and evaluation. During recent

years, the Bank has started to make significant efforts to ensure that clients frame objectives in

measurable terms, obtain baseline data, adhere to plans for routine monitoring, conduct periodic

surveys, and disseminate the results. It is important to avoid ambitious development objectives and

inappropriate performance indicators, and be realistic about what a project can achieve. Lessons

from ICRs show that it is important to: (i) follow a good result framework in project design and

M&E; and (ii) avoid using higher-level objectives, such as mortality reduction, as project

development objectives.

66. The government’s commitment and ownership are prerequisites for success. As stated

earlier, extensive analytical work and project preparation have been carried out with full MOH

involvement. The strong government support for strengthening the health system through the

implementation of the existing Revitalização municipal health systems strengthening approach

should also ensure the success of the project. Previous projects in Angola, including HAMSET,

have shown that when government leadership is strong, institutional changes and the sustainability

of investments are more guaranteed.

67. Flexible and simple design. The project adopts a simplified design with a limited geographic

scope rather than full national coverage, by prioritizing five provinces for activities. This will allow

17

A joint European Union – World Bank report

14

the MOH to build up institutional capacity before expanding at the national level. Also, the project

design makes the objectives of each component independent, measurable, and monitorable.

68. Intensive supervision will be required for this project given the country’s limited

institutional capacity. The project‘s supervision plan is presented in Annex 22.

E. Alternatives considered and reasons for rejection.

69. Why not HAMSET II? Through HAMSET, the Bank has been the first external financier to

help the government control HIV/AIDS, TB, and malaria. This has led the way to further funding

from the Global Fund and the U.S. President‘s Malaria Initiative, and increased financing for

HIV/AIDS control from the government itself. On the other hand, maternal and child health

indicators are appalling, justifying the strategic decision to give priority to investing in the

improvement of these health outcomes.

70. Angola is a large country with still low implementation capacity. Both the government and

the Bank considered that attempting a project on the national scale would be overly risky and

perhaps not feasible. By targeting only five provinces, the project design matches the country

capacity and reduces complexity, an important lesson from IEG‘s Evaluation of World Bank

Group Support for Health, Nutrition, and Population Since 1997

71. No project alternative. The ―no project‖ alternative is not desirable because child and

maternal mortality are very high in Angola, and malaria devastating. Without an operation that

supports an integrated service delivery model, Angola‘s chances of reaching the MDGs in 2015

would be slim.

III. IMPLEMENTATION

A. Partnership arrangements.

72. The partnership arrangements for project implementation will be with Total E&P Angola for

financing. The project will collaborate with UNICEF, WHO, and UNFPA on technical and

implementation issues. Total E&P Angola‘s financing of US$4.5 million will support training

under subcomponent 1a the rehabilitation and construction of 4 delivery rooms in health centers

and posts in Malange; and solar kits for maternal and child health care in component 4 (b)18

. All

other MHSS project components will be funded by the Bank (US$70.8 million).

73. Joint Project Implementation Reviews. A Steering Committee will monitor the progress

of the MHSS project. The Committee will be chaired by the Minister of Health or his designate. Its

members will be, inter alia, the Vice-Minister for Hospital Management, the Vice-Minister for

Public Health, the Director for Human Resources, the Director of Planning, the National Director

for Medical Equipment and Medicines, the Director for Public Health, and one representative of

Total E&P Angola.

74. Bi-annual Joint Project Implementation Reviews will be led by the MOH with the

participation of stakeholders and development partners. The Reviews will have three components:

(i) joint review of the past year‘s activities and of critical questions in a number of thematic areas;

18

To be procured from entities other than Total E&P Angola

15

(ii) a joint visit to a province to better understand the problems in the field and discuss with

stakeholders; and (iii) a plenary session to consolidate the field work and approve the plan of

activities for the following year.

B. Institutional and implementation arrangements.

75. Institutional arrangements are presented in Figure 2. The Ministry of Health will have the

overall responsibility for the implementation of the project. The National Department of Public

Health (DNSP) will be in charge of the day-to-day implementation of the project. In 2006, the

DNSP created the MHSS Central Coordinating Unit (CCU). The CCU is headed by a Coordinator

who reports to the National Director of Public Health, and will be strengthened by the addition of a

Deputy Coordinator, an M&E Specialist, an Infrastructure Specialist, a Training Specialist, a

Health Specialist, a Financial Management (FM) Specialist, and a Procurement Specialist, as well

as supporting staff.

76. The Financial Management and Procurement Specialists will be physically located within

the Central Project Coordinating Unit (located within the National Department of Public Health),

however that other specialists such as the Training Specialist, the Infrastructure Specialist, the

Monitoring and Evaluation Specialist could be physically located in other departments of the MOH

as this would allow other MOH staff to benefit from their experience, thus building capacity and

ensuring a better sustainability of the Project. Although all the above mentioned staff would work

in different offices, they will work as a team to coordinate Project implementation activities.

77. A Project Implementation Unit (the CCU) is justified because the Bank‘s Interim Strategy

Note for The Republic of Angola dated April 26, 2007 explicitly states that ―to reduce the risk of

poor governance to Bank projects, the Bank will take a ring-fenced approach until capacity in

government for sound fiduciary management can be built‖. In addition, the CCU will contribute to

building capacity of staff who will be fully integrated in the MOH after the end of the project.

78. At the provincial level, Provincial Health Directors are responsible for the implementation

of the MHSS. Their role is to coordinate program implementation in the municipalities that are part

of the province. To strengthen implementation capacity in each of the five provinces, the project

will contract a technical support team of two persons: (i) a public health systems specialist; and (ii)

an M&E Specialist.

79. The MOH will enter into subsidiary agreements with the five provinces whereby the

provinces will show their commitment to provide their share of human resources, drugs, supplies

etc. to ensure the good implementation of the project.

80. At the municipal level, the Municipal Health Officer‘s tasks are to: (i) prepare the MHSS

municipal operational plan; (ii) manage the municipal health teams; (iii) prepare a monthly plan of

visits to health units to monitor progress and provide implementation support to health staff and

mobile teams; and (iv) produce a monthly report documenting the maternal and child health

services provided in the municipality.

81. Training. While there is a large number of persons to be trained, this is feasible because: (i)

there are training institutes in each of the provinces and the overall training workload will be

divided into five; (ii) trainers from Luanda and Lubango will train the trainers in each of the

16

institutes; (iii) training materials and curriculums are available; (iv) there are enough supervisors

for the practical part of the training (e.g. for the midwives); and (v) there are clear responsibilities

in the CCU with a Training Specialist who will manage and coordinate the training program.

Details are provided in Annex 6.

82. The Infrastructure Specialist of the CCU will be responsible for managing the

implementation of civil works and equipment. TORs for the contracting of consultants will be the

responsibility of the Deputy Coordinator. The Health Care Waste Management Specialist, part of

the DNSP, will be in charge of implementing subcomponent 5. The pilot testing of demand-side

vouchers will be contracted to an NGO. Monitoring and Evaluation will be the responsibility of the

M&E Specialist who will work with the provincial and municipal staff, but the access and quality

surveys will be contracted out. Details are provided in Annex 6.

Figure 2: MHSS Institutional Arrangements

C. Monitoring and evaluation of outcomes and results.

83. Output indicators will be collected through the routine HMIS and during supervision visits.

However, since the HMIS has shortcomings in the quality, completeness and timeliness of data, the

project will also use annual rapid surveys to collect confirmatory data for outcome indicators. At

the same time, the project will strengthen provinces and municipalities in data collection and in the

use of data for decision-making (DDM).

Ministry of Health National Department of

Public Health

MHSS Central Coordinating Unit (CCU) Coordinator

Deputy Coordinator

M&E Specialist

Training Specialist

Infrastructure Specialist

FM Specialist

Procurement Specialist

Provincial Departments of Health Bengo, Malange, Lunda Norte, Moxico, and Uige

(Including Public Health Specialist and M&E Specialist supported by MHSS in each province)

Municipal Health Officers

Health Specialist

FM Officer Procurement Officer

Provincial Training Institutes

HCWM Specialist

17

84. Health Delivery Channel Household Survey (WHO Rapid KAP Survey). WHO and the MOH

have agreed on TORs for the first round of the survey. This survey will sample households from

target municipalities and provide information on knowledge, practices, coverage of key health

interventions, and reasons why mothers do not access services. After each annual survey, WHO

will conduct workshops to strengthen provinces‘ capacity to use data for planning.

85. Rapid Health Facility Assessment. The MHSS will support an annual rapid health facility

assessment focusing on obstetrical and emergency neonatal care services, and sick-child services

(IMCI). The survey will be contracted out to WHO. The latter will finalize the survey instruments,

carry out the surveys, and provide data analysis and reporting. This survey will be performed in

close collaboration with the Health Delivery Channel Household Survey, as the information they

provide is complementary.

86. Strengthening the HMIS. In theory, the HMIS is able to provide data on all of the key

indicators. However, at present, the information is either not easily available or is incomplete. The

project will help strengthen the M&E capacity of municipalities and provinces by: (i) developing a

training manual on DDM; (ii) training provincial M&E officers as DDM trainers; and (iii) helping

them to replicate the training for provincial directors and M&E officers. This will be the first step

in strengthening M&E capacity.

87. The second step includes support for quarterly reviews and planning sessions. At these

sessions, provincial M&E officers will host meetings for municipal directors and M&E officers

where the quarterly HMIS data are presented, together with other survey information that becomes

available during the period. The data will be presented, analyzed, and used to update municipal and

provincial work plans.

D. Sustainability.

88. Prospects for the project‘s sustainability are strong. First, sustainability efforts will focus on

demonstrating the feasibility of implementing the project cost-effectively in the five provinces.

Given the high level of poverty, the project focuses less on the financial sustainability of project

inputs through direct household contributions or other alternative local financing. Rather, the

project focuses on three critical ingredients of sustainability. First, on the supply side, the project

will promote institutional sustainability by showing that the basic package of services can be

delivered cost-effectively in the five provinces. To achieve this, health services will be

reconfigured so that they cater increasingly to community and outreach services.

89. Second, sustainability efforts will also be directed to achieving policy support at the national

level for the demonstrated improvements in health coverage and outcomes. This project is non-

threatening as it is based on an agreed-upon agenda, the government‘s Revitalização Program, and

is supported by evidence both through the modeling exercise conducted as part of the PER.

90. Third, the project will support demand-side household behavior change interventions. It will

promote positive change in household and community behavior in order to increase their demand

for health services. To this end, the acquisition of health knowledge will be promoted through IEC

activities and community involvement.

18

91. Fourth, the government will have the means to sustain and increase spending in the health

sector. Although GDP decreased slightly in 2009, economic growth will resume afterwards and

Angola‘s medium-term economic prospects are good. The Bank projects GDP to grow by around

6.5% per annum from 2010 to 2012. An analysis was made to assess the sustainability of

operational expenses after the project. These include the cost of outreach teams (per diem and

fuel), the increase in salaries of nurses and doctors who will have moved to a higher grade as a

result of training, maintenance of delivery rooms, staff houses, and vehicles, the cost of the CCU

including two additional staff in each province, and supervision and surveys. These would amount

to about US$5.5 million per year, which represents only 0.43 percent of the MOH budget, and is

easily sustainable.

92. By helping the MOH prepare a Health Infrastructure Investment Plan, a Medium-Term

Human Resources Development Plan, and a Medium-Term Expenditure Framework, the Bank will

help the government in the planning and scaling up of service delivery over the medium term, thus

making the proposed investment integrated into the MOH planning, which will facilitate

sustainability.

E. Critical risks and possible controversial aspects

Table 2: Risks

Risk Risk Mitigation Measure Risk

Rating19

Country Risk

Systemic corruption, governance

issues, and lack of transparency. In

the Transparency International‘s

Corruption Perception Index for

2009, Angola‘s score ranks 162th

out of 180 countries, compared to

147th in previous year.

The Bank is taking a number of measures: (i) the EMTA

project is helping to build the capacity of the public sector

in governance, contract enforcement, and property rights;

and (ii) the GAAP will enhance public disclosure and

compliance mechanisms, will help mitigate collusion and

fraud risks, and will improve institutional capacity to

manage the sector.

H

From Outputs to Objective

Decline in political commitment.

The MHSS does not introduce threatening policy changes

that could create resistance. It will, however, bring some

alterations in health service delivery at the local level, which

will require support from managers at the provincial and

central levels. Major stakeholders in the MOH at the central

and local levels will be regularly involved during project

implementation. Incentives to outreach health workers will

benefit the sector and will not induce controversy.

L

From Components to Outputs Insufficient management capacity at

the MOH central level leading to

delays in procurement and

disbursement of funds.

Staff with strong project management experience, will be

contracted by the MHSS Central Coordinating Unit. Given

that HAMSET will not have closed when the MHSS

becomes effective, the CCU procurement and financial

officers will be able to receive support from HAMSET‘s

international procurement and financial management

specialists. The CCU will also recruit a public health

specialist.

M

19

After mitigation

19

Lack of project implementation

capacity at the provincial and

municipal levels.

Training and supervision of provinces and municipalities by

the CCU (10 percent of project budget will be used for this

training).

S

Delays in training of additional

human resources required for scaling

up of health service delivery

While there are a large number of persons to be trained, this

is feasible because: (i) there are existing training institutes

in each province, therefore the overall training workload

will be divided into five; (ii) trainers from Luanda and

Lubango will train the trainers in each of the institutes; (iii)

training materials and curriculums are available; and (iv) a

Training Specialist in the CCU will manage and coordinate

the training program.

S

Implementation risks of demand-side

subsidies: (i) deviation of funds for

private gains; (ii) a program that

does not function well at the

beginning and loses credibility; and

(iii) program stimulates demand, but

supply cannot respond

Fund deviation risk will be mitigated by close cash flow

monitoring and control procedures, and audits focused on

potentially vulnerable areas. Credibility risk will be

mitigated by setting up clear institutional responsibilities, a

well-designed project cycle, clear rules for the selection of

beneficiaries, and a reliable management information

system. Excess demand risk will be addressed by increasing

the existing capacity for institutional delivery. The overall

risk will be mitigated by implementing the pilot in only two

municipalities.

S

Fiduciary problems, including

misuse of funds

Mechanisms built into the project design include: (i) prior

review of large contracts; (ii) random reviews of statements

of expenditures during implementation; (iii) financial

management reporting linking performance to financial

costs; (iv) random audits of small executing entities; and (v)

financial audits of all large executing agencies.

S

Overall Risk Rating S

H: High S: Substantial M: Moderate L: Low

F. Credit conditions and covenants

93. Conditions of effectiveness will be as follows:

(i) The Total E&P Co-financing Agreement has been executed and delivered and all

conditions precedent to its effectiveness or to the right of the Borrower to make

withdrawals under it (other than the effectiveness of the Financing Agreement) have

been fulfilled;

(ii) The MOH will have recruited qualified staff for the CCU, satisfactory to IDA,

including international specialists for financial and procurement management, a public

health specialist, and a training specialist with qualifications and experience, and

pursuant to terms of reference, satisfactory to IDA; and

(iii) The MOH has adopted an Operational Manual, including financial management and

accounting procedures annexes, in form and substance satisfactory to IDA.

20

94. Disbursement condition. The disbursement condition is as follows:

No disbursement will be made under component 2 (Piloting demand-side incentives to

encourage institutional deliveries) until no later than two years following the effective date: (i)

the Recipient will have adopted the Voucher Scheme Manual in a manner and substance

satisfactory to IDA; and (ii) the Recipient has issued an internal decree, satisfactory to IDA,

regulating the voucher system.

95. Other conditions will be as follows:

(i) The Recipient will implement the project in accordance with the Operational Manual

and any substantial change in the Manual would require prior IDA approval;

(ii) The Recipient will maintain the project management arrangements in form, substance,

resources, and with functions satisfactory to IDA;

(iii) The Recipient will conduct a mid-term review no later than December 31, 2012;

(iv) The Recipient will build houses for medical staff on Government land designated for

such purpose; the land acquisition and resettlement assessment will be documented; and

no resettlement will occur.

(v) The Recipient will cause the Project‘s external auditors to perform an audit of the

procurement for all goods, works, consultants‘ services, payments for grants under the

Voucher Scheme and Operating Costs required for the Project. Each audit will cover

two calendar years, commencing with the calendar year in which the first withdrawal

under the Project was made. The audit reports will be furnished to IDA not later than

forty-five days after the end of each period and include action plans to improve

performance and/correct shortcomings.

(vi) The Recipient shall ensure that under each yearly budget proposal to its legislature,

adequate arrangements are made by the Recipient to assume such portion of the costs

related to Recipient's in kind contribution, required to achieve the objectives of the

Project.

(vii) The Recipient shall, not later than three months following the effective date appoint the

Project‘s internal auditors under terms of reference, qualifications and experience

satisfactory to the Association.

(viii) The Recipient shall, not later than six months following the effective date appoint the

procurement auditors for the Project under terms of reference, qualifications and

experience satisfactory to the Association.

IV. APPRAISAL SUMMARY

A. Economic and financial analyses.

96. The justification for government involvement, cost-effectiveness of project interventions,

and the sustainability of the project are summarized below. A detailed analysis is presented in

Annex 19.

97. Justification for government involvement. Although Angola has an average per capita

income of US$740, relatively high for sub-Saharan Africa, 68 percent of the population lives

below the poverty line of $1.70 per day. Urban poverty is rising, mainly due to the influx of

21

displaced people into cities and the lack of job opportunities. Women‘s illiteracy is high (46%).

Government involvement is justifiable, given the project's focus on poor and remote provinces, the

overwhelming incidence of communicable diseases in these provinces, the absence of private

providers, and the need for the government to drive the health reform process and steward the

sector at the national and provincial levels. Thus, preventive and promotional health interventions

supported by the project will have significant externalities.

98. Cost-effectiveness of project interventions. The project design relies heavily on the analytic

work, conducted as part of the PER, which identified and costed out the packages of supply

interventions that could best reduce the burden of disease in the country. The results of this

modeling exercise are presented in Table 3.

Table 3: Impact on Under-Five and Maternal Mortality Reduction and Additional Cost Per

Capita of Five Health Service Delivery Steps in Angola Reduction

in IMR

Reduction

in U5MR

Reduction

in MMR

Cost (US$ per

capita per year)

Step 1: Undertake community-based social

mobilization and behavioral interventions

29% 39% 1% 2.51

Step 2: Scale up population-based outreach

services

9% 8% 9% 1.05

Step 3: Expand primary health care 17% 23% 1% 3.05

Step 4: Strengthen the first level referral care 2% 2% 3% 0.97

Step 5: Improve the second level referral care 1% 1% 3% 0.89

All five steps 51% 62% 17% 8.48

B. Technical.

99. The MHSS supports a package of interventions aimed principally at reducing child and

maternal mortality in the five selected provinces. Child care and maternal care key interventions

are supported by a body of evidence, notably in a series of Lancet20

articles published in 2003,

2006, and 2008 as well as Cochrane collaboration reviews21

on interventions to reduce maternal

mortality.

C. Fiduciary.

100. Financial management. The Ministry of Health will have the overall responsibility for the

management of the project. The National Department of Public Health (DNSP will be responsible

for the day-to-day management of the project through its Central Coordinating Unit (CCU). The

CCU staff, including financial management, contract management, procurement, monitoring and

evaluation, will work closely with the HAMSET Project Coordinating Unit, and will benefit from

their experience, including from HAMSET‘s internationally contracted Procurement and Financial

Management (FM) Specialists.

20

The Lancet, founded in 1823, is one of the oldest peer-reviewed medical journals in the world, published weekly in

England. The Lancet is considered to be one of the core general medical journals. 21

The Cochrane Collaboration, founded in 1993, was developed in response to Archie Cochrane's call for up-to-date,

systematic reviews of all relevant randomized controlled trials of health care. A group of over 6,000 specialists in health

care review biomedical trials and results of other research.

http://en.wikipedia.org/wiki/1823

http://en.wikipedia.org/wiki/Peer-reviewed

http://en.wikipedia.org/wiki/Medical_journal

http://en.wikipedia.org/wiki/Archie_Cochrane

http://en.wikipedia.org/wiki/Systematic_review

http://en.wikipedia.org/wiki/Randomized_controlled_trial

22

101. The project‘s financial management arrangements were reviewed in accordance with the FM

Practices Manual issued by the FM Board on November 3, 2005. The review concluded that the

overall risk rating for the project is substantial. Several mitigating measures are proposed, and are

summarized in an FM action plan that sets up the necessary arrangements for a smooth

implementation of the project. After the proposed measures, the residual risk is reduced to

moderate. Details are provided in Annex 7.

102. Procurement. The last Country Procurement Assessment Review (CPAR) for Angola was

conducted in April 2002. In March 2004 the government produced its own procurement reform

document, which is based on the CPAR, and is now supported by the Economic Management

Technical Assistance project (EMTA). The reform is still in the early stage of implementation,

with the drafting of the new procurement code continuing.

103. As mentioned above, the MOH has already established a Central Coordinating Unit (CCU)

reporting to the Director of Public Health. The CCU will be staffed with an international

procurement specialist and local procurement staff who have developed procurement experience

with the HAMSET project. The overall risk for procurement is rated moderate.

104. Procurement for the project will be carried out in accordance with the World Bank's

Procurement Guidelines and the provisions stipulated in the Legal Agreement. After the new

procurement code is ready, government procedures may be acceptable under National Competitive

Bidding if found satisfactory by IDA. Details are provided in Annex 8.

D. Social.

105. Local socio-cultural behavioral aspects that influence health and illness are important factors

in the effective implementation and outcomes of health interventions. A social assessment was

conducted to better understand these factors so as to improve the project design, implementation

and sustainability. The main social development issues reviewed were: (i) community mobilization

and participation; (ii) social diversity and gender; and (iii) socio-cultural barriers to services. The

assessment was conducted through meetings with focus groups in one urban and one rural area

each in the provinces of Malange and Bengo. The main results of the assessment and how the

analysis will be used are presented below.

Table 4: Observations from Social Assessment

Observations from Social Assessment Project measures to address them

In rural areas, people tend not to take many initiatives

and expect support from the government

In the initial selection process of CHWs,

traditional leaders will be encouraged to select

candidates recognized for taking some initiative.

Men do not see themselves as responsible for disease

prevention, such as using bed nets, using boiled water

or removing trash.

The training curriculum of CHWs will pay

particular attention to this aspect. Training of

CHWs will not be limited to health matters, but

will include inter-personal communications and

leadership.

23

The population complained about how poorly they are

received when they go to a health facility. This

discourages them from seeking care, resulting in

some women preferring to deliver at home.

The training program of health workers and

facility administrators will emphasize the

importance of relationships with patients. A

module will stress the importance of respect for

the community and the need to consider the

rural population as clients even if their health

knowledge is limited.

Many persons complained about user fees charged by

health workers.

As part of the GAAP, the MOH will start a

program to place posters in health facilities

informing the public that health services are free

and that no payment should be made to health

workers.

Women complained about their excessive number of

pregnancies.

The project will put emphasis on family

planning.

Many women do not go to a hospital if they have to

deliver at night.

CHWs will work with communities to identify

persons who can accompany women to the

hospital.

E. Environment.

106. The project has been classified as ―B‖ for environmental screening purposes. An assessment

of current health care waste management and disposal systems was undertaken. The detailed

findings are presented in Annex 10 and are summarized below.

107. When the HAMSET project was appraised in 2004, practices in health care waste handling,

storage and disposal raised environmental and social concerns. There were no national

environmental and social policies and regulations for the safe handling, storage and disposal of

health care waste. A thorough assessment was conducted, and under HAMSET, the government

developed a national Health Care Waste Management Plan. HAMSET helped the government start

implementing the plan, including capacity building, mitigation measures and their timely

monitoring. Financing for priority actions of the Plan, up to US$200,000 were included in the

HAMSET project.

108. The MHSS project adheres to the key objectives and activities of the National Health Care

Waste Management Strategy. The project will apply the lessons learned from the implementation

of the HCWM Plan during the HAMSET project to foster a sound management of health care

waste at the national level. The project will emphasize the implementation of this action plan in the

five targeted provinces.

109. This project will build on the progress already achieved under HAMSET to help the

government improve healthcare waste disposal in the project area and throughout the country. The

HCWM Plan was updated in March 2009, and revised to reflect the current realities faced in the

targeted provinces. The Medical Waste Management Plan (MWMP) and The Environmental and

Social Management Framework (ESMF) were published by the Bank in Infoshop on November

25, 2009, and on the MOH website on April 21, 2010.

110. The HCWM Plan will be applied through the life of the MHSS project. It involves intensive

training and capacity building activities, review of legal and institutional framework, the provision

of protective clothing and biosafety kits, basic equipment, technical support, and monitoring.

24

Financing of US$995,000 for activities of the HCWM Plan is included under Subcomponent 3.

This is over four times the budget allocated under HAMSET.

111. More progress is required in health care waste management in Angola. Despite the

inadequate picture of current health care waste management practices and context, there is

reasonably fertile ground for success for the health care waste management plan. The commitment

of the central, provincial and local government to the National Health Care Waste Management

strategy is encouraging. A new centralized incineration center for infectious health care waste has

been established. The government is also contracting three new private waste management service

providers to complement the activities of the existing provider, URBANA 2000, and broaden the

coverage of the waste management and disposal activities in a safe and timely fashion. Finally, a

number of NGOs have been playing a crucial role in public awareness and in behavior change

activities targeted at medical staff, cleaning personnel and the general public.

112. The project will build houses for medical staff in 18 municipalities. They will be built on

Government land designated for such purpose. The land acquisition and resettlement assessment

will be documented, and the project team will verify that no resettlement will occur.

113. In discussions with Government officials, the team has been assured that all houses would

be either built within hospital grounds or in Government land reserves designated for such purpose.

The team provided the government with translated copies of the Land Acquisition Assessment

Forms and asked to have them completed and signed to document the legal description of the land,

location, occupation, use. The ESMF includes copies of signed forms for each site, verifying that

no resettlement will occur.

114. To prevent environmental impacts due to the construction or rehabilitation of houses for

medical staff in health centers and posts, the ESMF addresses the General Environmental

Management issues associated with civil works and include an annex with Detailed Environmental

Management Conditions for Construction Contracts.

F. Safeguard policies.

Safeguard Policies Triggered by the Project Yes No

Environmental Assessment (OP/BP 4.01) [x] [ ]

Natural Habitats (OP/BP 4.04) [ ] [x]

Pest Management (OP 4.09) [ ] [x]

Physical Cultural Resources (OP/BP 4.11) [ ] [x]

Involuntary Resettlement (OP/BP 4.12) [ ] [x]

Indigenous Peoples (OP/BP 4.10) [ ] [x]

Forests (OP/BP 4.36) [ ] [x]

Safety of Dams (OP/BP 4.37) [ ] [x]

Projects in Disputed Areas (OP/BP 7.60)* [ ] [x]

Projects on International Waterways (OP/BP 7.50) [ ] [x]

* By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the

disputed areas

http://www.worldbank.org/environmentalassessment



















25

G. Policy Exceptions and Readiness.

115. The project does not require exceptions from Bank policies. It meets the Regional criteria

for readiness for implementation. The government is progressing well in meeting the three

conditions of effectiveness. Two of them are well advanced; (i) the draft Operational Manual is

ready; and (ii) the co-financing agreement with Total E&P Angola is currently being prepared by

IDA. As regards the third condition which is the recruitment of staff for the Central Coordinating

Unit, the government has prepared the TORs for these positions and started to prepare short lists of

candidates.

26

Annex 1: Country and Sector Background

ANGOLA: Municipal Health Service Strengthening Project (MHSS)

116. After a lengthy struggle between Portugal and the Angolan nationalist movement, Angola

gained independence in 1975. A civil war, lasting 27 years, broke out after independence over

power sharing options between the nationalist groups. The war severely damaged the country‘s

infrastructure, leaving its public administration network and social fabric in tatters. Angola has the

highest concentration of landmines globally with 6-7 million mines over 35 percent of the country.

The ruined infrastructure, broken public and social network, and the presence of landmines make

public service delivery difficult. Inequalities persist and are widening. Angola has an average per

capita income of US$740, relatively high for sub-Saharan Africa, but 68 percent of the population

lives below the poverty line of $1.70/day. Urban poverty is rising, mainly due to the influx of

displaced people and the lack of job opportunities. Women‘s illiteracy (46% nationally but 66% for

rural women) is far higher than that of men (16%). Most women only have access to unskilled

jobs, mainly in the informal sector (where two-thirds of the jobs are done by women).

117. Angola is a potentially rich country, blessed with rich deposits of oil and diamonds. It is the

second largest oil producer in sub-Saharan Africa, with rising oil production, which accounts for

almost half of the GDP and about 75 percent of government revenue. Angola is also the world‘s

fourth largest producer of rough diamonds, which represent 95 percent of non-oil exports.

Angola‘s economic outlook is promising, although it has been affected in 2009 by the global

economic crisis, GDP is expected to grow by 6.5 percent in real terms over the period 2010-2012.

Figure 3: Trends in under-5 mortality rate

118. Given these positive trends, Angola has a

great opportunity to make a difference in health

outcomes. The government recognizes the important

role of the health sector in economic growth. The

budget for the health sector has significantly

increased over the last five years, and even doubled

between 2005 and 2006. However, Angola faces

considerable challenges in addressing its current

health outcomes.

119. At 260 deaths per 1,000 live births, the child

mortality rate is the second worst in the world after Sierra Leone (270). As shown on the chart,

Angola has little chance of reaching its Millennium Development Goal (MDG) target with its

existing health services. Maternal mortality, estimated at 1,750 per 100,000 live births, is also

among the highest in the world. The prolonged war resulted in 65 % of health facilities being

destroyed, while many health staff took refuge in Luanda where 70% of doctors, 30% of nurses,

and 45% of other health staff have remained. The distribution problem has worsened the overall

shortage of health staff in remote provinces, whereas by contrast there is overstaffing in Luanda.

As a result, the coverage for basic health services is low, and the majority of the population is not

protected by basic and effective health services.

27

120. Even though the government is currently rehabilitating the health network, many facilities

particularly in the bottom tier (health centers and health posts) are still not functional, mainly due

to a damaged infrastructure that needs to be rebuilt or repaired, and the lack of staff and key inputs.

In 2002, 11 percent of hospitals, 10 percent of health centers, and 46 percent of health posts were

not operational, and yet these are required to deliver primary health care to the population. Angola

has 0.9 doctor per 10,000 inhabitants (or 8 doctors per 100,000 people) compared to 2.4 in

Botswana (2002), 1.3 in Zimbabwe (2003), and 0.2 in Mozambique (2000). People still have to

walk more than an hour to reach a health facility. The government relies on service delivery in

fixed facilities (hospitals and health centers), whereas experience from other countries shows that

service delivery should be complemented by outreach and community services that are highly cost-

effective.

121. Epidemiological profile. Angola has not gone through the epidemiological transition yet and

has a young growing population estimated at 18 million. There is a high prevalence of

communicable diseases and child and maternal mortality. Malaria, tuberculosis, diarrhea, and

HIV/AIDS are among the most serious diseases, which have affected the economic recovery and

quality of life. With an estimated 6 million cases per year, malaria is the principal cause of

mortality (of which 40 percent of perinatal22

and 25 percent of maternal mortality) and morbidity.

Diarrhea prevalence is 25 percent among the under-5 year olds (MICS II), but only 7 percent of

these cases were treated with rehydration fluids and continued feeding.

122. TB is one of the common reasons for visits to health facilities. Recent estimates indicate that

tuberculosis prevalence is increasing with around 7,000 new cases diagnosed every year. The

overall HIV prevalence rate is estimated at 2.5% (MOH), which is not very high when compared

with its neighbors. There is much variation between provinces, with a minimum of 0.8 percent in

the central province of Bié and a maximum of 11 percent in southern province of Cunene that

borders Namibia. Surveys of sex workers demonstrated a rapid increase in prevalence from 19

percent in 1999 to 32.8 percent in 2001. During the last five years there have been outbreaks of

Marburg disease, meningitis and cholera in specific areas that put an added burden on the already

weakened health system.

123. Angola compares unfavorably with other Sub-Saharan African countries, which themselves

have significantly higher rates compared to the rest of the world, in key health outcomes.

Table 5: Key health outcome indicators

Indicator Angola

Sub-Saharan

Africa Average

Life expectancy at birth (years - 2003) 40 49

Fertility rate (2002) 7.0 5.0

Infant mortality rate (per 1000 live births - 2000) 154 92

Under-five mortality rate (per 100,000 live births -

2000) 260 171

Maternal mortality ratio (estimates) 1,700 914

Contraceptive prevalence/100,000 (2003) 6.0 22.9

GDP/Capita US$ 975 1,073 Source: UNICEF MICS 2001 and World Development Indicator 2006

22

Deaths occurring during late pregnancy (at 22 completed weeks gestation and over), during childbirth and up to seven

completed days of life

http://en.wikipedia.org/wiki/Childbirth

28

124. Child (under-5) mortality is mainly caused by malaria (23%), acute diarrheal diseases

(18%), acute respiratory infections (15%), and premature birth (7%), which account for about 60

percent of child deaths23

. These can be easily prevented or treated at the primary health care level,

and through healthy practices and care at the household level. Regional differences in child

mortality are salient in Angola, with the west, central and capital regions showing the highest

under-5 mortality rates. These regions also possess the highest population concentration, which

indicates that a large share of child deaths occurs in these regions. Child malnutrition is alarmingly

high and comparable to Afghanistan and Southern Sudan. According to the 2001 MICS, 45 percent

of children are malnourished and underweight. Angola has a high level of stunting and wasting

which will make children vulnerable to diseases and health problems, and can have enormous

social and economic implications in the future.

125. The main causes of maternal mortality are malaria, hemorrhage, eclampsia, abortion

complications, and prolonged labor, and one in seven pregnant women die from avoidable reasons.

Only 25% of births are assisted by skilled staff; complications occur in 15% of all pregnancies.

Many of these causes are directly associated to poverty: delays in seeking care, lack of rapid access

to transport, and insufficient reproductive health services. Yet, with emergency obstetric care in

health facilities, skilled staff, proper surgical equipment, a safe blood supply and sufficient drugs,

maternal mortality can be greatly reduced.

126. Angola also has poor health service coverage, except for vaccination coverage for polio

(63%24 compared to 46% for Africa

25), deliveries in health facilities (45% compared to 39%), and

ante-natal consultations (66% of pregnant women attend one or more ante-natal consultations). A

2002 Management Sciences for Health (MSH) survey, covering only 3 municipalities in Luanda

province, found that only 17% of women of reproductive age use any method of contraception.

Combined with the data on attendance at ante-natal consultations and deliveries attended by trained

health personnel, services related to pregnant women still lag far behind the rest of the continent.

127. If Angola can use this knowledge and spend money efficiently on the right interventions, the

health status of the population can be improved in a relatively short time. Relative health

expenditures have been stable at 4-5 percent of GDP since 2001, but increased in absolute terms,

from US$213 million in 2002 to US$447 million in 200526

. In 2006, the health budget was US$1

billion27

representing 3.4 percent of GDP and US$71 per capita, substantially above the majority of

African countries and above the US$37 basic health package calculated by the Commission on

Macroeconomics and Health.

128. This spending is not having the expected impact on health outcomes, principally because of

low coverage, and the poor targeting and quality of services28

. Angola continues to have poor

health outcomes compared to other Southern Africa Development Community (SADC) countries

that spend less per capita. Zimbabwe spends less than Angola on health (US$14 per capita), but has

23

Ministry of Health -Angola. Studies, Planning and Statistics Office. Deaths in Luanda cemeteries.2002-2003 24

MICS 2001 survey only covered areas accessible during the war. 25

State of the World‘s Children, UNICEF 2002. 26

Estrategia de Combate a Pobreza (ECP, Angola‘s PRSP) and SIGFE; numbers for 2006 are budgeted numbers. 27

The exchange rate used for the proposed 2006 budget was of 94.2 kwanzas per US dollar. 28

Detailed analysis of issues and financing is available in ―Angola – Public Expenditure in the Health Sector‖ by the

European Union (EU) and the World Bank (2007).

29

a lower under-5 mortality rate with 129 deaths per 1,000 live births. South Africa spends US$114

per capita and has a maternal mortality ratio of 67 per every 100,000 live births, compared with

1,700 deaths per 100,000 live births in Angola29

.

129. The main donors are the European Union (EU), the Global Fund, the U.S. President‘s

Malaria Initiative (PMI), and the Bank, which together provide about US$75-80 million annually.

China has also been financing the rehabilitation of health facilities. With donor support, the

government has made commendable efforts to control the HIV/AIDS epidemic and has been

successful so far, with prevalence remaining at 2.5 percent. It is also scaling up its malaria control

efforts, notably through the distribution of bed nets in all provinces and the replacement of

chloroquine for malaria treatment by artemisin-based combination therapy (ACT). This will

contribute to child and maternal mortality reduction. Currently, efforts to rebuild health facilities,

from municipal hospitals to health centers, are being made in all provinces. It is expected that the

health infrastructure being built will improve the population‘s access to essential health services.

130. Support of the government health strategy. The government health strategy is presented in a

number of key documents: (i) the Government Program 2009-2012 (with a section on health); (ii)

the Health Sector Development Plan (currently being updated); (iii) the Municipal Health Service

Strengthening (MHSS) Plan30

; and, (iv) the Investment Plan for the Accelerated Reduction of

Maternal and Child Mortality (2007-2013) in Angola. These documents provide a general direction

in which the health sector should be heading. However, they usually do not link expected outcomes

with effective and efficient spending and do not include detailed implementation arrangements. As

a result, resources are not being used optimally and better health status has not been achieved.

131. The government developed an Investment Plan for Accelerated Child Survival and

Development to revitalize the country‘s primary health services and help achieve the health-related

MDGs. This investment plan will cover five of the country‘s 18 provinces and reach 33% of the

Angolan child population in the first phase (2007-2009) and aims to cover the whole country by its

completion. It is designed to save an estimated 58,000 children and 3,000 mothers‘ lives every

year. The proposed project will support this effort, in close collaboration with UNICEF.

132. The Strategic Plan for the Accelerated Reduction of Maternal and Child Mortality (2004-

2008) prioritized an essential package of interventions as its means to reduce child and maternal

mortality. The package is organized by service delivery mode: (i) primary health services; (ii)

mobile and advance health teams; and (iii) community health agents. The interventions included in

the package are proven cost-effective services with high impact on child and maternal mortality.

They are very much in line with the international best-buy list of interventions.

133. The donor community provides help in three different ways:

(i) Funds for vertical programs for the control of specific diseases such as malaria and

HIV/AIDS (including the Bank HAMSET project for US$21 million). There has been

growing support for more integrated approaches.

(ii) Institutional development and strengthening of implementation capacity. This is

provided to the MOH and provincial governments through technical assistance and

29

Health indicators in Angola are not reliable and, apart from the 2001 UNICEF MICS, there has been no adequate

health survey conducted after the war. 30

Revitalização dos Serviços Municipais de Saúde

30

training to help design policies and implementation strategies. The Bank supported

analytical work: (i) ―Capacity Assessment of the Ministry of Health (2006)‖; and (ii)

jointly with the EU, ―Public Expenditure in the Health Sector (2007).‖

(iii) Direct provision of services, mostly in remote areas, with donor funds channelled mainly

through NGOs. Service provision tends to be coordinated with municipal and provincial

authorities, but less so with the MOH.

134. The MOH is also in the process of increasing the supply and quality of basic health services

through the MHSS Program. This program aims to cover 79 percent of the total population, i.e.

about 14.8 million31

. It will cover 80 municipalities selected in function of: (i) population; (ii)

health status: (iii) accessibility, including low risk of mines; (iv) availability of infrastructure; (v)

inclusion in the decentralization program of the Ministry of Territorial Administration (to the

extent possible); (vi) availability of staff, drugs, and supplies; and (vii) presence of UNICEF and

WHO. The objectives of the MHSS are to improve the supply and quality of health services,

increase access, and thus equity.

135. The key elements of the MHSS Program are: (i) planning the supply of health services at the

municipal level in function of the needs of the population in the catchment area of the

municipality; (ii) developing an integrated network of health services consisting of fixed-based

facilities, outreach, and community health services; (iii) providing adequate resources for staffing,

equipment, and drugs; and (iv) strengthening the management of health services.

136. In 2006, the MOH started to gradually implement the MHSS with support from the EU,

UNICEF, WHO, and UNFPA in 19 municipalities located in four provinces: Huila, Bié, Cunene,

and Luanda. This allowed the MOH to test its new management and planning instruments and

learn key lessons that will be useful to expand the Program throughout the country. The MOH is

attempting to reverse the inequitable distribution of health personnel and outcomes through the

MHSS, notably by creating incentives for the settlement of specific cadres in the peripheral and

disadvantaged areas.

137. To expand the geographic coverage of the MHSS, the government has asked for support

from the World Bank and Total E&P Angola in the provinces of Bengo, Malange, Lunda Norte,

Moxico, and Uige. The total population of the selected municipalities in these five provinces is 1.9

million. Because of difficulties of access that cannot be solved in the near term, the project would

effectively cover a population of 1.5 million.

31

Based on a population estimate of 18,685,639, used by the DNSP of the MOH

31

138. Selected health indicators for the provinces are presented in Table 6 below.

Table 6: Key health indicators for the MHSS provinces

Bengo Malanje Lunda

Norte

Moxico Uige Angola



% prevalence of ARI32

18.3 4.8 1.7 4.8 3.9 7.0


% women receiving ANC33

80.1 67.7 67.7 71.4 67.7 79.8


139. The health system relies heavily on vertical arrangements for the delivery of some key

services. The MOH national departments are organized by diseases and supported vertically by

donors, which has created parallel management, logistics and information systems that are

generally not integrated. It is important to recognize that successes have been achieved through the

vertical arrangements. For example, the immunization program reached a relatively high coverage

level in a short time. The HIV/AIDS, TB, and malaria programs have been able to expand the

coverage of prevention and treatment services.

140. The experience of the Revitalização program. In 2006, the MOH started to implement the

Revitalização program in 19 municipalities located in five provinces: Huila, Bié, Cunene, Luanda,

and Moxico. The objectives of the Revitalização program are to improve the supply and quality of

health services, increase access, and thus equity. The key elements of the Program are: (i) planning

the supply of health services at the municipal level in function of the needs of the population in the

catchment area of the municipality; (ii) developing an integrated network of health services

consisting of fixed-based facilities, outreach, and community health services; (iii) providing

adequate resources for staffing, equipment, and drugs; and (iv) strengthening the management of

health services.

141. The key results of this program are as follows:

(i) The 5 provinces and 16 municipalities have prepared health maps, operational plans,

budgets, and received training in the use of these instruments. The training experience

went well and similar training will be provided in the provinces supported by the project;

(ii) The MOH has started to develop an HMIS, but results are limited. Much more work

needs to be done to develop the instruments and train staff in recording the data and

using it for decision-making;

(iii) The MOH has started to develop a community health workers (CHWs) program: 1671

community health workers were trained in Huila and 948 in Luanda. This experience has

allowed determining that CHWs should be contracted by municipalities, and not by the

MOH (because eventually their functions will be broadened to also cover other sectors

such as agriculture, nutrition, and sanitation). Their package of services, originally

32

ARI = Acute Respiratory Infection 33

ANC = Ante-Natal Care

32

limited to immunization has been broadened to include basic maternal and child

prevention activities, and the control of malaria, TB, and HIV/AIDS. They are expected

to visit 300 families per month and are paid on the basis of a report showing the tasks

they have performed. They mobilize communities and prepare them for outreach visits.

(iv) The outreach program has been initiated: 130 outreach teams were created and provided

with 117 motorcycles and 17 vehicles, and their routes of visits were planned. The

objective is to bring health services to populations who are too far to access health

facilities. They also provide an integrated package of health services and supervise the

CHWs.

33

Annex 2: Major Related Projects Financed by the Bank and other Agencies


Table 7: Major related projects financed by the Bank

Sector

Project

Latest Supervision Ratings

Implementation Progress

Development Objectives

HIV/AIDS,

Malaria, and

TB

HIV/AIDS, Malaria, and

Tuberculosis Control project

(HAMSET) (US$21 million)

MS S

Rehabilitation

of health

sector

Health component of Emergency

Multisector Rehabilitation Program

(EMRP) (US$8 million)

S S

Table 8: Organizations Present in the Five Provinces

Province/Municipality Name of Organization Area of Interest

Bengo Centro de Investigação em

Saúde (CISA)-IPAD and

F.C. Gulbenkian

Training of laboratory

technicians and support of

internships for medical

students. The partnership of

Gulbenkian with the Provincial

Institute is likely to improve

the quality of teaching.

Catholic Church -

St.Lucas Hospital

Training of Polish MDs. Could

support the training of Angolan

General Physicians

Lunda Norte Chemonics-USAID Provide in-service training and

TA to the Provincial Health

department in MCH.

Complements MHSS project.

Malange UNICEF Maternal and child health

OMS Malaria

ADRA (Associação para o

Desenvolvimento Rural de

Angola)

HIV/AIDS prevention

CONSAUDE In 2009, started training in

IMCI and malaria case

management. The training

program of MHSS takes this

34

into consideration to avoid

overlap.

Moxico UNICEF Revitalização

Uige

Uige (capital) CUAMM (Italy) Support to DPS in TB and

leprosy control. Potential

partnership with MHSS given

their experience in MCH and

management of health services.

ADB (African

Development Bank)

Provided training to about 3

doctors and a limited number

of nurses. Infrastructure

construction and rehabilitation

included in the ADB project

(but financing taken over by

the MOH). It complements the

MHSS.

Negage Catholic Church (Caritas) Provides health services in a

limited number of its own

facilities, complementing the

provincial health network

provincial health network

Rede HIV HIV prevention

35

Annex 3: Results Framework and Monitoring


Table 9: Project Development Objectives and Outcome Indicators

Project Development

Objectives Project Outcome Indicators Use of Project Outcome

Information Improve the population‘s

access to and quality of

maternal and child

healthcare services34

.

- Institutional deliveries (%) Lack of progress will result in

recommended modifications to

sector strategy and/or analysis to

understand relationship between

the implementation of the strategy

and the outcomes.

- Children 0-1 year immunized with

pentavalent vaccine 3rd

dose (%)

- Children immunized (number) CORE35

- Children receiving a dose of Vitamin A

(number) CORE

- Pregnant women receiving antenatal care

during a visit to a health provider

(number) CORE

- Direct Project Beneficiaries (number) of

which female (%) CORE

- People with access to a basic package of

health, nutrition and population services

(number) CORE

Intermediate Results

Intermediary Results Indicator Use of Results Monitoring

Component 1 Improved availability of

infrastructure, trained

personnel and equipment in

targeted delivery rooms

- Health facilities constructed, renovated

and/or equipped (number) CORE

- Delivery rooms built (number)

Progress will be assessed by

government and partners at the

Annual Reviews (based on most

recently available data). Lack of anticipated progress will

result in analysis of obstacles to

implementation and

reconsideration of assumed

linkages between inputs/processes

and outcomes.

- Delivery rooms in designated health

centers with necessary trained personnel,

equipment, supplies and medicines to

provide 24-hour emergency obstetrical

and neonatal care (%)

Improved monitoring of

health facilities - Health facilities receiving at least 2

supervision visits per year using

standardized checklists (%)

Improved planning capacity

at the municipal and

provincial level

- MHSS municipalities that have an annual

municipal plan (number)

- Provinces that have an investment plan

(number)

Improved conditions for

and knowledge of health

personnel

- Staff houses built (number) - Health personnel receiving training

(number) CORE - CHWs trained (number)

- General nurses trained in EmONC

(number)

34

Many of these indicators will cover the five provinces of Bengo, Lunda Norte, Malange, Moxico and Uíge where the

project will be implemented. 35

CORE = IDA 15 Indicators

36

- Nurse midwives who received pre-

service training (number)

- Nurses trained in IMCI (number)

Intermediate Results

Intermediary Results Indicators Use of Results Monitoring

Increased outreach to

targeted areas - Ambulances and 4x4 station wagons

purchased (number)

- Programmed communities receiving at

least 3 outreach visits per year (%)

- Motorcycles purchased for outreach

teams (number)

- Municipalities that have implemented

80% of municipal outreach plans

(number)

Component 2 Increased demand for basic

and emergency obstetrical

and comprehensive

neonatal care at municipal

level

- Women receiving vouchers (number) Progress will be assessed as part

of the pilot and will inform the

decision to adjust and scale up the

program.

- Women that deliver in a health facility

that redeem vouchers (number)

- Mothers satisfied with transportation and

direct vouchers (%)

- Municipalities with voucher pilot

completed (number)

Component 3 Strengthen the managerial,

planning and M&E capacity

of the MOH and

Municipalities

- Municipal Annual Health Reports

Received on time (%) Progress will be assessed by

government and partners at the

Annual Reviews (based on most

recently available data). Lack of anticipated progress will

result in analysis of obstacles to

implementation and

reconsideration of assumed

linkages between

inputs/processes and outcomes.

- Health professionals trained in health

system management (number)

- MHSS municipalities with operational

plans (number)

Table 10: Monitoring Framework

Target Values Data collection and reporting

Outcome Indicators Baseline

(2009)

Year 1 Year 2 Year 3 Year 4 Year 5 Frequency

of

reporting

Data

collection

instruments

Responsibility

for data

collection

1. Percentage of institutional

deliveries 41

36 50% 52% 55% 57% 60% Annual Annual

Report MOH

2. Percentage of children 0-1

year immunized with Penta

vaccine 3rd

dose.

27 29 31 33 35 38 Annual KAP Survey

MOH

3. Children immunized37

(number) CORE 34,000 42,000 49,000 56,000 61,000 64,000 Annual Annual

Report MOH

4. Pregnant women receiving

antenatal care during a visit

to a health provider

(number) CORE 81,000 86,000 93,000 98,000 103,000 109,000 Annual

Annual

Report MOH

5. Direct Project Beneficiaries

(number) 38

of which female

(%) CORE 0

(70%)

128,300

(67%)

270,300

(66%)

424,300

(64%)

588,300

(63%)

762,672

(63%) Annual

Annual

Report MOH

36

IBEP. Preliminary results, 37

Estimate based on the coverage of fully immunized children (according to information provided by the mother and health card) of 29%, found in the IBEP report

(preliminary results). It is assumed that this percentage should reach at least 50% by the end of the project. 38

The total number of beneficiaries is equal to the number of children immunized and women receiving Ante-natal care. The number of institutional deliveries was

not taken into account because of the risk of double counting and the fact that the M&E system cannot track the overlap. Also the % of female beneficiaries goes

down because the number of children fully immunized increases at a faster rate than that of the deliveries according to our projections. Also no addition of children

immunized to estimate the indirect benefit on women was done.

38

6. People with access to a39

basic package of health,

nutrition and population

services (number) CORE

N/A

1

visit/person

/year

Annual MOH

Component 1 – Improvement in Service Delivery

7. Health facilities

constructed,

renovated and/or

equipped (number)

CORE - delivery rooms

built40

0 0 12 24 36 36 Annual Supervision

visits MOH

(DNSP)

8. Delivery rooms in

designated health

centers with all

necessary trained

personnel,

equipment,

supplies and

medicines to

provide 24-hour

emergency

obstetrical and

neonatal care (%)

0 0 50% 60% 70% 90% Annual Supervision

visits MOH

(DNSP)

9. Health facilities

receiving at least 2

supervision visits

per year using

0 20% 30% 40% 55% 70% Annual Supervision

visits MOH

(DNSP)

39

It is proposed to use number of outpatient visits per inhabitant as a proxy of access to basic HNP services 40

In Angola the health infrastructure has been severely damaged during the war. The number and types of health facilities is not fully known. A mapping exercise

will soon take place and will help establish a baseline in 1-2 years.

39

standardized

checklists (%)

10. MHSS

municipalities that

have an annual

municipal plan

(number)


visits MOH

(DNSP)

11. Provinces that have

an investment plan

(number)


visits MOH

(DNSP)

12. Staff houses built

(number)


visits MOH

(DNSP)

13. Health personnel

receiving training

(number) CORE


visits MOH

(DNSP)

- CHWs trained

(number) 0 0 500 1080 1080 1080 Annual Supervision

visits MOH

(DNSP)

- General nurses

trained in EmONC

(number)


visits MOH

(DNSP)

- Nurse midwives

who received pre-

service training

(number)


visits MOH

(DNSP)

- Nurses trained in

IMCI (number) 0 0 80 160 240 345 Annual Supervision

visits MOH

(DNSP)

14. Ambulances and

4x4 station wagons

purchased

(number)


visits MOH

(DNSP)

40

15. Programmed

communities

receiving at least 3

outreach visits per

year (%)


visits MOH

(DNSP)

16. Motorcycles

purchased for

outreach teams

(number)


visits MOH

(DNSP)

17. Municipalities that

have implemented

80% of municipal

outreach plans

(number)


visits MOH

(DNSP)

Component 2 – Voucher Scheme Pilot

18. Women receiving

vouchers (number) 0

19. Women that

deliver in a health

facility that

redeem vouchers

(number)

0 1

20. Mothers satisfied

with transportation

and direct

vouchers (%)

0 40% 50% 65% 70% 75%

21. Municipalities

with voucher pilot

completed

(number)


visits MOH

(DNSP)

41

Component 3 – Project Management and M&E

22. Municipal Annual

Health Reports

Received on time

(%)

0% 30% 50% 75% 85% 95% Annual MOH reports MOH

23. Health

professionals

trained in health

system

management (%)


visits MOH

(Human

Resources

Department)

24. Municipalities

with operational

plans (number)


visits MOH

(DNSP)

The following IDA 15 CORE Indicators were not included in this project because they are tracked under the IDA-financed Angola HAMSET Project,

currently under implementation, that directly targets malaria and HIV:

(i) Long-lasting insecticide-treated malaria nets purchased and/or distributed (number)

(ii) Adults and children with HIV receiving antiretroviral combination therapy (number)

(iii) Pregnant women living with HIV who received antiretroviral to reduce the risk of Mother-To-Child Transmission (number)

http://intranet.worldbank.org/WBSITE/INTRANET/UNITS/INTOPCS/0,,menuPK:6250526~contentMDK:22228723~pagePK:51455324~piPK:3763353~theSitePK:380832,00.html#7



42

142. All the output indicators for the project will be collected through the routine HMIS and

supervision visits. However, as regards outcome indicators, the HMIS has shortcomings in the

quality, completeness and timeliness of data. Thus, for outcome indicators, the MHSS will also use

rapid surveys to collect confirmatory data for all of the indicators at least annually. At the same

time, the MHSS will strengthen municipal and provincial HMIS data collection as well as the use of

data for decision-making.

143. Rapid Health Facility Assessment. The MHSS will support an annual rapid health facility

assessment focusing on obstetrical and emergency neonatal care services, and sick-child services

(IMCI). This survey will be performed in a sample of four health facilities in each target

municipality, including the provincial reference facilities and each facility where a new delivery

room is constructed and equipped. The survey instrument will be based on a draft survey instrument

developed by WHO, which focuses on obstetrical and emergency neonatal care services. An

additional module will be developed to provide information on the quality of IMCI services,

including the direct observation of five sick child consults in each facility.

144. The survey will be implemented through the contracting of WHO. The agency will be

responsible for finalizing the survey instruments, carrying out the surveys and analysis and

reporting. The MHSS CCU M&E officer will provide oversight and technical assistance for the

survey, in collaboration with WHO. This survey will be performed in close collaboration with the

Health Delivery Channel Household Survey, as the information they provide is highly

complementary.

145. Health Delivery Channel Household Survey (WHO Rapid KAP Survey). WHO and the

MOH have agreed on terms of reference for the first round of the Health Delivery Channel

Household Survey. This survey will sample households from target municipalities providing

information on knowledge, practices and coverage of key maternal and child health interventions, as

well as information about why mothers do not access services. The survey will include all MHSS

target provinces by groups, with each survey area requiring a sample of about 300-500 households.

The survey instrument will be based on a model developed by WHO which is now being translated

and adapted to the Angolan context. The MHSS will provide some financial support for the MHSS

target provinces. Technical assistance will be provided by WHO and the MHSS CCU M&E officer.

Implementation of the survey will be done through a procurement contract with WHO, with

considerable participation from the MOH. This survey will be closely coordinated with the Health

Facility Assessment, which will provide information that is highly complementary. After each

survey round, WHO will support provincial workshops to strengthen data use for planning.

146. Strengthening the HMIS. The MOH HMIS design in theory is able to provide all of the

indicators listed as sourced from the HMIS. However, at baseline the information is either not easily

available or is incomplete. The MHSS will support the strengthening of the M&E capacity of

municipalities and provinces. This will include the development of a training manual on data for

decision-making, training of provincial M&E officers as DDM trainers, and support for them to

replicate the training for provincial directors and M&E officers. This will be the first step in

strengthening M&E capacity.

147. The second step includes support for quarterly review and planning sessions. At these

sessions, provincial M&E officers and provincial MHSS officers will host meetings for municipal

directors and M&E officers where the quarterly HMIS data are presented, together with any other

43

relevant survey information or other information that becomes available during the period. The data

will be presented, analyzed, and used to update municipal and provincial work plans. Training

materials and instruments for conducting the quarterly review and planning meetings will form part

of the DDM training materials described above.

Evaluation of the Demand-Side Incentives Pilot

148. The demand-side incentives pilot will require special arrangements for monitoring and

evaluation, as both ongoing monitoring and impact evaluation are important to guarantee both

coverage and transparence, as well as to evaluate the impact on demand for services and to identify

bottlenecks and correct them. The following table lists the indicators that will be tracked together

with the source of information:

Table 11: Indicators and data source

Indicator Data source Comments

Number of women

receiving vouchers

HMIS—requires additional

form to record this

MHSS CCU will design

forms for recording the

information at pilot health

facilities. Number of women that

deliver in a health facility

that redeem vouchers

HMIS—requires additional

form or place on registry to

note it down and report it.

This is not routinely

collected.

Percentage of all women

delivering that redeem

vouchers

HMIS—calculated from

previous indicator divided

by total institutional

deliveries

Number and % of transport

vouchers redeemed

HMIS—requires new

system (recorded at

redemption site)

Number and % of other

(direct) vouchers redeemed

HMIS—requires new

system. Recorded at

redemption site.

Number of and % of

institutional deliveries

As above: HMIS confirmed

by MICS and WHO rapid

KAP annually.

% of facilities that report no

difficulty attending to the

demand for institutional

deliveries

Rapid Health Facility

Assessment

44

% of mothers receiving

transportation and direct

vouchers41 during the

previous pregnancy.

WHO rapid KAP survey,

annual

% of mothers that received


vouchers during the

previous pregnancy that

redeemed them.


annual

% of mothers satisfied with


vouchers


annual

Drivers‘ satisfaction with

vouchers (waiting time for

redemption, amount)

Questionnaire of sample of

drivers at the time of

redemption of vouchers in

sentinel sites. Semi-

quantitative questionnaire

MHSS CCU M&E officer

will design and tabulate.

Total value of voucher

program Financial reports MHSS CCU

149. The data sources that will be required are described below.

150. Routine Health Information System. The MHSS CCU M&E officer will work with the

MOH M&E unit to design and implement instruments for collecting the routine indicators listed

above as deriving from the HMIS. This will require the following special instruments:

Design of a registry form for use during antenatal care to capture the number of

transportation and clothing vouchers issued by health facilities to pregnant women.

Design of a registry for use at the time the post-partum mother requests a copy of the birth

registration to give to the driver so he can redeem the voucher. The person issuing the birth

registration form will record that the woman used a transportation voucher and requested a

birth registration copy for the purpose of redeeming the form.

It may be advisable to design an additional redundant registry for use by nurses interviewing

women that arrive for delivery about whether she used a transportation voucher to come pay

for transportation to the facility. This would help identify obstacles between using the

voucher for transportation and acquiring the birth registration so the driver can redeem the

voucher.

151. Rapid health facility assessment. A series of questions will be added to the health worker

interview that ask about increased demand for institutional deliveries and whether the facility is able

41

There are two types of vouchers: (i) transport voucher subsidies; and (ii) direct subsidies for pregnant women to

encourage them to give birth in a health facility.

45

to cope with the demand. This information will be collected annually in the municipalities where

the pilot is implemented. It will be the responsibility of the MHSS M&E officer to make certain that

these questions are included in the HFA.

152. Delivery Channel Household Survey (WHO Rapid KAP Survey). A series of questions

assessing mothers‘ satisfaction and ease of use of the voucher system will be added to the Delivery

Channel Survey only in the municipalities where the pilot is being implemented. The questions will

assess the coverage of the distribution of the vouchers, whether the voucher was a factor in her

decision to deliver at the facility, why or why not, and ease of redemption (for both transportation

and clothing). This information will be collected annually in the areas where the pilot is being

implemented. It will be the responsibility of the MHSS M&E officer to make certain that these

questions are included in the Delivery Channel Household Survey.

153. Questionnaires at Sentinel Sites. At least one sentinel voucher redemption sites will be

designated in each province where the program is being implemented. At the time that vouchers are

redeemed by providers of transport and pregnant women, a questionnaire will be administered to a

sample of transportation providers and of women. The questionnaires will ascertain their

satisfaction with the vouchers, their value, prior knowledge about the voucher system, ease of

redemption, time it took to redeem them, and whether a secondary market for vouchers has arisen,

Responsibility for the design of the sentinel site sampling and questionnaires will be the

responsibility of the MHSS CCU M&E officer. Implementation, supervision and reporting will be

shared between the CCU and the provincial MHSS officers.

46

Annex 4: Detailed Project Description


154. The project would have three components: (i) improving service delivery in five provinces

of Bengo, Malange, Lunda Norte, Moxico, and Uige in 18 municipalities 42

(US$56.3 million); (ii)

piloting of demand-side incentives to increase institutional deliveries (US$0.8 million); and (iii)

strengthening the capacity of the MOH and municipalities (US$18.2 million). It would have a life

of five years.

155. The project would support an integrated model of health service delivery with a package of

interventions (detailed in Annex 16) aimed principally at reducing child and maternal mortality. By

bringing health services to the population through outreach and community health workers, the

project would help municipalities deliver a higher volume of cost-effective preventive and curative

services to a population that would not have sought these services in the first place. This is because

people face tradeoffs on the use of their time between walking long distances to reach health

centers and employing it for productive or other family activities. Also, better planning and

management would help increase the volume of services in both urban and rural areas. The

provision of demand-side incentives as well as the improvement of the supply and quality of

obstetric care would increase the number of institutional deliveries and help reduce maternal

mortality.

156. Considering the enormous size of the provinces and the fact that it will take many years to

build and staff a network of health facilities in the most distant villages, the MOH has developed a

strategy of outreach teams, for areas beyond a range of 20 km. Outreach teams are scheduled to

visit each community at least four times a year.

157. Teams of community health workers (CHWs) would be developed in each village. They

would be trained to undertake health promotion and prevention. Outreach teams would provide

technical support to CHWs when visiting their area.

158. To increase access to obstetric care, the project will have a dual strategy: (i) it will provide

equipment to existing municipal health centers, thus helping to improve the quality of care; and (ii)

it will expand the supply of obstetric care by building 36 new delivery rooms in health centers and

posts, bringing the services closer to the population.

159. Finally, the strategy calls for the training of midwives and nurses who will provide obstetric


primary care mobile teams that will visit the most distant communities at least four times a year.

The training process will focus mostly on the improvement of practical skills rather than on

theoretical concepts.

160. Component 1 - Improvement of health service delivery (US$56.3 million). Component 1

will help strengthen the Angola health system in the five targeted provinces through training of

health personnel, scaling up of outreach and community health services, strengthening of obstetric

42

The list of municipalities covered is provided in Annex 22.

47

care, and improvement of hospital waste management, The training subcomponents (1a and 1b) are

substantial. Their organization and feasibility are described in Para. 74 and Annex 6. There will be

six subcomponents as described below.

161. Subcomponent 1a - Strengthening of municipal health services at the primary level43

,

entirely financed by Total E&P Angola, would finance the following training activities:

(i) Training of 20 trainers in Emergency Obstetric and Neonatal Care (EmONC);

(ii) Training of 180 general nurses in EmONC;

(iii) Pre-service training of about 80 nurse midwives;

(iv) Training of 22 trainers in the Integrated Management of Childhood Illnesses (IMCI); and

(v) Initial in-service training of about 345 general nurses in IMCI.

162. Subcomponent 1b - Strengthening of municipal health services at the primary level will

finance goods, consultants, and training for the following activities:

(i) Pre-service training of about 75 general nurses;

(ii) Training of about 92 staff in health service management and planning;

(iii) A specialization course (public health, management of common diseases, and selected

surgical procedures) for about 20 general physicians;

(iv) Printing and distribution of manuals and information, education, and communication

(IEC) posters;

(v) Teaching and learning materials, and library books;

(vi) Introduction of telemedicine in five provincial hospitals;

(vii) A study of drugs planning, budgeting, acquisition and logistics;

(viii) Provision of drugs and supplies in kind by the MOH and provinces; and

(ix) An 18-month buffer stock of essential drugs and supplies.

163. Subcomponent 2 – Scaling up of outreach services will finance training and goods for the

following activities:

(i) A refresher course for about 300 nurses in common disease management;

(ii) Integrated outreach activities by mobile teams (per diem and fuel);

(iii) Vehicles (4x4s, ambulances) and maintenance;

(iv) Quad vehicles and maintenance kits;

(v) Motorcycles and maintenance kits;

(vi) Solar kits and camping kits for outreach teams.

164. To simplify accounting and reporting, operating costs for outreach activities by mobile

teams (per diem and fuel) are included with all other operating costs under component 3.

165. Subcomponent 3 – Improving community interventions will finance training and goods for

the following activities:

(i) Training of about 28 trainers for community health;

(ii) Training of about 1,080 community health workers (CHWs);

43

This subcomponent is split into 1a and 1b to allow Total to finance a discrete number of activities totaling US$3.3

million equivalent under 1a.

48

(iii) Yearly refresher courses for CHWs;

(iv) Mobilization and education training meetings with traditional birth attendants (TBAs);

(v) Kits (T-shirts, caps etc.) for CHWs, TBAs, and traditional healers (THs);

(vi) Clean delivery kits for TBAs; and

(vii) Kits for THs.

166. Subcomponent 4 (a) – Improving obstetric care will finance works, goods, and consultants

for the following activities:

(i) Rehabilitation and construction of about 32 delivery rooms (for pre and post delivery,

and child care) in health centers and posts44

;

(ii) Construction of about 24 houses for health professionals at provincial and municipal

levels45

;

(iii) Management and supervision of civil works;

(iv) Goods and equipment for pre-natal care, family planning, delivery and IMCI rooms, and

maternities;

(v) Radios for ambulances;

(vi) Review of norms for delivery kits (normal and C-sections); and

(vii) Delivery kits.

167. Subcomponent 4 (b) – Improving obstetric care, entirely financed by Total E&P Angola,

would finance works and goods for rehabilitation and construction of 4 delivery rooms (for pre and

post delivery, and child care) in health centers and posts in Malange.

168. Subcomponent 4 (c) – Improving obstetric care, entirely financed by Total E&P Angola,

would finance goods for solar kits for maternal and child health care46

.

169. Subcomponent 5 – Improving hospital waste management disposal (HWMD) will finance

goods, consultants, and training for the following activities:

(i) Materials and equipment for HWMD by municipal hospitals, health centers, and health

posts;

(ii) Training in HWMD for provincial supervisors and municipal-level personnel;

(iii) Training in biosafety and universal protection; and

(iv) Supervision and quality control of HWMD.

170. Component 2 – Voucher Scheme Pilot (US$0.8 million). This component will finance provision

by the government of : (i) cash transfers to beneficiaries residing in the municipalities of Negage and

Caculama to facilitate access to child delivery services and pre-natal care, all in accordance with the

provisions of the Voucher Scheme Manual; and (ii) technical assistance to manage these activities.

171. The project will pilot vouchers to encourage pregnant women to deliver in a health facility.

These consist of: (i) transport voucher subsidies; and (ii) direct subsidies for pregnant women. The

pilot will start in the second year. Vouchers will be available to pregnant women living within the

selected municipalities. The municipalities chosen, Negage in Uige province, and Caculama in

44

The location of delivery rooms to be built or rehabilitated is provided in Annex 6. 45

Houses will be provided with access to water, electricity, and telecommunications. 46

Not to be procured from Total E&P Angola because of conflict of interest.

49

Malange province, already have a reasonable supply of obstetric care which will be further

strengthened during year 1 of the project (see Annex 20).

172. Communities and hospitals will be sensitized about the scheme to ensure the support of the

male and local community leaders within the target areas. The ability of women to redeem their

vouchers may be in the hands of other household members, therefore the target segments for the

marketing campaign includes: (i) women between the age of 15-45 years; (ii) transport providers;

(iii) health workers; and (iv) other critical community members such as fathers and community

leaders. The social assessment suggests that men, especially husbands of pregnant women, must be

targeted with advocacy and health education activities to make them more involved in the early

stages of preparing for the birth.

173. Health facilities will be prepared about the mechanics of the scheme (e.g. the need to

provide copies of a delivery certificate to each woman who delivers), but will also be encouraged

to increase their productivity and at least maintain the quality of their services so as to meet the

increased demand. These hospitals will also receive support (goods and equipment, training, etc.)

through component 1 of the project.

174. At community level, CHWs and TBAs will be informed about the scheme and encouraged

to accompany pregnant women to the hospital. Partnerships with local NGOs, Faith-based

organizations, village committees, or women‘s groups where they exist, will help ensure the

availability of transport.

175. The Recipient will issue an internal decree (Decreto Executivo) at Ministry level, regulating

the voucher scheme through a pilot approach. A Voucher Scheme Manual will establish the system

and procedures for the pilot. Both will be conditions of disbursement for component 2 whose

implementation will start in year 2.

176. The overall management of the scheme will be contracted to an NGO. M&E will also be

contracted out. Details on the voucher scheme are provided in Annex 18. A manual of procedures

governing the administration and monitoring of the vouchers is under preparation. The adoption of

the manual establishing the system for the vouchers, satisfactory to IDA, is a condition of

disbursement for this component.

177. This component will finance consultants.

178. Component 3 – Project Management and Monitoring and Evaluation (US$18.2 million). This

component will have three subcomponents: (i) strengthening program management; (ii)

strengthening the capacity of the Department of Planning of the MOH; and (iii) strengthening of

monitoring and evaluation.

179. Subcomponent 1- Strengthening Program Management. This subcomponent will finance

consultants and operating costs for the following activities:

(i) Strengthening the staffing of the Central Coordinating Unit;

(ii) Strengthening the capacity of Provincial Departments of Health through the contracting

of two specialists (health service management and M&E) for each of the five provinces;

(iii) Supervision of provinces (per diem and transport);

(iv) Outreach activities by mobile teams (per diem and fuel)

50

(v) Participation in international conferences and training;

(vi) Coordinating meetings for implementation planning and monitoring;

(vii) Financial and procurement audits; and

(viii) Preparation of detailed provincial and municipal health plans.

180. Subcomponent 2 - Strengthening the Capacity of the Department of Planning of the MOH.

This subcomponent will finance consultants to support the preparation of: (i) a Medium-Term

Human Resources Development Plan; (ii) a Health Infrastructure Investment Plan and (iii) a

Medium-Term Expenditure Framework (MTEF).

181. Subcomponent 3 - Strengthening of Monitoring and Evaluation (M&E). This subcomponent

will finance goods, consultants, and training for the following activities:

(i) Strengthening the M&E capacity of the MOH in the use of the current HMIS;

(ii) Capacity building in data for decision-making at central, provincial, and municipal level;

(iii) Preparation and conducting of access and quality surveys;

(iv) Mid-term and final evaluations of the project; and

(v) Computers, training manuals, and stationery for M&E.

51

Annex 5: Project Costs


1.2 Scaling-up of population-based outreach services

Refresher course for 300 nurses in common diseases management 195,000

Outreach activities as integrate health interventions by mobile teams (per diem

and fuel) 5,937,800

Mobile solar kits for outreach activities 18,400

Camping kit ( to include tents, blankets, sleeping bags) per mobile team 40,000

Vehicles ( 4x4, ambulances and maintenance) for municipal, provincial and UCC

levels 3,672,000

Quad vehicles and maintenance kit, Municipal, Provincial, UCC levels 360,000

Motorcycles and maintenance kit, Municipal, Provincial, UCC levels 554,800

1.3 Improving community interventions

Training of 28 trainers for community health 96,450

Training of 1080 community health workers (CHWs) 5,900,000

Refresher course CHWs 63,000

Bicycles for CHW 60,000

Mobilization and education meetings with TBAs 53,500

Non-monetary incentives, i.e. kits for CHWs/TBA/TH 205,920

Clean delivery kits for TBAs 882,020

Table 12: Detailed Project costs

Component 1 - Improvement in service delivery

1.1 (a) Strengthening of municipal health services at primary level

Training of 20 trainers (TOT) for emergency obstetric care (EmONC) and Safe

motherhood 99,350

Training of 180 general nurses (medium-level nurses) in EmONC 378,000

Pre-service training of 80 nurse midwifes 1,890,000

Training of 20 trainers in IMCI 68,050

Initial training of 345 nurses in IMCI 815,000

Subtotal 3,250,400

1.1 (b) Strengthening of municipal health services at primary level (continued)

Pre-service training of 75 general nurses 3,780,000

Training of 92 staff in health management and planning at provincial and

municipal level 283,500

Specialization course for 20 general physicians 756,000

Printing and distribution of FP, PNC, Delivery, Pediatric Care, EDP manuals and

IEC posters 486,000

Teaching and learning materials, library books, and internet connection 32,200

Introduction of telemedicine in 5 provincial Hospitals 72,000

Study of drugs acquisition, planning, distribution budgeting and logistics 76,400

Buffer stock of drugs and commodities 5,174,982

52

1.4 (a) Improving obstetric care

Rehabilitation/construction of 32 delivery rooms (for pre and post delivery, and

child care) 4,732,000

Housing for health professionals at municipal and provincial levels 7,980,000

Management and supervision of civil works 840,000

Equipment for PNC/FP, delivery and IMCI rooms and provincial maternities 635,500

Radios for ambulances, municipalities and provincial DPS 834,000

Review of norms for delivery and C-Section kits 19,350

Provide Kits for normal deliveries 4,884,239

Kits for C-Section 1,953,696

Kits for THs 162,000

Subtotal 6,857,285

1.4 (b) Improving obstetric care (continued)

Solar kits for MCH care 720,000

Rehabilitation/construction of 32 delivery rooms (for pre and post delivery, and

child care) in Malange 560,000

Subtotal 1,280,000

1.5 Improving Hospital waste management disposal (HWMD)

Provision of basic materials and equipment for HWMD by municipal hospitals,

health centers and health posts 324,000

Basic training in HWMD for municipal level personnel 171,000

Training in HWMD for provincial supervisors 80,850

Training in biosecurity and universal protection 230,000

Supervision and quality control of HWMD 188,754

Total component 1 56,265,760

Component 2 – Voucher Scheme Pilot

Qualitative study in two municipalities of cultural, economic, and social

determinants of demand for reproductive health and delivery services 52,200

Management of voucher system by NGO, including awareness and BCC

campaigns 295,000

Cost of vouchers 332,663

Monitoring and Evaluation of the pilot 100,000

Total component 2 779,863

Component 3 – Project Management and M&E

3 (a) Strengthening program management

Strengthening the staffing of Central coordination unit 4,718,000

Strengthening the capacity of Provincial Health Departments (contracting of

health management and M&E specialists in 5 provinces) 4,200,000

53

Table 13: Project Costs By Component

Project Cost By Component Local

(US$ million)

Foreign

(US$ million)

Total

(US$ million)

Improvement in service delivery 17.0 34.0 51.0

Piloting of demand-side incentives to

encourage institutional deliveries

0.7 0.1 0.8

Strengthening the Capacity of the

Ministry of Health at the Central,

Provincial, and Municipal Levels

14.8 2.0 16.8

Government contribution for drugs 1.0 15.5 16.5

Physical Contingencies 1.8 1.6 3.4

Price Contingencies 1.7 1.6 3.3

Total Project Costs 37.0 54.8 91.8

Total Financing Required 37.0 54.8 91.8

Local travel 120,000

Per diem for support visits to the provinces- Technical assistants 300,000

Per diem for support visits to the provinces- coordinators 150,000

Per diem for support visits to Luanda 75,000

Transportation between Provinces and to Luanda 80,000

Support to supervision to provinces from regional coordination and technical

support teams 2,869,500

Participation in international conferences and training 69,600

Coordinating meetings for implementation planning and monitoring 1,200,000

Financial and procurement audits 750,000

Preparation of detailed provincial and municipal health plans 950,700

3 (b) Strengthening the capacity of the Department of Planning of the MOH

Preparation of Human Resources Development Plan, Infrastructure Development

Plan, and MTEF 321,600

3 (c) Strengthening Monitoring and Evaluation

Strengthening M&E capacity of MOH in the use of the current HMIS 379,500

Capacity building in data for decision-making at central, provincial and

municipal level 119,000

Training at central level of 2 M&E staff of each of the 5 provinces in the use of

HMIS 100,000

Preparation and conducting of Access and Quality surveys 1,246,464

Mid Term Evaluation and Final Evaluation 300,000

Computers, training manuals, and stationery for M&E 303,680

Total Component III 18,253,044

Government contribution for drugs 16,500,000

TOTAL PROJECT COST 91,888,667

54

Annex 6: Implementation Arrangements


Table 14: Municipalities covered by the MHSS

Province Municipality Health Unit

Bengo Dande/Caxito PS Ùcua

PS Kikabo

Icolo e Bengo CS/Maternidade Sede

PS Maria Teresa

Ambriz PS Tabi

CS Sede

Uige Negage CS Dimuca

CS Useke/Quisseke

Uige

Sanza Pombo Alfandega

CS Materno Infantil (HQ)

Maquela do Zombo

Malange Malange PS Kambaxi

PS Ngola Luixi

Cacuso PS Kizenga

PS Pungo Andongo

Caculama PS Caxinga

PS Muquixe

Calandula CS Sede

PS Cota

Moxico Luena PS Mandunbwe

PS Sangondo

Camanongue PS Muxivingugi

CS da Sede

Luau H. Municipal

PS Marco 25

Lunda Norte Chitato Hospital Municipal

Lucapa Repair of Maternity

Nzaji Maternity

Cuango Centro de Saúde (HQ)

CS Calonda

182. Institutional arrangements are presented in Figure 4. The Ministry of Health will have the

overall responsibility for the management of the project. The National Department of Public Health

(DNSP) will be in charge of the day-to-day management of the project. In 2006, the DNSP created

the MHSS Central Coordinating Unit (CCU). The CCU is headed by a Coordinator who reports to

the National Director of Public Health, and will be strengthened by the addition of a Deputy

55

Coordinator, an M&E Specialist, an Infrastructure Specialist, a Training Specialist, a Health

Specialist, a Financial Management (FM) Specialist, and a Procurement Specialist, as well as

supporting staff.








184. The CCU‘s responsibilities are to: (i) manage the expansion of the program throughout the

country; (ii) make resources available for the MHSS and ensure their rational use; (iii) ensure that

Regional Coordinating Teams respect their implementation timetables; (iv) guarantee the quality of

the training program; (v) monitor and supervise the MHSS program, prepare quarterly reports, and

organize national meetings to review progress; (vi) transfer experience between regions; (vii)

promote the MHSS program at the national level. The CCU is supported by four working groups:

(i) monitoring and evaluation; (ii) supervision and training; (iii) logistics; and (iv) health promotion

and education.

185. Depending directly from the CCU, there are six Regional Coordinators, each supported by a

technical team. The responsibilities of the Regional Coordinator are to: (i) analyze the

epidemiological profile as well as the supply and demand of health services in each province

included in the region, municipality by municipality; (ii) help prepare municipal operational plans;

(iii) train provincial and municipal teams; (iv) help municipalities prepare the annual MHSS

budgets and ensure their inclusion in the overall municipal budget; (v) help municipalities mobilize

resources; (vi) ensure that provincial and municipal teams respect their implementation timetables;

(vii) organize the training of provincial health teams; (viii) monitor and supervise the

implementation of municipal operational plans, and prepare quarterly reports; (ix) help exchange

experience between regions through monthly or bi-monthly meetings; and (x) promote the MHSS

program at the regional level.

186. Joint Project Implementation Reviews. A Steering Committee will monitor the progress

of the MHSS project. The Committee will be chaired by the Minister of Health or his designate. Its

members will be, inter alia, the Vice-Minister for Hospital Management, the Vice-Minister for

Public Health, the Director for Human Resources, the Director of Planning, the National Director

for Medical Equipment and Medicines, the Director for Public Health, and one representative of

Total E&P Angola.

187. Bi-annual Joint Project Implementation Reviews will be led by the MOH with the

participation of stakeholders and development partners. The Reviews will have three components:

(i) joint review of the past year‘s activities and of critical questions in a number of thematic areas;

(ii) a joint visit to a province to better understand the problems in the field and discuss with

stakeholders; and (iii) a plenary session to consolidate the field work and approve the plan of

activities for the following year.

56

Figure 4: MHSS Institutional Arrangements

188. At the provincial level, the governor is responsible for the implementation of the MHSS

through the Vice-Governor for the Social Sector, supported by the Provincial Health Director. The

attributions of the Provincial Health Director as regards the MHSS are similar to those of the

Regional Coordinators, but with a focus on the coordination of program implementation in the

municipalities that are part of the province.

189. At the municipal level, the Municipal Health Officer is responsible to: (i) prepare the MHSS

municipal operational plan and ensure their integration in the overall municipal budget; (ii) manage

the municipal health teams and ensure that they deliver an integrated package of maternal and

health services through fixed-based and mobile teams, and provide them with the logistical means;

(iii) prepare a monthly plan of visits to health units to monitor progress and provide

implementation support to health staff and mobile teams; and (iv) prepare a monthly report

documenting the maternal and child health services provided in the municipality, inventory of

drugs and supplies, vaccines and the status of the cold chain, as well as the epidemiological

situation of the municipality.

190. Outreach teams. Considering the enormous size of the provinces and the fact that it will

take many years to build and staff a network of health facilities in the most distant villages, the

MOH has developed a strategy of outreach teams, for areas beyond a range of 20 km. Outreach

teams have been used in Angola, but until now they only provided vaccination services. The

Revitalização program has now determined that mobile teams are expected to provide integrated

Ministry of Health National Department of

Public Health

MHSS Central Coordinating Unit (CCU) Coordinator

Deputy Coordinator

M&E Specialist

Training Specialist

Infrastructure Specialist

FM Specialist

Procurement Specialist

Provincial Departments of Health Bengo, Malange, Lunda Norte, Moxico, and Uige

(Including Public Health Specialist and M&E Specialist supported by MHSS in each province)

Municipal Health Officers

Health Specialist

FM Officer Procurement Officer

Provincial Training Institutes

HCWM Specialist

57

primary health care services. They are responsible for health promotion and health prevention

activities, dissemination of health messages related to specific diseases prevalent in the area, safe

motherhood practices, birth preparedness, and encouraging women to give birth in a health facility.

191. Outreach teams are scheduled to visit each community at least four times a year. The

outreach teams will be composed of three nurses. One of them will be a midwife or a nurse trained

in EmONC and pre-natal care. A second one will have been trained in IMCI and the management

of most common infectious and chronic diseases. Finally, the third nurse will be in charge of

promotion and prevention services.

192. The mobile teams will ensure the link with community health workers, TBAs and even

traditional healers. During their visits, the nurses will supervise the CHWs, collecting information

and data on the promotion activities CHWs have done. They will provide immediate feedback and

training in technical problems raised by CHWs. They will also hold meetings with traditional

authorities such as ―Sobas‖ to listen to their queries and suggestions related to health problems in

the community.

193. Teams of community health workers (CHWs) will be developed in each village. They will

be trained to undertake growth monitoring, provide oral rehydration therapy, immunization, female

education including the use of bed nets, family planning and contraceptive use, promotion of

exclusive breast feeding, nutrition, good hygiene such as washing hands, avoidance of risky sexual

behavior, and increasing the capacity of families to recognize the early danger signs of common

diseases so to seek care sooner. Outreach teams will provide technical support to CHWs when

visiting their area.

194. Obstetric care. To increase access to obstetric care, the project will have a dual strategy: (i)

it will provide equipment to existing municipal health centers, thus helping to improve the quality

of care; and (ii) it will expand the supply of obstetric care by building 36 new delivery rooms in

health centers and posts, bringing the services closer to the population.

195. Three criteria were used to select the facilities: (i) the population to be covered (the higher

the better); (ii) the distance of these facilities from current maternities located in municipal health

centers or hospitals (faraway facilities were chosen to bring services nearer the population); and

(iii) accessibility of roads to ensure the referral of patients. In total, the project will rehabilitate or

create delivery rooms in 12 municipal hospitals used as referral centers, and in 24 peripheral health

posts in the project municipalities.

196. Finally, the strategy calls for the training of midwives and nurses who will provide obstetric


primary care mobile teams that will visit the most distant communities at least four times a year.

The training process will focus mostly on the improvement of practical skills rather than on

theoretical concepts.

197. Increased access to institutional deliveries is expected to create more demand for not only

normal deliveries, but will allow increasing the detection and referral of complicated cases that will

need surgery or specialized treatment. As a result the current low prevalence of C-sections would

also increase.

58

198. Training program. The training of nurses and midwifes in EmONC and IMCI will be

undertaken by a team of 20 trainers (four from each province) who will be trained in Luanda

Maternity (Lucrecia Paín) for 15 days in the case of EmONC and 10 days for IMCI. The courses

will be provided by the Provincial Technical Institutes of Bengo, Malange, Uige, and Moxico. The

trainers and supervisors will consist of Cuban and Angolan doctors already present in the

provinces. Training curriculums and materials are also available.

199. The same principle will apply to the training of CHWs. A group of 28 trainers from the

provinces and municipalities will be trained by the DNSP, with UNICEF support, for a period of

10 days. In each province, the course will be given by a team of two trainers from the Provincial

health Department and one from the municipality. The course will benefit 60 CHWs from each of

the 18 municipalities. It will last 45 days.

200. Training in health services management will be provided by the Lubango Institute who will

send trainers to each province. The course will benefit 60 nurses in each of the 5 provinces.

201. In the CCU a full-time Training Specialist will be in charge of programming the courses,

making the appropriate arrangements with the trainers from Luanda and Lubango, liaising with the

provinces, and supervising the implementation of the training program. Details on this program are

provided below.

Table 15: Training Program

Activity Description Cost (US$)

Training of 20 trainers in

EmONC

Four trainers from each province to be

trained in Luanda Maternity (Lucrecia

Pain) by a team of 2 doctors and one

nurse. One of the trainers form the

province will be the Pedagogical

Director of the Provincial Training

Institute. A 2-week course.

459,350

In-service training of 180

general nurses in EmONC

The course will benefit 10 nurses from

each of the 18 municipalities. The course

will take place in provincial and selected

municipal hospitals. A 2-week course.

360,000

Pre-service training of 80

nurse midwives.

Nurses who are currently working as

general nurses will be trained as nurse

midwives. The course will last 18

months. Of these 36 will be the

coordinators for each of the new delivery

rooms in the 18 municipalities of the

project (2 per municipality). Courses in

Bengo, Malange, Uige, Lunda Norte and

Moxico.

1,800,000

59

Pre-service training of 75

general nurses.

Nurses come from the existing pool of

nurses in each province will be upgraded

from basic to mid-level nurses, allowing

for a higher salary. The course will take

place in Bengo, Malange, and Uige. The

course will contribute to upgrading of

skills and allow provinces to rebalance

the distribution of nurses. The course

will last 2 years.

3,600,000

Training of 20 trainers in

IMCI

Similar to the training of trainers for

EmONC, but for a duration of 10 days.

68,050

Initial in-service training of

345 general nurses in IMCI.

This course will train 15 nurses from

each of the 18 municipalities, plus 15

from each provincial hospital. The

course will last 6 days. It will allow

nurses to improve their skills in case

management of child diseases, for their

work in facilities and outreach teams.

The course will take place in each

province within the provincial and

selected municipal hospitals.

776,250

Training of 92 staff in

health service management

and planning

Training of 4 staff from each of the 5

DPSs and 4 from each of the 18

municipalities. The course will be

provided by the Lubango Training

Institute which will go to each province

to provide the course at the Provincial

Training Institute.

270,000

Training of 20 general

physicians

Training of doctors in public health,

management of common diseases, and

selected surgical procedures. The course

will take place at Luanda University

Hospital for a period of 3 years.

720,000

Refresher course for 300

nurses in common disease

management

This 5-day refresher course will benefit

60 nurses per province. The trainers will

come from the provincial level and

provide the course in each of the 18

municipalities.

195,000

Training of 28 trainers to

train CHWs

Training by the DNSP (with UNICEF

support) of one trainer from each of 18

municipality and 2 from each DPS. The

course will last 10 days.

96,450

60

Training of 1080

community health workers

This 45-day course will benefit 60

CHWs from each of the 18

municipalities. The course will be given

by a provincial group of 2 trainers and

one municipal trainer.

5,900,000

Refresher training for

CHWs

One-day course each year. 63,000

202. Civil works and equipment will be under the overall responsibility of the Infrastructure

Specialist in the CCU. For delivery rooms, technical norms will be provided by the MOH

Department of Planning (GEPE). Contracting will be undertaken at the provincial level through

national competitive bidding (check). GEPE will also provide the norms for staff houses. These

will be packaged and contracted through international competitive bidding. The Infrastructure

Specialist will also be in charge of the equipment (ambulances, vehicles, radios, solar panels) and

commodities (delivery kits and essential drugs), working in close collaboration with the Health

Specialist for the latter.

Table 16 - Location of Delivery Rooms to be Built/Rehabilitated

Province Municipality Health Facility

Bengo Dande/Caxito PS Ùcua

PS Kikabo

Icolo e Bengo CS/Maternity (HQ)

PS Maria Teresa

Ambriz PS Tabi

CS HQ

Uíge Negage CS Dimuca

CS Useke/Quisseke

Uige 2 PS

Sanza Pombo PS Alfandega

CS Materno Infantil (HQ)

Maquela do Zombo 2 PS

Malange Malange PS Kambaxi

PS Ngola Luixi

Cacuso PS Kizenga

PS Pungo Andongo

Caculama PS Caxinga

PS Muquixe

Calandula CS HQ

PS Cota

61

Moxico Luena PS Mandunbwe

PS Sangondo

Camanongue PS Muxivingugi

CS (HQ)

Luau H. Municipal

PS Marco 25

Lunda Norte Chitato Municipal Hospital –

Maternity

PS Lovua

Lucapa Repair of Maternity

CS Camunongo

Cuango Maternity of Health Center

PS Loremo

Cambulo/N‘Zagi CS Calondo

CS Cassanguidi

203. Contracting of consultants. TORs will be the responsibility of the Deputy Coordinator

with support from DNSP and GEPE, as well as UNICEF and WHO when needed.

204. Pilot testing of vouchers to encourage institutional deliveries. This will be contracted to

an NGO who would work closely with communities, health centers, hospitals, drivers, and the

municipal administration financial departments. The M&E of the pilot would be contracted to a

local Angolan consulting firm or an NGO.

205. Monitoring and Evaluation will be the responsibility of the M&E Specialist of the CCU

who will be in charge notably of: (i) ensuring the availability of routine indicators from the HMIS;

(ii) training of staff; and (iii) coordination with other partners. Access and quality surveys will be

contracted to WHO.

62

Table 17: MHSS Implementation Schedule

Activities

PPF 1º YEAR 2º YEAR 3ºY 4ºY 5ºY

1 T

2 T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T

Responsible Participant General Preparatory and launching activities Prepare TORs and contract M&E specialist for CCU DNSP-CCU HAMSET Prepare TORs and contract specialist for qualitative survey with mothers on incentives

DNSP-CCU Consultant HAMSET

conduct survey DNSP-CCU DPS Conduct a survey and prepare document on the existence, role and projects by NGOs in the 5 provinces DNSP-CCU DPS Base line survey on needs for maternal health - obstetric care in the five provinces DNSP-CCU DPS Prepare TORs and contract training, infrastructure, procurement, financing specialists DNSP-CCU HAMSET Prepare the protocols to be signed by the governors and municipalities by each province DNSP-CCU DPS Organize meeting with Provincial Governors to sign implementation protocols Preparing the Operational Manual I - Improving Health Services delivery in five provinces

(a) Strengthening of municipal health services at

primary level Meeting with DNRH to ensure prioritization of allocation of nurses and MCH nurses to the 5 provinces DNRH DNSP Agreement protocol on HR training and allocation prepared and signed between DNRH and DPS

DNRH, DNSP-CCU DPS

Training of nurse midwifes Mobilize candidates from provinces DPS DNRH

Implement course ETPS ETPS

Graduation ETPS ETPS

Arrive to Municipalities DPS DMS Training of general nurses (Medium level nurses) Mobilize candidates from provinces DPS DNRH

Implement course ETPS ETPS

Graduation ETPS ETPS

63


Activities


1 T

2 T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T

Arrive at Municipalities DPS DMS

Training on IMCI Training of trainers for 5 provinces DNSP-CH CCU, DPS Do training for municipal nurses in each province DPS, DMS DNSP, CCU

Refresher training on IMCI DPS DMS

Training in Safe motherhood

Provinces chose trainees DPS DMS Preparing training materials and organize course logistics DNSP-SRH CCU, DPS

Do training for each province DNSP-SRH CCU, DPS Refresher training on Safe motherhood DPS DMS Training in Health Management and Planning at provincial and municipal level Adapt existing PASS training materials CCU, DNSP GEPE Organize course logistics and mobilize candidates CCU, DPS DMS

Do training for each province DNSP GEPE, DPS

Refresher training DPS CCU, GEPE (a-2) Scaling-up of population-based outreach services a)Implement Outreach activities as integrate health interventions by mobile teams Define outreach service provision protocols with organizational structure, responsibilities, case management and health promotion activities

CCU, DNSP, DNRH DPS

Refresher courses on common diseases case management and health promotion for existing nurses in outreach teams DNSP, DPS DNRH Prepare specifications, procure , buy and distribute Solar kits for outreach teams

CCU, HAMSET, DPS DNSP, DPS

Procure, buy and install solar kits for each team


Prepare specifications, tender documents, launch bid and buy Vehicles ( 4x4, ambulances and maintenance) for municipal, provincial and CCU levels


Prepare specifications, tender documents, buy and distribute motorcycles, quad


64


Activities


1 T

2 T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T

motorcycles, and maintenance

Prepare specifications, tender, buy and install, radios for mobile teams, municipalities and provincial DPS


Implement at least 4 outreach visits a year in hard to reach communities

DAMS, Mobile team DPS

(b) Improving obstetric care Rehabilitation/construction of Delivery rooms( pre, post and delivery ) including improvement of water and sewage facilities and reproductive and sexual health equipment

CCU, HAMSET, DPS DNSP, DMS

Identify Health Centers where obstetric rooms will be rehabilitated/constructed CCU, DPS DMS

Prepare tender and launch bids for construction and equipment

HAMSET, CCU DMS

construct and hand out rooms to the DMS Prepare technical specifications, tender buy and install Solar kits for delivery rooms

CCU, HAMSET, DPS DPS, DMS

Prepare Technical Specification, tender, buy and distribute Kits for normal deliveries CCU, DNSP DPS, DNME Prepare Technical Specification, tender, buy and distribute Kits for caesarean CCU, DNSP DPS, DNME

(c) Train Community workers Define schedule, identify, prepare teaching materials and do Training new CHWs CCU, DNSP DPS Refresher course existing CHWs CCU, DNSP DPS Define schedule, identify, prepare teaching materials and do Training to TBAs CCU, DNSP DPS Define list and buy Non-monetary incentives, i.e. kits for CHWs CCU, DNSP DPS Prepare Technical Specification, tender, buy and distribute Clean delivery kits for TBAs and mothers CCU, DNSP DPS Prepare Technical Specification, tender, buy and distribute Clean cut kits for THs CCU, DNSP DPS

d) Improving Hospital waste

65


Activities


1 T

2 T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T

management disposal (HWMD)

Provision of basic materials and equipment for HWMD at municipal hospital, health centers and health posts CCU, DNSP DPS, DNME Basic training for HWMD for municipal level personnel CCU, DNSP DPS, DNME Training on HWMD for provincial supervisors CCU, DNSP DPS, DNME

Training on biosafety and universal protection

CCU, DNSP, INLS DPS

Supervision and quality control on HWMD CCU, DNSP DPS

ii) Voucher Scheme Pilot Develop qualitative studies in each one of the five provinces to identify cultural, economic and social and health service determinants on demand side RH and delivery services CCU, TA DPS, DMS Based on study define precise strategy and implementation activities CCU, DNSP, DPS Design and implement community based awareness and BCC intervention to women to deliver in the health facility

CCU, DNSP, DPS DMS

Provide incentives on transportation

III. Project Management and M&E (a) Strengthen the program management Strengthening the staffing of Central coordination unit Prepare integrated supervision manual, train health professionals and Implement at least 3 yearly supervision visits to provinces from regional coordination and technical support teams CCU, DNSP Prepare TORs, Procure and contract DPS-operational technical consultant and administrative assistant for 5 Provinces CCU, DNSP

DPS., HAMSET

Strengthening with TA the capacity of GEPE of MOH CCU, DNSP DPS Prepare TORs, Procure consultants, and contract TA to develop HRDP, PIP, MTEF CCU, DNSP

DPS., HAMSET

Strengthening M&E capacity in MOH

66


Activities


1 T

2 T 1 T 2 T 3 T 4 T 1 T 2 T 3 T 4 T

5 day training at central level of 2 M&E people for each of the 5 provinces for the use of HMIS TA, GEPE CCU; DNSP Prepare specifications, tender documents, Bid and buy and distribute computers and Stationery materials for M&E including the 5 provinces

HAMSET, CCU DPS

Implement Provincial and Municipal HMIS CCU, HAMSET DNSP, DPS Prepare TORs , launch Bid and contract firm and do Annual financial audits Prepare TORs, Bid, contract external evaluator and do Mid Term Evaluation Prepare TORs, Bid, contract external evaluator and do Final Evaluation CCU, DNSP DPS, GEPE Prepare regulation and implement Revitalization coordination committee-regional/National meetings for project monitoring and for planning CCU, DNSP GEPE, DPS Prepare Regulation and guidelines for coordination committee CCU, DNSP

GEPE, Minister

Discuss with partners CCU, DNSP GEPE, DPS Do meetings and disseminate recommendations CCU, DNSP GEPE, DPS Implement Provincial and Municipal health plan in provinces Prepare TORs and Contract PASS specialists team for TA and support

CCU, DNSP, HAMSET GEPE, DPS

Prepare national team (MOH specialists, architecture students and public health doctor) CCU, DNSP GEPE, DPS

construct Mapa Sanitario CCU, DNSP GEPE, DPS Prepare Health plan in each province Prepare design specifications, tender and Build Housing for health professionals at municipal level

CCU, HAMSET GEPE, DPS

67

Annex 7: Financial Management and Disbursement Arrangements


206. The financial management assessment was carried out because World Bank policy requires

the borrower and project implementing entities to ―maintain financial management systems --

including accounting, financial reporting, and auditing systems -- adequate to ensure that they can

provide IDA with accurate and timely information regarding project resources and expenditures.‖

207. The objective of the assessment was to determine whether the entity implementing the

project has acceptable financial management arrangements. The arrangements include the entity‘s

system of accounting, reporting, auditing, and internal controls, and are deemed acceptable if:

they ensure that funds are used only for the intended purposes in an efficient and

economical way;

they are capable of correctly recording all transactions and balances, and supporting

the preparation of regular and reliable financial statements;

they are capable of safeguarding the entity‘s assets; and

they are subject to auditing arrangements acceptable to IDA.

208. World Bank policy requires that acceptable accounting and internal control systems are in

place when project implementation begins. In practice, it is desirable to ensure that acceptable

arrangements are in place no later than the date of Credit effectiveness. The assessment report was

discussed with the Borrower

209. Summary of Assessment. The Ministry of Health will have the overall responsibility for

the management of the project. The National Department of Public Health (DNSP) will be in

charge of the day-to-day management of the project through the CCU. The DNSP‘s proposed

arrangements were reviewed in accordance with the Financial Management Practices Manual

issued by the Financial Management Board on November 3, 2005:

The overall risk rating for the project is Substantial. Several mitigating measures

were proposed, including use of an existing project Central Coordinating Unit (CCU)

for the day to day management of the project, the hiring of an International Financial

Management Specialist for the project, modification of the existing CCU FM Manual

to take into account interaction with municipal authorities, and the hiring of internal

and external auditors specifically for the project;

The project will have 100% IDA financing. The government will ensure that under

each yearly budget proposal to its legislature, adequate arrangements are made by the

government to assume such portion of the costs related to government‘s in kind

contribution, required to achieve the objectives of the project (US$16.5 million over

the life of the project).

Co-financing has been secured from Total E&P Angola. IDA will finance all

categories, except for Component 1, subcomponents 1.1(a), 1.4(b), and 1.4(c) which

will be financed 100 percent by Total E&P Angola.

68

210. The residual risk after the proposed mitigating measures is expected to be moderate, as the

bulk of these measures have been adopted for the ongoing HAMSET project and can very easily be

taken on by the new MHSS Project.

211. Implementation Arrangements. The Ministry of Health will have the overall responsibility

for the management of the project. The National Department of Public Health (DNSP) will be in

charge of the day-to-day management of the project through the CCU. In 2006, the DNSP created

the MHSS Central Coordinating Unit (CCU). The CCU is headed by a Coordinator who reports to

the National Director of Public Health, and will be strengthened through the project by the addition

of a Deputy Coordinator, an M&E Specialist, an Infrastructure Specialist, a Training Specialist, a

Health Specialist, a Financial Management Specialist, a Financial Officer, a Procurement

Specialist, a Procurement Officer, as well as supporting staff. A key responsibility of the FMS,

internationally recruited under HAMSET and continuing with the MHSS, will be the hands-on

training of the Project Financial Management Specialist.








213. The CCU‘s FM responsibilities include the management of financial resources for MHSS

implementation and the rational use of funds, the supervision of the financial management of

MHSS funds, and the preparation of the quarterly financial management reports and annual audit

reports to review financial management progress. The CCU will also be responsible for developing

the withdrawal applications for submission to IDA. The CCU will also help municipalities prepare

the annual MHSS budgets and ensure their inclusion in the overall municipal budget; and help

municipalities mobilize resources, as needed.

214. The current internationally-recruited Financial Controller for the HAMSET project is

expected to be retained, initially to manage the work and train a successor in the process, then later

in implementation to act only as advisor to Angolans selected to satisfy the longer term staffing

needs of the department.

215. Country Issues. The most recently completed FM-related ESW for Angola is still the

combined Public Expenditure Management and Country Financial Accountability Review

(PEMFAR) completed in 2004. It highlighted the existence of major institutional weaknesses

which have aggravated the country‘s already weak fiscal stance. Unexplained discrepancies

between stated government funds and actual revenue were deemed significant and the review

further concluded that the pervasive deficiencies in the country‘s public financial management

impaired good macroeconomic management. The situation is exacerbated by the existence of a

dual public expenditure system, where ―conventional‖ expenditures are processed by the National

Treasury Directorate, while ―unconventional‖ expenditures, aimed at facilitating transactions such

as the servicing of key external debt, are centered on the national oil company, Sonangol. The

review recommended the discontinuation of the ‗parallel‘ spending process, as the underlying

reasons for its emergence (during the war) were no longer valid. Proposals were made for the way

69

forward, being primarily to strengthen the ―Conventional‖ leg and ‗ring-fencing‘ and eventually

phasing out the ―Unconventional‖ portion.

216. The PEMFAR noted with appreciation government‘s efforts to make the system work better.

Progress on the Government IFMIS (Integrated Financial Management Information System – or

SIGFE in Portuguese – Sistema Integrado de Gestão das Finanças do Estado) is particularly noted.

The system is gradually being rolled out to budget units and will eventually be the cornerstone of

the public financial management system in the country.

217. A new Accounting Law and Chart of Accounts were promulgated, but the process of

implementation is far from complete. Lastly, the review noted that ‗audit and control‘ systems,

although regulated by law, do not operate efficiently in practice, as the National Inspectorate of

Finance is weak and needs to be strengthened. A follow-up review is proposed for FY10 to provide

an update of developments within the public financial management area in the country.

218. The IDA team sought additional insight into the accounting professionals market in the

country by way of discussions with the established professional accounting firms in the country.

Indications are that qualified accounting professionals are still thin on the ground, leading to rather

pricey competition for those that are available. The most competitive sector is still ‗oil‘, as

expected, and tends to get all the very best of what is available, locally and from the regional

markets as well as Portugal and Brazil. The private sector takes the next ‗notch‘, meaning the

public sector resorts to whatever is left over. It is generally felt that Financial Management is in a

slightly better position than Procurement in terms of available human resources, but for both

qualified Angolans are few and far between.

219. Recent developments seem to indicate that the authorities are now committed to improving

the management of the economy. The last few months have seen an increasing willingness to

publicly acknowledge the macroeconomic and transparency issues that affect the country.

Important inroads have been made in granting the public access to sensitive documents and reports,

and addressing the issues of quasi-fiscal and extra-budgetary spending. Nevertheless, focused

efforts on improving public financial management systems and practices, as well as on

strengthening the ―agencies of restraint‖ are still at the embryonic stage.

220. Governance and Accountability. The quality and capacity of the bureaucracy in Angola is

very weak. A recent MIGA Country Risk Assessment indicates that the risks of Expropriation and

Breach of Contract are average-to-high. Enforcement of contracts and recognition of property

rights depend largely on informal mechanisms. The country currently ranks 176 out a sample of

178 countries in the 2008 Doing Business Report question on enforcing contracts.

221. In the Transparency International‘s Corruption Perception Index for 2007, Angola‘s score

remained unchanged at 2.2, but it now ranks 147th (as opposed to 142nd from last year).

222. Conflict of interest and ethics rules for public servants are not observed/enforced.

Implementation of laws and policies is distorted by corruption.

223. With this background, the ongoing Bank-financed EMTA project is supporting several

capacity building initiatives, as well as the revision of the existing procurement legislation. But

change will not be instantaneous, and therefore the following steps will be undertaken to

minimize/identify early, the incidence of corruption during implementation of the project:

70

Financial Management and Accounting system- due to perceived weaknesses in the

country systems, a reinforced CCU will be engaged to handle the administration and

financial management of the project. The CCU will introduce a fully computerized

accounting system to improve control and reduce errors resulting from manual

processing of data and transactions, as well as improve the audit trail.

Audit - The TOR s for both internal and external auditors will include specific

responsibilities towards the detection and reporting of fraud and corruption in project

activities.

224. Summary risk analysis. The following are necessary features of a strong financial

management system:

the CCU should have an adequate number and mix of skilled and experienced staff;

the internal control system should ensure the conduct of an orderly and efficient payment

and procurement process, and proper recording;

the accounting system should support the project‘s requests for funding and meet its

reporting obligations to fund providers including Government of Angola, IDA, and other

donors;

the system should be capable of providing financial data to measure performance when

linked to the outputs of the project; and

an independent, qualified auditor should be appointed to review the Project‘s financial

statements and internal controls.

225. Risks and risk mitigation measures. The table below lists the key risks identified for the

proposed project. The CCU will face these risks in achieving the above objectives, due to the weak

control environment. A carefully determined risk management action has been identified for each,

to mitigate the negative effects of the particular risk, and ensure positive results:

Table 18: Summary Risk Table Risk Risk

Rating

Risk Mitigation Measures

incorporated in

Project Design

Residual

Risk

Condition of

Effectiveness,

Board or

Negotiation

(Yes

or No)

Remarks

Inherent Risks

Country Level

Governance issues have

previously been identified

(in the Transparency

International‘s Corruption

Perception Index for 2009,

Angola‘s score now ranks

162th out of 180 countries,

compared to 147th in

previous year) and hence

there is a risk that funds may

not be used in an efficient

and economical way and

exclusively for purposes

intended.

H Appropriately qualified and

experienced staff will be

recruited to manage the

fiduciary aspects of the project.

Internal control procedures will

be documented in a procedure

manual and staff will ensure

those guidelines are adhered to

religiously

H Yes,

Effectiveness

To be addressed at Project

Level.

71

Implementing Entity

The government may not be

able to meet the costs related

to its in-kind contribution

under the form of

pharmaceuticals.

S This is a possibility given the

competing requirements on

treasury, and the

unpredictability of government

flows. However, the risk is

modest because economic

growth is expected to resume in

2010 and Angola‘s medium-

term economic prospects are

good, with GDP projected to

grow by 6.5% per annum from

2010 to 2012. This risk is

mitigated by including in the

project the financing of a buffer

stock of pharmaceuticals for an

amount of US$5.2 million.

M No

Program Level

The project may be unable

to find and engage

appropriately qualified staff

to manage implementation

within each municipality.

S Due to agreed poor capacity in

each municipality, fiduciary

management will be largely

centralized in a PIU. This

enables the hiring of qualified

specialist staff at commercially

competitive remuneration.

M Yes,

Effectiveness.

As a condition of

effectiveness, the MOH

will have recruited

qualified staff for the

PIU, including

international specialists

for financial and

procurement

management, a public

health specialist, and a

training specialist with

qualifications and

experience, and to terms

of reference, satisfactory

to IDA.

Overall Inherent Risk S S

Control Risk

1. Budgeting

Risk that budget process

may not be based on valid

assumptions and procedures

for approvals and variations

may not be clearly laid out

or followed.

H Planning process will be

consultative and in line with

agreed project objectives, and

coordinated by the qualified

FM Specialist.

M During Joint project

Implementation Reviews.

2. Accounting:

Risk that acceptable

accounting standards may

not be used, as well as poor

control due to lack of

qualified accounting staff.

S A Financial Management

Specialist to be hired before

effectiveness, and accounting

to be on an established

accounting software.

M Yes FM Specialist already in

place in HAMSET, but

Financial Management

Specialist to be hired

specifically for the project

to be in place prior to

effectiveness.

Computerized accounting

system for the CCU

already in place.

3. Internal Control: risk

that accounting policies and

procedures to be applied

may not be clearly defined,

and that where available,

risk that desired procedures

may not be followed

consistently.

S The policies and procedures are

to be captured in a

FM/Accounting Procedures

Manual acceptable to IDA, and

strict adhered to be monitored

by qualified staff.

M Yes CCU FM manual already

approved by the Bank,

but the same manual to be

adapted for use by the

new project prior to

effectiveness

72

4. Funds Flow

Funds may not reach

intended beneficiaries in a

timely manner.

H Close to 90% of all

procurements and

disbursements will be handled

centrally, with only the goods

or services being distributed to

the municipalities. Amounts to

be transferred to regions will

primarily be for per diems and

will be known for specified

names in specified amounts, as

opposed to advances to the

regions.

M No. While no funds can flow

till the DA is opened, this

is not usually made a

condition of

effectiveness.

5. Reporting and

Monitoring-

Risk that there may be no

regular FM reporting

comparing performance to

budget, and that if available,

reports may not effectively

used by management.

S Reporting requirements will be

set out within FM manual to be

revised and approved by IDA.

These will include quarterly

un-audited IFRs, as well as

annual financial reports. Draft

IFR formats have been

provided to the CCU.

M Yes Agreements on formats

for IFRs and content of

Annual Financial

Statements to be reached

at negotiation.

6. External Audit-

The Supreme Audit function

in Angola is still developing,

and does not yet possess the

necessary human capacity to

discharge its statutory duties

satisfactorily. Risk that the

annual audit may not meet

IDA requirements.

S The audit of the project

activities will be covered by a

firm of auditors recruited for

the purpose on TORs

satisfactory to IDA. The client

has been provided with draft

TORs.

M Yes and No Appointment of the

auditors is a dated

covenant to ensure that

they are in place within 3

months of credit

effectiveness. The TORs

for the appointment of

auditors will be agreed

with IDA at negotiation.

Overall Control Risk S M

Overall Risk Rating for the

Project

S M

Risk Rating – H (High Risk), S (Substantial Risk), M (Modest Risk),L (Low Risk) N (Negligible Risk)

Strengths and Weaknesses

226. Weaknesses. While the project will have a centralized CCU, the actual implementation will

be dispersed in the selected municipalities, whose administration and financial management

capacity is generally accepted as low. The project will thus be geographically dispersed, and would

otherwise consist of several, small contracts per municipality. Because this situation has inherent

weaknesses with regard to both execution and the accuracy and timeliness of information, which

the CCU would need to collate and report on, as well as the effectiveness of internal checks and

controls in the remote areas, it has been decided to centralize fiduciary management and reporting.

Only goods and services already procured will be sent down to the municipalities. In addition, a

critical component of the CCU‘s International Financial Management Specialist‘s role will

therefore be the grooming and mentoring of FM staff within both the CCU and the beneficiary

municipalities to improve their FM capacity and performance for the long term benefit of the

country.

227. Strengths. The CCU will be benefit from the assistance of the existing HAMSET project

implementation unit that has been successfully managing an ongoing Bank financed project in the

same sector. FM staff from the CCU will thus have the necessary experience of working with the

Bank, as well as dealing with the government in terms of both actual implementation and sourcing

the in-kind counterpart contribution.

73

Financial Management

228. Budgeting. The project will prepare annual budgets, which will be in line with the project

development objectives and the government‘s overall health delivery policy. The budgeting

process will be consultative to ensure accommodation of the views of all key players, will include

all project activities, and be completed in line with the government‘s budget preparation

timetables. Budget management will be the responsibility of the Financial Management Specialist,

and budget implementation will be carefully monitored through the quarterly interim unaudited

financial reports (see below), which will measure actual performance against target for each

period. The government will ensure that under each yearly budget proposal to its legislature,

adequate arrangements are made by the government to assume the portion of the costs related to

government‘s in kind contribution, required to achieve the objectives of the project.

229. Accounting. As with the ongoing HAMSET project, accounting will be in accordance with

international accounting standards, and accounting processing will be on an acceptable platform, in

this case the same SAC 3.0 software that is in use for the current project. Staffing will include a

qualified FM Specialist supported by HAMSET‘s internationally recruited FM Specialist. For

capturing FM information, the existing chart of accounts for HAMSET, will be adapted and

designed to include all project activities. The design will facilitate easy reporting by project

component and project categories.

230. Internal Control. Per above, approval and authorization controls for the CCU are well

documented in the existing procedures manual, and compliance therewith is monitored by qualified

accounting staff. The existing FM manual will be adopted for the new project, although some

customization to incorporate interactions with provincial and municipal authorities will be

necessary. Such modifications will need to be completed prior to effectiveness.

231. The existing procedures manual documents the major transaction cycles of the project, funds

flow processes, accounting records, supporting documents and chart of accounts. It also

summarizes authorization procedures, the financial reporting process, financial and accounting

policies for the project, budgeting procedures, financial forecasting procedures, procurement and

contract administration and management, as well as replenishment procedures for the Designated

Account and the auditing arrangements.

232. Reporting and Monitoring. The project will produce interim un-audited financial reports

(IFRs) on a quarterly basis, using formats to be agreed with IDA. Formal adoption and agreement

with IDA on the IFR formats, as well as the formats for the Annual Financial Statements were

agreed at negotiations.

233. The quarterly reports will be prepared and submitted to the Bank within 45 days of the end

of each calendar quarter reported on. The financial reports will be designed to provide quality and

timely information to project management, implementing agencies, and various stakeholders on

project performance. These quarterly reports will include designated Account Activity statements,

Summary Statement of DA expenditures Subject to Prior review, and not Subject to Prior review,

Sources and Uses of Funds by Expenditure Category; Detailed Use of Funds by Project

Component, Narrative explanation of the performance for the quarter, and comparison of actual

expenditure with budgets; summary schedules of assets acquired under the project, as well as six

monthly cash flow forecasts.

74

234. Internal Audit. There is no internal audit in the CCU at the moment. Due to the

decentralized nature of the project‘s activities (several municipalities/regions), it is recommended

that an internal audit firm be hired to carry out the duties of internal auditor. The firm will be hired

using TORs acceptable to IDA, with a strong emphasis on value for money and physical

verification of decentralized activities. The hiring of the internal auditor will be made a dated

covenant in the legal agreement, to ensure that it is carried out in a timely manner and the auditors

are in place within three months of effectiveness.

235. External Audit. The Ministry is subject to audit by the Tribunal, but a separate auditor with

qualifications acceptable to IDA, will need to be hired to carry out the annual audit of the project.

The TORs for the external audit engagement were agreed with IDA at negotiations. The audit will

be conducted in accordance with International Standards on Auditing. Finalization of the audit

arrangement needs to be made very early in implementation, thus the hiring of the auditors is a

dated covenant to ensure they are in place within three months of effectiveness. One audit opinion

covering all project financing will suffice. The audit report must be submitted to the IDA within

six months of the end of the government‘s financial year. A management letter highlighting any

deficiencies in the system of management and internal controls, incorporating the necessary

responses by management, should also be submitted as part of the audit submission package.

Action Plan

Engage required FM staff (a Financial Management Specialist within the CCU to be hired

for the new project– condition of credit effectiveness

Complete modification/update of existing FM Procedures Manual - condition of credit

effectiveness

Contract project external auditors within 3 months of effectiveness

Contract project internal auditor within 3 months of effectiveness

236. The accounting software is already in place and in use for the current project, hence no

additional actions are required with respect to that.

Conditionalities

Effectiveness Conditions

Appointment of Financial Management Specialist

Update of existing CCU Financial Management Procedures Manual

Disbursement Condition

No disbursement will be made under component 2 (Piloting demand-side incentives to encourage

institutional deliveries) until no later than two years following the effective date: (i) the Recipient

will have adopted the Voucher Scheme Manual in a manner and substance satisfactory to IDA; and

(ii) the Recipient has issued an internal decree, satisfactory to IDA, regulating the voucher system.

75

Financial covenants

A financial management system, including records and accounts will be maintained by the

implementing agency for the life of the MHSSP. Financial Statements will be prepared in a

format acceptable to IDA, and will be adequate to reflect resources and expenditures of the

MHSSP, in accordance with sound accounting practices.

The Recipient shall prepare and furnish to IDA, not later than forty-five (45) days after the

end of each calendar quarter, interim unaudited financial reports for the MHSSP covering

the quarter, in form and substance satisfactory to IDA.

The Recipient shall have its Financial Statements audited by an independent auditor

competitively selected with qualifications and experience acceptable to IDA. Each audit of

the Financial Statements shall cover the period of one Fiscal Year of the Recipient,

commencing with the Fiscal Year in which the first withdrawal under the MHSSP was

made. The audited Financial Statements for each such period shall be furnished to IDA not

later than six months after the end of such period.

Dated covenants

Within 3 months of effectiveness of the credit, the CCU shall: (i) contract project external

auditors; and (ii) contract project internal auditors.

237. Supervision plan. The project risk rating after implementation of the proposed risk

mitigation measures is ‗moderate‘. In the first year of implementation, supervision will include an

initial onsite visit to confirm readiness to disburse, thereafter quarterly desk reviews of the

unaudited quarterly IFRs will be complemented by at least two onsite visits to the project for the

first year. Subsequently, the number of onsite visits will depend on the evolving FM risk rating for

the project.

Funds flow

238. Designated Account for Pooled Funds. The MOH, through the DNSP, will open and

maintain a pooled Designated Account (DA) to receive the financial proceeds of the IDA Credit.

The DA, which will be under the control of the DNSP‘ s CCU, will be established with a

Commercial Bank acceptable to IDA, and will be maintained in US dollars. The ceiling for the DA

will be determined separately, and advised through the Disbursement Letter.

239. Disbursements from IDA will finance 100 percent of goods, works, consultant services,

training, and operating costs under Parts A1b, A2, A3, A4a, A5, B, C1, C2, and C3 of the Project

as indicated in the Financing Agreement.

240. Designated Account – Total E&P Angola: to be managed by the CCU: Denominated in

$US, disbursements from the Total E&P Angola grant will be deposited in this account to finance

100 percent of training, works and goods under Parts A1a and A4b as indicated in the Financing

Agreement.

241. The funds flow arrangement is illustrated in Figure 5 below:

76

Figure 5: Funds Flow Arrangements

242. Payments to suppliers are generally made from the US$ account. Transfers from the

Designated Account to the Municipalities will relate only to allowances to be paid to staff. These

will be based on an approved list showing the computations and exact amount required, against

each listed beneficiary. There will be no general advances to the provinces. Transfers to

implementing institutions, such as the training colleges, will be for invoiced training costs only.

Stipends for nurses on training who have no ‗own‘ bank accounts can also be made to the

institutions, supported by a detailed remittance advice listing the individual beneficiaries.

243. Regarding the pilot voucher scheme to encourage institutional deliveries, its overall

management would be contracted to an NGO. The contractor‘s responsibility would be to: (i)

undertake communication activities to promote the transport and mother voucher schemes to

beneficiaries, and explain the rules to health centers, the hospital, and the municipal administration;

(ii) design the transport voucher ensuring the minimum security features to reduce fraud, and make

IDA Credit

Account

(WB - USA)

US $ Designated

Account (WB funds

managed by DNSP –

Commercial Bank,

Luanda)

CCU handles

payments to all

suppliers of goods and

services.

Transfers to Municipalities/

Regions (***) with respect to

payments of specific amounts to

nominated staff members.

Transfers to commercial bank branches

in the Provinces for the transport

vouchers scheme.

Transport providers and women

cash vouchers at commercial

banks.

Staff collect their per diems

and allowances from

participating institutions.

Total

Designated

Account

Total

Commercial bank

surrenders cashed

vouchers for

replenishment of account

Municipality

provides

justification for

advances

Suppliers of

goods and

services

77

it available in health centers; (iii) help the hospital to design delivery certificates; (iv) design, in

line to the MHSS, the information system to capture information on the total vouchers, number of

users, mothers and drivers, age of users and problems related to the application of the scheme; (v)

ensure that the municipality opens a bank account where voucher funds will be transferred from

the MHSS project CCU in Luanda or from the DPS; (vi) help determine responsibilities for

payment of vouchers including appropriate accounting mechanism, preparation of SOEs, and

maintaining of sufficient funds on account for regular payment of vouchers for transport; (vii)

undertake a risk analysis covering: (a) the cultural factors that could affect the success of a subsidy

scheme: (b) the legal and regulatory issues that could affect its success; (c) the institutional

opportunities and constraints; (d) increase in total pregnancies per woman; and (e) other types of

risks the incentive scheme could face. It would propose ways of mitigating these risks.

244. The NGO will record all advances to commercial bank branches and on a monthly basis will

collect and record the funds used to pay vouchers. The NGO will prepare and submit a monthly

report to the project financial management unit that will contain information of advances and uses

of funds on pilot voucher schemes. The information provided in those reports will serve as a basis

for disbursement claims. The NGO has the responsibility of maintaining all necessary records and

supporting documentation of the pilot voucher scheme.

245. Transfers will be made to selected commercial bank branches within the target

municipalities upon agreement with the institutions (referred to as partner banking institutions).

The annual ‗forecast maternity outturns‘ for each area will be used to estimate the projected births

for the area in any given year. Using the unit transportation charge for each maternity trip agreed

with the transport providers association in the area, an advance equivalent to six months‘ births

will be made to the local branch of the partner bank. The local health service office in the area

makes the vouchers, good to the value of the agreed unit transport charge, available to pregnant

women prior to delivery. On the day of delivery, the expectant mother uses the voucher to procure

transport to the delivery hospital. The delivery room clerks will sign and stamp the voucher upon

admitting the patient, whereupon the transport operator can present the voucher to the partner bank

and exchange it for cash equivalent. More details of the transport incentive scheme can be found In

Annex 18.

246. Disbursement Arrangements. IDA will deposit into the Designated Account its

contribution. Disbursements from the Designated Account will be made on the basis of quarterly

IFRs. The IFRs will be submitted and reviewed by IDA for disbursement purposes. Detailed

disbursement procedures will be described in the Project Accounting Manual of Procedures.

247. Total E&P Angola will finance 100 percent of training expenses under Component 1,

subcomponent 1.1(a) of the Project (US$3.3 million); and 100 percent of the rehabilitation and

construction of 4 delivery rooms (for pre and post delivery, and child care) in health centers and

posts in Malange (US$520,000) under subcomponent 1.4 (b); and solar kits for maternal and child

health care (US$720,000) under subcomponent 1.4 (c).

248. The project will use report-based disbursements. This method relies on the FM team‘s

experience with bank reporting, including timely submission of IFRs. The team worked with

transaction based disbursement during the life of the HAMSET project, but is expected to be able

to cope with the more flexible method of replenishing their Designated Account. The Bank will

78

issue the ―Disbursement Letter‖ which will specify the additional instructions for withdrawal of the

proceeds of the Credit.

249. The contribution of each donor is as follows:

Allocation of Financing by Disbursement Category

Category IDA (US$)

Total

E&P

Angola

Percentage of

expenditures to be

financed (inclusive

of taxes)

Goods, civil works and Training for Part 1.1 (a), 1.4

(b), 1.4 (c) 4,500,000 0

Goods, consulting services, training expenditure and

works for Part 1, except training for Part 1.1 (a) , and

goods and works for Part 1.4 (b) and 1.4 (c)

49,230,000

100

Cash transfers and consulting services under Part 2 740,000

100

Goods, services, operating costs and training for Part 3 17,330,000

100

Unallocated 3,500,000

Total financing 70,800,000 4,500,000

250. Conclusions of the FM Assessment. The proposed FM arrangements for the Municipal

Health Service Strengthening Project, as reinforced by the FM Action Plan above, meet the

minimum requirements for financial management under OP/BP 10.02.

79

Annex 8: Procurement Arrangements


General

251. Procurement for the Municipal Health Service Strengthening Project will be carried out in

accordance with the World Bank‘s "Guidelines: Procurement Under IBRD Loans and IDA

Credits" dated May 2004, revised October 2006; and "Guidelines: Selection and Employment of

Consultants by World Bank Borrowers" dated May 2004, revised October 2006, and the provisions

stipulated in the Legal Agreement. The various items under different expenditure categories are

described in general below. For each contract to be financed by the Credit, the different

procurement methods or consultant selection methods, the need for pre-qualification, estimated

costs, prior review requirements, and time frame are agreed between the Borrower and the Bank in

the Procurement Plan. The Procurement Plan will be updated at least annually or as required to

reflect the actual project implementation needs and improvements in institutional capacity.

252. The last Country Procurement Assessment Review (CPAR) for Angola was conducted in

October 2002. The Action Plan of the CPAR provided for (i) Identifying a champion to spearhead

the Procurement reform and organize a high-level workshop; (ii) Activate/empower the task force

to pilot the reform implementation and the creation of a comprehensive procurement framework;

(iii) Review procurement legal and regulatory framework; (iv) Establish a directorate at Ministry

of Finance to undertake procurement policy formulation and procurement analysis; (v) Introduce

record keeping to establish a transparent procurement system in at least three Ministries during a

first year pilot program; (vi) Propose sound reorganization of procurement processing and train

procurement staff in pilot ministries and (vii) Strengthen National Inspectorate of Finance, the

High Authority Against Corruption and the external controls by the Tribunal of Accounts.

253. The Government of Angola is currently reforming its own Procurement Regulations and

Procedures, following the Bank 2002 CPAR. The Bank is supporting the Procurement Reform

under the Economic Management Technical Assistance Project (EMTA). The selection process for

an international firm to aid the Government in the reform was initiated in 2005. This is an on-going

work and the Consultants have to date produced several drafts and once the work is finalized the

procedures and regulations should be aligned with international best practices. A procurement

regulatory body is also expected to be established in the framework of the on-going reform.

254. The Ministry of Health (MOH) will have the overall responsibility for the implementation

and coordination of activities under the project. The National Directorate of Public Health (DNSP)

will be in charge of managing the day-to-day activities of the project, through a Central

Coordinating Unit (CCU). The MOH is at present implementing the Bank-financed HIV/AIDS,

Malaria and Tuberculosis Control (HAMSET) project and has a Closing Date of June 30, 2010.

The staff for the CCU, including financial management, procurement and monitoring and

evaluation, will be contracted by effectiveness. The MHSS Procurement Specialist will receive

support from the HAMSET internationally-recruited Procurement Specialist.

255. Procurement of Works. Works procured under this project would include the rehabilitation

and construction of delivery rooms, construction of houses for health professionals and

80

improvements of water and sewage facilities, among other infrastructure. The procurement will be

carried out using the World Bank‘s Standard Bidding Documents (SBD) for all International

Competitive Bidding (ICB) contracts. National Competitive Bidding (NCB) documents in

Portuguese language, translated documents from the ICB version will be used as agreed upon by

the World Bank. For contracts estimated to cost less than US$3,000,000 equivalent per contract,

NCB procedures will apply. Small simple works estimated to cost less than US$100,000 equivalent

per contract may be procured by requesting at least three written quotations from qualified

contractors. Community Participation in Procurement method may be used in remote areas where

small contractors are not likely to be identified and unskilled workers would be suitable for the

rehabilitation of minor health facilities. The unskilled workers would be hired in the communities

close to the works, such as bricklayers, carpenters and locksmiths.

256. Procurement of Goods. Goods procured under this project would include: office furniture,

office equipment, information technology equipment, vehicles, motorcycles, quad bikes, house

furniture and appliances, laboratory equipment, training manuals, solar kits, radios, kits for

deliveries, kits for community health workers, and equipment for hospital waste disposal, among

others. The procurement will be done using the World Bank‘s SBD for all ICB. National

Competitive Bidding (NCB) documents in Portuguese language, translated documents from the

ICB version will be used as agreed upon by the World Bank, for Contracts estimated to cost less

than US$250,000 equivalent per contract. Small value goods estimated to cost less than US$75,000

equivalent per contract may be procured under shopping procedures, with the solicitation of written

quotations from at least three reputable suppliers. UN Agencies and direct contracting may also be

considered with World Bank prior review and approval, for the procurement of vehicles,

ambulance and specialized health sector goods. Because of conflict of interest, solar kits will not

be procured from Total E&P Angola.

257. Selection of Consultants. Consultants‘ services required would cover consultancies for:

quality control of health waste management, social assessment of characteristics that influence the

demand for institutional deliveries, community awareness campaign, strengthening of Provincial

Health Departments, preparation of Human Resources Development Plan, Medium-Term

Expenditure framework, Infrastructure Plan, strengthening Monitoring and Evaluation capacity of

MOH, impact evaluation of pilot for institutional deliveries, financial audits, and mid-term and

final evaluations, among others.

258. All consulting service contracts costing more than US$200,000 equivalent for firms will be

awarded through Quality and Cost Based Selection (QCBS) method. Contracts for highly

specialized assignments estimated to cost less than US$200,000 equivalent may be contracted

through Consultants‘ Qualification Selection (CQS).

259. Least-Cost Selection (LCS) will be used for selecting consultants for assignments of a

standard or routine nature (audit services, works supervision) where well-established practices and

standards exist and are estimated to cost less than US$200,000. Consulting firms for services,

which meet the requirements under paragraph 3.2 of the Consultant Guidelines, would be selected

through Quality-Based Selection (QBS).

260. Single Source Selection (SSS) may be employed with prior approval from the World Bank

and will be in accordance with paragraphs 3.9 to 3.12 of the Consultant Guidelines. A survey of

Maternal Health Care indicators may be entrusted to the World Health Organization (WHO), based

81

on their exceptional experience in this field and the need to use a methodology developed by

WHO.

261. All services of individual consultants (IC) will be procured under individual contracts in

accordance with the provisions of paragraphs 5.1 to 5.4 of the Guidelines.

262. Short lists of consultants for services estimated to cost less than US$100,000 equivalent per

contract may be composed entirely of national consultants in accordance with the provisions of

paragraph 2.7 of the Consultant Guidelines.

263. Training. This category would cover all costs related to the carrying out of study tours,

training courses and workshops, i.e. hiring of venues and related expenses, stationery, and

resources required to deliver the workshops as well as costs associated with financing the

participation in short-courses, seminars and conferences including associated per diem and travel

costs. Training programs would be part of the annual procurement plan. Prior review of training

plans, including proposed budget, agenda, participants, location of training and other relevant

details, will be required only on annual basis.

264. Training Institutes. For the provision of training at provincial and central levels to nurses,

midwives, community health workers, traditional birth attendants and traditional healers, the

Government-owned Instituto Medio de Saúde (IMS) and Escolas Tecnica Provinciais de Saúde

(ETPs) have been identified as possessing experience of exceptional worth and will be selected on

single source for the provision of training activities. The IMS and ETPs will be reimbursed for

expenditures required to defray the cost incurred in the delivery of agreed training sessions,

inclusive of a nominal management fee. These expenditures will be included on the DNSP annual

training program.

265. Operating Costs. Operating costs shall consist of the incremental expenses incurred on

account of the Project implementation, management and monitoring, including: (a) office supplies;

(b) office utilities and communications expenses; (c) office rental expenses; (d) Project vehicles‘

maintenance costs, fuel and spare parts; (e) travel expenses and per diems for official Project staff

(excluding salaries of Recipient‘s civil servants); and (f) operation and maintenance of office

equipment, financed with the proceeds of the Credit. The operating cost items will be procured

using the existing MOH administrative procedures, similar to the ones in place for the HAMSET

Project, which were reviewed and found acceptable to the Bank.

266. The procurement procedures and SBDs to be used for each procurement method, as well as

model contracts for works and goods procured, and selection of Consulting Services are included

in the Operations Procurement Manual prepared by the implementing agency which was agreed

prior to negotiations. The Operations Manual will be an update of the HAMSET Manual.

B. Assessment of the agency’s capacity to implement procurement

267. Procurement activities for the Project will be carried out by a Central Coordination Unit

(CCU) created within the DNSP, in its capacity of Implementing Agency and responsible for the

overall coordination of activities under the Project. The CCU Coordinator will respond to the

Director of Public Health as the Project Coordinator. The Deputy Coordinator will be responsible

for the day-to-day coordination of the unit.

82

268. The core five staff of CCU, will be recruited by effectiveness. The Procurement Specialist

will receive support from the HAMSET internationally-recruited Procurement Specialist.

269. An assessment of the capacity of the Implementing Agency to implement procurement

actions for the project was carried out by Antonio Chamuço, Procurement Specialist, during

appraisal. The assessment reviewed the organizational structure for implementing the project and

the interaction between the project‘s staff responsible for procurement and the staff responsible for

Financial Management as well as the coordination of both HAMSET and MHSS projects.

270. The assessment revealed that the available capacity for carrying out procurement is adequate

for the CCU to carry out procurement for the MHSS project. The outstanding activities under

HAMSET project are limited in quantity and are not of a complex nature. This will leave sufficient

time for the HAMSET Internationally-recruited FM Specialist to give support to the MHSS

Procurement Specialist.

271. The key issues and risks concerning procurement for project implementation of the project

have been identified and include (i) the retention of current staff at HAMSET responsible for

procurement and financial management, and (ii) the availability of adequate procedures manual to

ensure that procurement activities will be carried out in a manner consistent with the Financing

Agreement. In addition, to provide for adequate control mechanisms and assurance that funds are

used for the purpose intended, procurement audits will be carried out by the Borrower.

Furthermore, to enhance oversight and accountability, only activities agreed in the Procurement

Plan will constitute eligible expenditure under the Project. Moreover, an internationally recruited

Procurement Advisor should be retained by DNSP, on a retainer contract, throughout the lifespan

of the Project. The corrective measures which have been agreed are listed in the Action Plan

below:

Table 19: Procurement Management Action Plan to Mitigate Procurement Risk

Risk Action Deadline

1. Capacity to manage

procurement

inadequate.

MHSS Procurement Specialist to

receive support from HAMSET

internationally-recruited Procurement

Specialist.

Effectiveness

2. Procedures for

procurement not laid

out properly;

Update the HAMSET Procurement

Manual to incorporate applicable

procedures under the MHSS Project,

as part of the operations manual. The

draft Manual has been reviewed and it

found substantially satisfactory. There

are items that need to be addressed,

however for the purpose of fulfilling

the effectiveness condition.

Effectiveness

3. Project proceeds not

used for the purposes

intended;

Carry out Procurement Audits to

ensure that proceedings of the Credit

as used in accordance with the

provisions of the legal agreement.

During Program

implementation,

every two years

83

Table 19: Procurement Management Action Plan to Mitigate Procurement Risk

Risk Action Deadline

4. Expenditures

incurred not

systematically agreed

with the Bank;

Procurement Plan (PP) should be

updated at least once annual or as

required. Only expenditures for

activities in the PP a eligible for

financing.

Continuous, at

least during

project

supervision

272. The country context for procurement is rated substantial as per the last CPAR. The valuable

experience gained by HAMSET staff and their absorption into the CCU of the MHSS, will enable

MOH to be able to implement procurement activities in a manner satisfactory to IDA. The overall

project risk for procurement is therefore moderate.

C. Procurement Plan

273. The Borrower developed a procurement plan for project implementation which provides the

basis for the procurement methods. This plan is available at the DNSP of the MOH in Luanda. It

will also be available in the project‘s database and on the World Bank‘s external website. The

Procurement Plan will be updated in agreement with the Project Team annually or as required to

reflect the actual project implementation needs and improvements in institutional capacity, and

should cover at least the next 18 months.

D. Procurement Audits

274. Given the country context above indicated, the need for a more systematic ex-post review is

substantial. In addition to the semi-annual supervision missions by the Bank, the Government will

carry out procurement audits of the project every two years. These audits will be carried out under

terms and conditions and by independent consultants whose qualifications are acceptable to the

Bank. The audits will include an action plan to improve performance, where required, which will

be submitted to the Bank and discussed with Government.

84

E. Frequency of Procurement Supervision

275. In addition to the prior review supervision to be carried out from Bank offices, the capacity

assessment of the Implementing Agency has recommended semi-annual supervision missions to

visit the field to carry out post review of procurement actions. The Supervision missions will also

include on-site visits, at least once every year.

276. The thresholds for the use of the various procurement and selections methods are

summarized below:

Table 20: Procurement Thresholds

Expenditure

Category

Contract Value

Threshold (US$)

Procurement

Method

Contracts Subject to

Prior Review (US$) *)

1. Works >3,000,000

100,000 – 3,000,000

<100,000

ICB

NCB

3 quotations

DC

All

First three contracts

None (small works)

All

2. Goods and

Services (other than

Consultants‘

Services)

>250,000

75,000-250,000

<75,000

ICB

NCB

Shopping

DC

All


None

All

3. Consultants‘

Services

Firms

Individuals

>200,000

<200,000

>100,000

<100,000

QCBS

LCS, QBS and

CQS

SSS

IC

IC

SSS

All


All

All


All

*) During the updates of the Procurement Plan the Bank will determine if prior review is required for a

sample of contracts with estimated cost below the mandatory prior review threshold.

F. Details of the Procurement Arrangements47

Involving International Competition

1. Goods, Works, and Non Consulting Services

(a) List of contract packages to be procured:

Ref. No. Contract

(Description)

Estimated

Cost

Procurem

ent

Method

Prequali

fication

(yes/no)

Domestic

Preference

(yes/no)

Review

by Bank

(Prior /

Post)

Expected

Bid-

Opening

Date

MHSS/G-05 Buffer stock of Essential

Drugs 4,971,938 ICB No No Prior Feb. 2011

MHSS/G-13 Procurement Kits for

normal delivery 4,884,239 ICB No No Prior Feb. 2011

47

Procurement Plan dated November 2, 2009

85

Ref. No. Contract

(Description)

Estimated

Cost

Procurem

ent

Method

Prequali

fication

(yes/no)

Domestic

Preference

(yes/no)

Review

by Bank

(Prior /

Post)

Expected

Bid-

Opening

Date

MHSS/G-08 Vehicles -Ambulances/

and 4x4 Station Wagons 3,121,200 ICB No No Prior Mar. 2011

MHSS/W-

02 Housing for Health

Professionals 7,600,000 ICB No Yes Prior June 2011

MHSS/G-14 Procurement of delivery

Kits for caesarean

1,953,696 ICB No No Prior June 2011

MHSS/G-16 Procurement for Clean

delivery Kits for TBAs

and Mothers

882,020 ICB No No Prior June 2011

MHSS/G-12

Procurement and

installation of Lot 1-

Mobile radio, Lot2 Fixed

Radios with antenna(18 +

23)

834,000 ICB No No Prior Sept. 2011

MHSS/G-07

Procure and installation

of: Lot 1-Solar kits for

(each team) and Lot 2-

Solar Mobile Kits

Delivery rooms(72+23)

738,400 ICB No No Prior Sept.2011

MHSS/G-22

Equipment for PNC/FP

delivery IMCI rooms and

Provincial maternities

635,500 ICB No No Prior Oct. 2011

MHSS/G-01

Printing and distribution

of FP, PNC, Delivery,

Pediatric Care, EDP

manuals and IEC posters

486,000 ICB No No Prior Dec. 2010

MHSS/G-09 Motorcycles 443,840 ICB No No Prior Dec. 2011

MHSS/G-18

Procurement of Basic

Materials equipments for

HWMD

324,000 ICB No No Prior Dec. 2011

MHSS/G-10 Quad vehicles 288,000 ICB No No Prior Dec. 2011

MHSS/G-19 Stationary(kits) 234,000 NCB No No Post Dec. 2010

MHSS/G-15 Kits for CHWs 205,920 ICB No No Prior Dec. 2011

MHSS/G-17 Procurement for Clean cut

Kits for THs 162,000 NCB No No Post Dec. 2010

MHSS/G-21 Procurement of Laptop

Computers 67,200 NCB No No Post Dec. 2010

MHSS/G-04 Telemedicine Room

Equipment Kit 60,000 NCB No No Prior Jan. 2011

MHSS/G-11 Bicycles for CHW 48,000 Shopping No No Post Nov. 2010

MHSS/G-06 Camping Kit 40,000 Shopping No No Post Dec. 2011

MHSS/G-02 Library Kit 21,600 Shopping No No Post Dec. 2010

MHSS/G-23 A review GIS Software 19,500 Shopping No No Post Oct. 2011

MHSS/G-24 GPS equipment 15,600 Shopping No No Post Oct. 2011

MHSS/G-03 Modem 4,600 Shopping No No Post Dec. 2010

MHSS/G-20 Training Manuals 2,480 Shopping No No Post Oct. 2010

86

(b) ICB contracts estimated to cost above $3,000,000 for works and US$250,000 for goods and

services per contract and all direct contracting will be subject to prior review by the Bank.

2. Consulting Services

(a) List of consulting assignments:

Ref. No. Description of Assignment Estimated

Cost

Selection

Method

Review

by Bank

(Prior /

Post)

Expected

Proposals

Submission

MHSS/C-

26

Base line and follow up Access and

Quality surveys (KPA & HFA) 1,250,00 QCBS Prior Mar 2012

MHSS/C-

11

Technical Assistance strengthening

capacity of GEPE of MOH 379,500 QCBS Prior Mar. 2011

MHSS/C-

12 TA to develop HRDP, PIP, MTEF 321,600 QCBS Prior Mar. 2011

MHSS/C-

13 Annual Financial audit 500,000 QCBS Prior Dec. 2010

MHSS/C-

22

Consultant for design, construction

supervision of Works Housing for

Health Professionals

800,000 QCBS Prior Dec. 2010

MHSS/C-

25

Supervision and quality control on

HWMD 190,000 QCBS Prior Dec. 2010

MHSS/C-

16

Design and implementation of

community based awareness and BCC

intervention

295,000 QCBS Prior Jan. 2011

MHSS/C-

21

Study on bottlenecks in drug

acquisition, planning, distribution,

budgeting and logistics

76,400 CQS Prior June 2012

MHSS/C-

01 Project Coordinator 420,000 IC Prior June 2010

MHSS/C-

02 Consultant M&E 420,000 IC Prior June 2010

MHSS/C-

03

Training and health systems

coordinator 420,000 IC Prior June 2010

MHSS/C-

04 Infrastructure specialist 294,000 IC Prior June 2010

MHSS/C-

05 Procurement specialist 420,000 IC Prior June 2010

MHSS/C-

06 Financial Management Specialist 490,000 IC Prior June 2010

MHSS/C-

07 Procurement Advisor 500,000 IC Prior June 2010

MHSS/C-

08 Financial Management specialist 500,000 IC Prior June 2010

MHSS/C-

19

Expert for supervision and quality

control and HWMD 190,000 IC Prior June 2010

MHSS/C- Specialist to develop qualitative 52,000 IC Prior June 2010

87

Ref. No. Description of Assignment Estimated

Cost

Selection

Method

Review

by Bank

(Prior /

Post)

Expected

Proposals

Submission

20 studies

MHSS/C-

09

Specialist to design and implement

community based awareness and BCC

intervention

295,000 IC Prior Feb 2011

MHSS/C-

17 Social Sector TA Consultant 188,000 IC Prior Apr 2011

MHSS/C-

18

Preparation of Sanitary Map and

Health Plan 188,000 IC Prior Apr 2011

(b) Consultancy services estimated to cost above $200,000 per contract for firms and US$100,000

equivalent per contract for individuals and all single source selection of consultants (firms and

individuals) will be subject to prior review by the Bank.

(c) Short lists composed entirely of national consultants: Short lists of consultants for services

estimated to cost less than $200,000, equivalent per contract for Construction Supervision and

$100,000 equivalent per contract, for all other type of assignments, may be composed entirely of

national consultants in accordance with the provisions of paragraph 2.7 of the Consultant

Guidelines.

88

Annex 9: Economic and Financial Analysis


277. This annex provides the economic analysis of the MHSS. It reviews the project rationale,

the justification for Bank and government involvement, the cost-effectiveness of project approach

and interventions, and the sustainability aspects of project components and thrusts. The analysis

confirms the overall soundness of the project. The country as a whole has improved some health

indicators, but these continue to be woeful. Thus, seven years after the civil war ended, there

continues to be justification for government involvement in the sector, and for Bank support not

only for financing, but for technical support and innovation. The economic analysis demonstrates

the cost-effectiveness of the chosen project approach, as well as the specific health interventions to

be supported by the project, underpinned as they were by a thorough economic modeling using the

marginal budgeting for bottlenecks (MBB) framework (World Bank, 2007). The analysis also

highlights the potential benefits to be generated by the project, and its focus on disadvantaged

provinces. Finally, the analysis documents some of the continuing challenges in health financing

that hamper service delivery, and which the project and other Bank non-health instruments and

programs should deal with.

A. Review of Project Rationale

278. Poor health status indicators are a sequel of the prolonged civil war. The independence

struggle and the civil war have had a severe impact on all aspects of society. During the war, about

one million Angolans were killed, 4.5 million, or one-third of the total population, were internally

displaced. Many concentrated in Luanda and other big cities, and 450,000 fled the country. Even

though the civil war ended in 2002 and much progress has been made, there are still refugees and

internally displaced people who live in extreme poverty. The majority of the population still lives

in harsh living conditions. Poor water and sanitation cause disease outbreaks, such as the 2006

cholera epidemic, that have resulted in thousands of deaths.

279. The epidemiological profile in Angola features a high prevalence of communicable diseases

and high child and maternal mortality. The infant mortality rate is 154 per 1000 live births; the

under-5 mortality rate is 260 per 1000 live births (MICS 2001); the total fertility rate is estimated

to be 7.2 births per woman (MICS 2001); and the average life expectancy is only 40 years. The

maternal mortality ratio is reported by WHO at 1,700 per 100,000 (2003), one of the highest in the

world. This compares unfavorably with other Sub-Saharan African countries, which themselves

have significantly higher rates compared to the rest of the world (Table 22). One in every seven

pregnant women dies from avoidable reasons. Angola was ranked 166th

out of 177 counties in the

UNDP‘s Human Development Index.

89

Table 21: Key health outcome indicators

Indicator Angola

Sub-

Saharan

Average

Life expectancy at birth (years - 2003) 40 49

Fertility rate (2002) 7.0 5.0

Infant mortality rate (per 1000 live births - 2000) 154 92

Under-five mortality rate (per 1000 live births - 2000) 260 171

Maternal mortality ratio (estimates) 1,700 914

Contraceptive prevalence/100,000 (2003) 6.0 22.9

GDP/Capita US$ 975 1,073 Source: MICS 2001 and World Development Indicator 2006

280. Health status has not improved over time, even after the peace agreement. For example, as

shown in Figures 7 and 8, although the average infant mortality rate and under-five mortality rate

of the Sub-Saharan Africa region and the world as a whole have been declining consistently, child

mortality in Angola has stagnated since 1980, showing no sign of improvement.

Figure 6: IMR in Angola and Sub-Saharan Africa

0

50

100

150

200

250

1960 1970 1980 1990 1995 2000 2004

per

1,0

00 liv

e b

irth

s

Angola IMR

Sub-Saharan IMR

World IMR

90

Figure 7: Under-five mortality rates in Angola and Sub-Saharan Africa

Source: World Bank: World Development Indicators 2006

281. Inequalities are widening. Although Angola has an average per capita income of US$740,

relatively high for sub-Saharan Africa, 68 percent of the population lives below the poverty line of

$1.70 per day, with 28 percent living in extreme poverty on less than $0.70 per day. Urban poverty

is rising, mainly due to the influx of displaced people into cities and the lack of job opportunities.

282. Women‘s level of illiteracy (46%) is far higher than that of men (16%). The situation is even

worse for rural women, 66 percent of whom are illiterate. Most women only have access to

unskilled jobs, mainly in the informal sector (where two-thirds of the jobs are done by women).

283. Angola needs additional health investments for the country to reach the health MDGs. The

government has formulated a number of strategic documents such as (i) The Government Program

2009-2012 (with a section on health); (ii) the Health Sector Development Plan (currently being

updated); (iii) the Municipal Health Service Strengthening Plan48; and (iv) the Plan for the

Accelerated Reduction of Maternal and Child Mortality in Angola. These documents provide the

direction in which the health sector should be heading. However, they usually do not link expected

outcomes with effective and efficient spending and do not include detailed implementation

arrangements. As a result, resources are not being used optimally and better health status has not

been achieved.

284. The MHSS will help Angola ensure that the rebuilding efforts are effective, and resources

well used. To that effect, the project is designed such that:

Money is spent toward solving the main health problems, such as high child and maternal

mortality and the high level of infectious diseases;

Money is spent on cost-effective services, which have an impact on the main health

problems;

Money is spent on workable and integrated service delivery arrangements;

Money is spent on the necessary inputs of the service delivery system; and

48

Revitalização dos Serviços Municipais de Saúde

0

50

100

150

200

250

300

350

400

1960 1970 1980 1990 1995 2000 2004

Per

1,0

00 liv

e b

irth

s

Angola U-5 MR

Sub-Saharan U5MR

World U5MR

91

Money is spent on the frontline of services and the removal of bottlenecks of expending

service coverage.

285. In its Strategic Plan for the Accelerated Reduction of Maternal and Child Mortality in

Angola (2004-2008), the MOH prioritized an essential package of interventions as its means to

reduce child and maternal mortality. The package is organized by service delivery mode: (i)

primary health services; (ii) mobile and advance health teams; and (iii) community health agents).

286. The interventions included in the package are proven to be cost-effective and with high

impact on child and maternal mortality. They are very much in line with the international best-buy

list of interventions. Money will be well spent to finance these interventions, if they are delivered

properly.

287. The project will help Angola invest in effective service delivery modes. The MHSS is

designed to deliver health services in an integrated manner that involves: (i) facility-based clinical

care; (ii) population-based outreach services; and (iii) community-based care.

288. Government involvement is highly justifiable, given the project's focus on poor and remote

provinces, the overwhelming incidence of communicable diseases in these provinces, the absence

of private providers, and the need for the government to drive the health reform process and

steward the sector, both at the national and provincial levels. The project will focus on the

provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige. No significant private sector

providers currently operate in these areas, though non-profit NGOs do assist in certain health

activities. Selected health indicators for the provinces are presented below.

Table 22: Selected health indicators in the five MHSS provinces compared to national average

Bengo Malanje Lunda

Norte

Moxico Uige Angola



% prevalence of ARI49

18.3 4.8 1.7 4.8 3.9 7.0


% women receiving ANC50

80.1 67.7 67.7 71.4 67.7 79.8


% children immunized with

pentavalent vaccine51

100.0 60.0 68.0 37.0 100.0 81.0

289. Table 23 shows that the burden of disease or the implementation of key health interventions

in these provinces is generally worse than the national average. Thus, preventive and promotional

health interventions (e.g. IEC) supported by the project will have significant externalities. Maternal

and child health interventions, though individualized for the most part, are all considered socially

meritorious. In addition, all are oriented at currently disadvantaged population groups and,

therefore, have clear anti-poverty objectives. These services tend to be under-provided by the

private sector operating under market forces, and therefore indicate a clear government

49

ARI = Acute Respiratory Infection 50

ANC – Ante-Natal Care 51

Diphtheria, Pertussis, Tetanus

92

involvement in their financing and stewardship. The project encourages contracting out specific

service delivery to non-profit providers and community-based organizations, where they are

available, and where it can be clearly demonstrated that this is a cost-effective approach under

public/private partnership arrangements. Nevertheless, it is clear that in Angola as in other poor

countries, the government is needed to drive the process of change in service delivery and

financing, and to provide leadership and stewardship, both at the national and the provincial levels.

B. Justification for Bank Involvement and Project Alternatives Considered

290. The project is in line with the Government Program and the ISN. The project's poverty

orientation (focusing on five poor provinces) is in line with Angola‘s poverty-eradication strategy

as specified in the Government Program 2009-2012 and the Bank's ISN. The programmed

institution-building activities that will be conducted in Bengo, Malange, Lunda Norte, Moxico, and

Uige also support the government's efforts to increasingly decentralize social services and

strengthen the capacity of municipalities. The Bank brings to bear its technical leadership in this

project, which the government and other donors recognize. The Bank combines policy reform,

impact evaluation, and large-scale implementation experience that the project can use. In this

process, this project will work closely with the Bank's existing macroeconomic instruments so that

the project's sector reform thrusts get firmer traction.

291. The preparation team considered alternative approaches for the project, and concluded that

the current design reflects the best feasible approach, taking into account the actual situation in

Angola as well as what the national and provincial governments aim to achieve. The alternatives

considered are as follows:

Why not HAMSET II? Through HAMSET, the Bank has been the first external financier to

help the government control HIV/AIDS, TB, and malaria. This has led the way to further

funding from the Global Fund and the US President‘s Malaria Initiative, as well as increased

financing for HIV/AIDS control from the government itself. On the other hand, maternal

and child health indicators are appalling, justifying the strategic decision to give priority to

investing in the improvement of these health outcomes.

No project alternative. The ―no project‖ alternative is not desirable because child and

maternal mortality are very high in Angola, and malaria devastating. Without an operation

that introduces an integrated service delivery model, Angola‘s chances of reaching the

MDGs in 2015 would be slim.

292. The following project features should be highlighted for their cost-effective elements: (i) the

focus on a few key interventions that have a significantly large impact on reducing disease burden,

rather than outright provision of a comprehensive package; and (ii) the conduct of impact

evaluation to demonstrate the cost-effectiveness of service delivery packages, and to compare ex-

ante (assumed) vs. ex-post (actual) costs.

293. Project interventions have been shown to be the most cost-effective packages. The project

design process relied heavily on the analytic work, conducted as part of the PER, which identified

and costed out the packages of supply interventions that could best reduce the burden of disease in

the country. This modeling exercise presented five steps, their respective impact on mortality, and

additional cost per capita, as follows:

93

Step 1: Undertake social mobilization and behavioral interventions as well as supply

essential materials to households through community-based interventions;

Step 2: Organize outreach and mobile teams to provide a set of standardized services to

populations without access to health facilities;

Step 3: Expand the primary health care network to provide preventive and basic curative

care;

Step 4: Strengthen the first-level referral care that can provide comprehensive and

emergency health care;

Step 5: Improve the second-level referral care that can provide specialized care.

294. Table 24 illustrates the impacts on under-five and maternal mortality reduction and additional

cost per capital of these four options. These are "ex-ante" impact and cost figures, but the intention

of the project is to validate these during project implementation.

Table 23: Impact on Under-Five and Maternal Mortality Reduction and Additional Cost

Per Capita of Four Health Service Delivery Steps in Angola Reduction

in IMR

Reduction

in U5MR

Reduction

in MMR

Cost (US$ per

capita per year)

Step 1: Undertake community-based social

mobilization and behavioral interventions

29% 39% 1% 2.51

Step 2: Scale up population-based outreach

services

9% 8% 9% 1.05

Step 3: Expand primary health care 17% 23% 1% 3.05

Step 4: Strengthen the first level referral

care

2% 2% 3% 0.97

Step 5: Improve the second level referral

care

1% 1% 3% 0.89

All five steps 51% 62% 17% 8.48

Source: PER (2007).

94

C. Sustainability of Project Investments

295. First, sustainability efforts will focus on demonstrating the feasibility of implementing the

basic package of services cost-effectively in poor provinces. Given the high level of poverty in the

five provinces where the project will be located, the project focuses less on the financial

sustainability of project inputs through direct household contributions or other alternative local

financing. Rather, the project will focus on four critical ingredients of sustainability. First, on the

supply side, the project will promote institutional sustainability by showing that the basic package

of services can be delivered cost-effectively in the five provinces. To achieve this, health services

in the five provinces will have to be reconfigured so that they cater increasingly to community and

outreach services. A key challenge in this regard - and which has significant budgetary

implications - is the provision of adequate staff training, remuneration, incentives, transport, and

supervision support.

296. Second, sustainability efforts will also be directed to achieving policy support at the national

level for the demonstrated improvements in health coverage and outcomes. This policy reform

project is non-threatening as it is based on an agreed-upon agenda, and is supported by evidence,

both through the modeling exercise that was conducted as part of analytical work, and also through

the impact evaluation work that will be done as the project proceeds.

297. Third, the project will support demand-side household behavior change interventions. On

the demand side, the project will promote positive change in household and community behavior in

order to sustain their interest in, and increase their demand for, the health services in the project.

Towards this end, the acquisition of health knowledge will be promoted through IEC activities.

Community involvement in decision-making will also be enhanced. Finally, the social assessment

documents cultural and social impediments to household demand for health services, and to

propose ways of easing these obstacles.

298. Fourth, the government will have the means to sustain and increase spending in the health

sector. Angola‘s economic outlook is promising. Angola‘s economy has been growing strongly at

close to 20 percent per annum over the last three years. Economic growth is likely to continue with

the output of crude oil forecast to reach 2.1 million barrels/day in 2010, although production could

rise at a slower rate because of OPEC quotas.

299. Rising oil output, along with expansion in agriculture, manufacturing and construction, will

drive strong real GDP growth. Although GDP is decreased by 0.6% in 2009, economic growth is

expected to resume and Angola‘s medium-term economic prospects are good. The Bank projects

GDP to grow around 6.5% from 2010-2012.

95

Annex 10: Safeguard Policy Issues


300. The MHSS is classified as Category ―B‖ for environmental screening purposes. A partial

environmental and social analysis is considered appropriate to address specific environmental and

social issues associated with the provision of medical supplies, which triggers concerns about

healthcare waste management and the construction of staff housing, and which raises potential

issues about land acquisition and resettlement and construction or rehabilitation of buildings. A

stand-alone Environmental and Social Management Framework has been prepared to provide an

environmental and social screening process to allow for the identification, assessment and

mitigation of potential negative environmental and social impacts related to the project.

301. An assessment of current health care waste management and disposal systems, carried out

under the HAMSET project, showed that the current state of waste management is inadequate.

Current practices in health care waste and contaminated health care waste handling, storage and

disposal, in particular, raise environmental and social concerns. The need for sound management

and disposal of contaminated health care waste is of paramount importance because health-related

activities produce waste on daily basis as a result of preventive and curative service delivery.

Waste produced is in the form of sharps (needles, syringes, scalpels etc.), non-sharps, blood and

other infected and non-infected materials, chemicals, pharmaceuticals and medical devices. Health

workers, waste handlers, users of health facilities and the general public are all exposed to health

care related waste and may become infected, as a result of poor management.

302. The MHSS team will actively monitor ongoing activities for compliance with the

requirements and recommendations of this assessment, and modify or end activities that are not in

compliance. If additional activities are added to this project that are not described in this project

document, an amended EA will be prepared and approved prior to implementation of those

activities.

303. The project will not be considering the malaria control component as per the government‘s

request during preparation. The MOH has sufficient financing from other donors for all indoor

residual spraying activities (pesticides or spraying equipments), thus no need for a Vector

Management Plan.

304. Health Care Waste Management Plan. The Healthcare Waste Management Plan

developed under the HAMSET Project was updated to fit the needs of the MHSS project and

disclosed prior to appraisal. It will be used and monitored during project implementation.

305. Current practices in health care waste and contaminated health care waste handling, storage

and disposal still raise some environmental concerns. Poor practices in healthcare waste

management can lead to negative effects such as hospital acquired infections, development of drug

resistant bacteria, disease transmission from infected needles, or negative health effects from the

release of toxic substances.

306. At present, there are no available national environmental and social policies and regulations

that speak to safe handling, storage and disposal of waste in general, and health care waste in

particular. A sound policy and regulatory environment needs to be put in place so that the

96

government can have the means and capacity to enforce safeguard policies and regulations

pertaining to health care waste, and monitor required mitigation measures.

307. The MHSS project adheres to the key objectives and activities of the National Health Care

Waste Management Strategy. The MHSS project will make use of the lessons learned from the

implementation of the HCWMP during the HAMSET project to foster a sound management of

health care waste at the national level. The MHSS project will emphasize the implementation of

this action plan in the targeted five targeted provinces of Bengo, Malange, Lunda Norte, Moxico,

and Uige.

308. The approach adopted by this project is to build on the progress already achieved under the

HAMSET project to help the government improve healthcare waste disposal in the project area and

throughout the country. HAMSET facilitated the implementation of the plan, including capacity

building, mitigation measures and their timely monitoring. Financing for priority actions of the

Plan were included in the MHSS project.

309. The HCWM Plan was updated in March 2009, and revised to reflect the current realities

faced in the targeted provinces. It will be applied through the life of the MHSS project. It involves

fairly intensive training and capacity building activities, review of legal and institutional

framework, and provision of protective clothing and biosafety kits, provision of basic equipments

and technical support, and specific monitoring actions. Financing for activities of the HCWM Plan

are included under the MHSS under Component 1, Subcomponent 4 – Improvement of hospital

waste disposal. MHSS is committing up to US$ 995,000 to facilitate the implementation of the

plan. This is significantly higher (over four times) than the allocated budget under the HAMSET

project. Additional sources of financing would also be sought, including from the government

budget itself.

310. The Ministry of Health, the Ministry of Urbanism and Environment, the provinces of Bengo,

Malange, Lunda Norte, Moxico, and Uige, and municipalities within these provinces, health

facility directors, health workers, and patients are the key stakeholders under this project. The

Medical Waste Management Plan (MWMP) and The Environmental and Social Management

Framework (ESMF) were published by the Bank in Infoshop on November 25, 2009, and on the

MOH website on April 21, 2010. Comments and inputs from the general public and key

stakeholders will be incorporated in the final draft that will also be disclosed to the public.

311. Despite the somewhat inadequate picture of current health care waste management practices

and context, there is reasonably fertile ground for success for the health care waste management

plan. The current commitment of the central, provincial and local government to the National

Health Care Waste Management strategy is encouraging. This strategy was developed by the

Ministry of Health in conjunction with the Ministry of Urbanism and Environment and designed to

revamp current management practices of waste, in general, and health care waste in particular,

through the establishment a new centralized incineration center for infectious health care waste.

The government is also contracting three new private waste management service providers to

complement the activities of the existing private service provider, URBANA 2000, and broaden

coverage of the waste management and disposal activities in a safe and timely fashion.

Furthermore, there are a number of NGOs in the country that are very active in the area of

environmental health, and have been playing a crucial role in public awareness and in behavior

change activities targeted at medical staff, cleaning personnel and the general public.

97

Land Assessment for civil works

312. The MHSS project is proposing to rehabilitate or build 36 delivery rooms in health centers

and posts and construct new houses for medical staff in 18 municipalities. In discussions with

government officials, the team has been assured that all houses would be built on government land

without the presence of squatters. The land legal status will be documented in the provided Land

Acquisition and Resettlement Assessment Form. The MHSS Project Coordinator will be

responsible for ensuring that the land and asset issues are dealt with properly, with assistance from

the Municipal Administrator. The Municipal Administrator will identify government land to be

used for construction under the project. He or she will conduct an assessment of the land and will

send the form to the MHSS project coordinator certifying that the land identified is government

land and is free of squatters. This will be verified with the submission of completed Land

Assessment Forms. The team provided the government with translated copies of the Land

Acquisition Assessment Forms and asked to have them completed and signed to document the

legal description of the land, location, occupation, use. The ESMF copies of signed forms for each

site, verifying that no resettlement will occur, will be kept by the Project Coordinator.

313. Should there be a case where the land does not belong to the government and/or there would

be squatters, it would be immediately rejected by the MHSS project coordinator who would

request the Municipal Administrator to find alternative land.

314. To prevent environmental impacts due to the construction or rehabilitation of houses for

medical staff and delivery rooms in health centers/posts, the ESMF addresses the General

Environmental Management issues associated with civil works and includes an annex with

Detailed Environmental Management Conditions for Construction Contracts to be integrated in

each construction site to minimize potential environmental impacts associated with project

activities.

315. As part of the ESMF review, the Task Team took the necessary actions to ensure due

diligence in complying with all safeguard requirements. First, the team got full commitment from

the government that proper mechanisms are in place to ensure that no involuntary resettlement,

loss of livelihood or loss of access to land will occur. Second, no squatters will be negatively

impacted by any project activities. Land with squatters, land used for pasture or other livelihood

activities will not be considered for construction under this project.

98

Annex 11: Project Preparation and Supervision


Planned Actual

PCN review June 17, 2008 June 18, 2008

Initial PID to PIC June 23, 2008 June 24, 2008

Initial ISDS to PIC June 23, 2008 June 24, 2008

Appraisal March 2, 2009 July 6, 200952

Negotiations February 15, 2010 April 23, 2010

Board/RVP approval June 3, 2010

Planned date of effectiveness September 15, 2010

Planned date of mid-term review December 31, 2012

Planned closing date December 31, 2015

Key institution responsible for preparation of the project: Ministry of Health

Bank staff and consultants who worked on the project included:

Name Title Unit

Evarist Baimu Counsel LEGAF

João Blasques de Oliveira Public Health Specialist Consultant

Eduardo Brito Senior Counsel LEGAF

Antonio Chamuço Procurement Specialist AFTPC

Gabriela Cohen Social Sector Specialist Consultant

Humberto Cossa Senior Health Specialist AFTHE

Alberto Chueca Mora Country Manager AFMAO

Jean-Jacques de St. Antoine Task Team Leader AFTHE

Cassandra de Souza Operations Analyst AFTHE

Ricardo Gazel Senior Economist AFTP1

Geraldine Geraldo Program Assistant AFMAO

Mary Green Program Assistant AFTHE

Kjetil Hansen Senior Public Sector Management Specialist AFTPR

Abdelaziz Lagnaoui Senior Pest Management Specialist ENV

Suzanne Morris Senior Finance Officer CTRFC

Eva Ngegba Program Assistant AFTHE

Jonathan Nyamukapa Senior Financial Management Specialist AFTFM

Jenni Pajunen Junior Professional Officer AFMAO

Monica Sawyer Country Officer AFCS2

Bank funds expended to date on project preparation:

1. Bank resources:US$172,500

2. Total: US$172,500

52

Date the Regional Operations Committee upgraded the March 2009 mission to appraisal.

99

Estimated Approval and Supervision costs:

1. Remaining costs to approval: US$10,000

2. Estimated annual supervision cost: US$100,000

100

Annex 12: Documents in the Project File


1. World Bank. HIV/AIDS, Malaria And Tuberculosis Control Project (HAMSET) Project

Appraisal Document.

2. European Union and World Bank. Angola Public Expenditure in the Health Sector (September

2008).

3. Ministry of Health of Angola. Strategic Plan For the Accelerated Reduction of Maternal And

Child Mortality in Angola.

4. Ministry of Health. Revitalização dos Serviços Municipais de Saúde.

5. Ministry of Health. Revitalização dos Serviços Municipais de Saúde, Iº Encontro de

Padronização Luanda, 7 de Maio De 2007.

6. Adérito De Castro Vide (Engineer) – Angola HAMSET Project: Health Care Waste

Management Plan in Angola (November 2004)

7. UNICEF Angola. Making the World a Better Place for Children Striving for the Millennium

Development Goals

101

Annex 13: Statement of Loans and Credits


Original Amount in US$ Millions

Difference between

expected and actual

disbursements

Project ID FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev‘d

P105101 2010 AO-Local Dev. Program SIL (FY09) 0.00 81.70 0.00 0.00 0.00 79.54 0.00 0.00

P093699 2009 AO-Market Oriented Smallholder Agr 0.00 30.00 0.00 0.00 0.00 29.35 0.00 0.00

P096360 2009 AO-Water Sector Institutional Dvlp 0.00 57.00 0.00 0.00 0.00 53.60 13.03 0.00

P095229 2007 AO-MS ERL 2 0.00 102.00 0.00 0.00 0.00 79.40 83.93 0.00

P083180 2005 AO-HAMSET SIL (FY05) 0.00 21.00 0.00 0.00 0.00 4.12 3.56 0.00

P083333 2005 AO-Emerg MS Recovery ERL (FY05) 0.00 50.70 0.00 0.00 0.00 13.39 13.47 0.00

P072205 2003 AO-Econ Mgmt TA (FY03) 0.00 16.60 0.00 0.00 0.00 4.92 2.95 2.93

Total: 0.00 359.00 0.00 0.00 0.00 264.32 116.94 2.93

ANGOLA

STATEMENT OF IFC‘s

Held and Disbursed Portfolio

In Millions of US Dollars

Committed Disbursed

IFC IFC

FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic.

1998 AEF Flecol 0.61 0.00 0.00 0.00 0.61 0.00 0.00 0.00

2005 CNO OSEL 10.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

2003 EBA 0.00 0.70 0.00 0.00 0.00 0.70 0.00 0.00

2005 Nossa Seguros 0.00 0.00 1.00 0.00 0.00 0.00 1.00 0.00

Total portfolio: 10.61 0.70 1.00 0.00 0.61 0.70 1.00 0.00

Approvals Pending Commitment

FY Approval Company Loan Equity Quasi Partic.

Total pending commitment: 0.00 0.00 0.00 0.00

102

Annex 14: Country at a Glance


104

Annex 15: Key High-Impact Health Interventions by Service Delivery Level


Table 24 : Key High-Impact Health Interventions Service Delivery

Arrangements

Child Health Maternal Health Malaria Environmental

Health

HIV / AIDS TB

1. Family

Community

based health

interventions

Breastfeeding

promotion

Safe Water Handling

and Storage promotion

(including Chlorine)

Hand-Washing

promotion

ITNs use promotion

children less than 5

ORT

Zinc treatment in

association with ORT

Advise on

Complementary and

supplementary Feeding

Clean Delivery

Temperature

Management and

Kangaroo care

Clean Delivery

Condom

Promotion

Oral

Contraceptive

Promotion

Supplementary

feeding for

malnourished

pregnant women

ITNs promotion

general population

Anti-malarials

(chloroquine) for


and adults

Latrines

Safe Water

Storage

Handling

promotion (including

Chlorine)

Hand-Washing

promotion

Solid and Liquid

Waste management

promotion

Awareness

raising through

peer based

education

Safe

Sex Promotion

Behavior change

(number of sexual

partners

Discuss

traditional norms,

rituals and taboos

favoring

HIV/AIDS

transmission

Condoms

marketing

Condom

Promotion

Mass media

campaigns

Support to

orphans

-

2. Population

based outreach

services

Supervision of Health

Promoters

Family Planning

Iron and Foliate

supplementation

Tetanus Toxoid

BCG, Measles, DPT3

Vitamin A

supplementation

HIB vaccine

ACT anti-malarials for


Supervised ORS

Surveys/HMIS

Supervision of

Health Promoters

Family Planning

(Depo-Provera, )

Iron and Foliate

acid supplementation

to pregnant women

Births planning

and complications

readiness

ITNs pregnant

women

Prenatal care,

postnatal care

Surveys/HMIS

Supervision of

Health Promoters

Indoor

Insecticide spraying

Surveys/HMIS

Healthy homes

environment

promotion

Identification

Management of

mosquito breeding

places

Indoor

Insecticide spraying.

Control of

insects, rodents etc

Food safety

measures

Education on

prevention of

accidents and

illnesses

Surveys/HMIS

Supervision of

Health Promoters

Management

Support and

care

First Aid

Universal

Precautions

TB awareness

raising

Case

identification

TB DOTS

follow-up

3. Clinical

services

a. primary

clinical care

Assisted deliveries

Antibiotics for

pneumonia (ARI tt)

Antibiotic treatment

for dysentery

Resuscitation

Treatment of Severe

Anemia

Vitamin A treatment

Treatment of neonatal

sepsis

PMTCT

Severe malaria

Assisted

deliveries

Antibiotics for

premature rapture of

membrane (PRM)

Tt of STI

Basic to

comprehensive EOC

Post-abortion

care

Norplant

IUD insertion

ACT UP TT of STI

HAART

follow up

PMTCT

Treatment of

Opportunistic

infections

UP

TB

identification and

DOTS initiation

b. referral

clinical care

Management of severe

prematurity/LBW and

neonatal sepsis

Management of

complicated Malaria

CEOC

Blood Safety

Management of

complicated Malaria

Management

of resistant AIDS

Management

of Multi drug

Resistant TB

105

Annex 16: Terms of Reference for the Development of a Human Resources Development Plan


316. Background. At an aggregate level, the human resources for health (HRH) indicators for

Angola are similar to those of other Sub-Saharan countries (SSA). Likewise, the distribution of

HRH is imbalanced across regions and between urban and rural areas. As a result of the war that

afflicted the country for approximately three decades, many health staff moved to Luanda, the

capital, in search of refuge. In 2004, the proportion of doctors and nurses working and living in

Luanda was thought to be 70% and 30 % respectively. However, during the last 2-3 years the

situation seems to have changed considerably. According to the results of a survey conducted on

health facilities that provide obstetric and neonatal, the number of doctors in most provinces and

municipalities increased significantly53.

317. In 2004, Angola HRH indicators were worse than its immediate neighbors with the

exception of the Democratic Republic of Congo that has lower indicators (Table 1). These

aggregate indicators should be interpreted with caution as they do not provide a full picture of the

country-wide availability of HRH and other characteristics, e.g. productivity. Also, data on HRH is

not readily available and often the figures are not consistent.

Table 25: HRH data in Angola and selected SADC countries per 10,000 persons54

Population

Number of health

professionals Doctors Nurses

Physician/

Inhab.

Nurse and

midwife/Inhab.

Health

Profess./Inhab.

Angola 16,577,000 21,537 1,165 18,977 0.70 11.45 12.99

Botswana 1,858,000 6,668 715 4,753 3.85 25.58 35.89

DRC 60,644,000 37,017 5,827 28,789 0.96 4.75 6.10

Namibia 2,047,000 7,741 598 6,145 2.92 30.02 37.82

South Africa 48,282,000 292,602 34,829 184,459 7.21 38.20 60.60

Zambia 11,696,000 28,134 1,264 22,010 1.08 18.82 24.05

Zimbabwe 13,228,000 13,960 2,086 9,357 1.58 7.07 10.55

Average of SSA 2.17 11.72 26.26

318. According to MOH official sources, 2,500 physicians were working in Angola in 2008. Of

these 1,200 are Angolan nationals. The number of nurses was estimated at 36,000 nurses and other

health and medical technicians at 4,000 adding to a total number of 42,500 health professionals.

319. Data derived from the 2007-2008 survey ―A Situação do Atendimento Obstétrico em

Angola‖ shows the HRH available in all facilities that provide obstetric and neonatal care. While

the data does not cover the entirety of HRH of the sector, it provides interesting clues about the

current context of HRH in Angola, in particular because it also captures data from private

providers, both for profit and not-for-profit (Table 2).

320. Medical personnel. The first important observation is that in Angola today, there are more

doctors outside Luanda than there were some 3-5 years ago. For example, out of the 983 identified

in the surveyed facilities, 668 (70%) work at provincial level. Of these, 445 (65%) are medical

53

Situação do Atendimento Obstétrico em Angola, UNICEF 54

http://www.who.int/whosis/. The number of health professionals includes only nurses and midwives, physicians,

pharmacist, dentists and other health workers. It excludes management and administrative staff. All statistics are for the

year 2004.

http://www.who.int/whosis/

106

specialists (obstetricians and gynecologists, general surgeons, pediatricians, neonatologists, and

anesthesiologists) and 243 (35%) general practitioners. Interestingly, all provinces have more

medical specialists than general practitioners except Cunene province where the number of general

practitioners is slightly higher than that of specialists. This is an unusual pattern of distribution of

medical specialists and it is the result of government decision to hire specialists from Cuba and

other countries to fill the gap in the specialized clinical care at provincial level. One third of

medical specialists (222 out of 667) work in Luanda. In general Luanda is better supplied by

medical and other health specialties as shown in Table 27 Luanda has about 36% of the total

population of the country (5.2 million) distributed in 9 municipalities. However not all inhabitants

of Luanda benefit equally from the services of these specialists as most doctors (192 out of 222)

work in two municipalities only (Ingombotas and Kilamba Kiaxi).

Table 26: Health staff in facilities providing obstetric and neonatal care.

Province Medical

Specialists General

Practitioners

Total No. of

Doctors

University Level

Nurses Mid Level

Nurses

Basic Level

Nurses Mid-

wives Laboratory Technicians Total

Bengo 10 10 20 3 34 246 8 28 339

Benguela 63 36 99 2 722 901 75 111 1910

Bié 23 37 60 0 452 882 5 35 1434

Cabinda 32 5 37 7 124 151 13 71 403

Cunene 24 29 53 0 45 471 17 25 611

Huambo 30 14 44 9 987 1145 79 74 2338

Huíla 49 23 72 6 182 627 1 88 976 Kwando-Kubango 33 5 38 7 13 164 38 24 284 Kwanza Norte 11 7 18 0 51 174 9 10 262 Kwanza Sul 32 17 49 0 31 482 1 41 604

Luanda 222 73 295 25 1140 1601 177 429 3667 Lunda Norte 24 18 42 3 10 431 100 44 630 Lunda Sul 39 12 51 9 12 425 24 28 549

Malange 6 2 8 0 85 304 4 14 415

Moxico 8 4 12 8 149 301 8 12 490

Namibe 22 6 28 2 108 349 4 56 547

Uíge 24 9 33 0 15 852 61 70 1031

Zaire 15 9 24 4 50 309 1 23 411

Total 667 316 983 85 4210 9815 625 1183 16901

321. The five provinces of the Municipal Health Services Strengthening (MHSS) project are

reasonably served by both medical specialists and general practitioners. More importantly, all

municipalities of these provinces, with the exception of Malange have both medical specialists and

generalists. This is a major achievement of the Angola MOH. While this achievement should be

commended some caution should also be exercised as it appears that too many specialists are

delivering care that could also be delivered by non specialists. Excessive reliance on specialized

care may unnecessarily drive up health care costs.

322. Nurses and midwives. According to the survey, there are 14,735 nurses and midwives

working in surveyed facilities. Of these 9,815 (66.6%) are basic level nurses, 4210 (28.6%) are

mid-level nurses, 625 (4.2%) are midwives, and 85 (0.6%) are university level nurses. The

107

distribution of basic nurses and mid level nurses across provinces seems reasonable (Table 29). The

distribution of midwives is imbalanced: some provinces have more than 100 midwives and others

have less than five. More importantly, there seems to be a distortion of the composition of the

medical teams between and within provinces. For example, the ratio of midwives to Obstetricians

varies between 0.1:1 (Huíla) to almost 13:1 (Kwando-Kubango). Relatively to basic nurses there

seems to be a better nurse to doctors ratios, however in some provinces there are more than 25

nurses per doctor, including Malange and Moxico (38:1 and 25:1 respectively). This relationship

suggests an excess of nursing staff in these provinces.

323. Laboratory staff. In general, laboratory technicians are distributed more evenly between

provinces. Like other medical cadres Luanda has 36% of the total number of laboratory technicians

(1,183).

324. Production of health staff. The training of doctors is ensured by the Ministry of Education.

There are also private universities that train physicians. As for other health cadres, the training is

offered by training institutions of the Ministry of health located in Luanda and at provincial level.

Despite the fact that Angola has a university level training institution (Instituto Superior de

Enfermagem – ISE), the number of nurses with a university degree is relatively low (Table 30).

Other private training institutions also play a role in the training of health staff. Recently concerns

about the quality of training of nurses and midwives have been raised by health providers and the

MOH.

325. The current output of medical schools (public and private) indicates that Angola may take

considerable time to produce enough qualified doctors to match the country needs. This is why the

government is resorting to contracting doctors from Cuba and other countries to fill the gap. The

long term solution will be to increase the output and effectiveness of the training in medical

schools and other health training institutions.

326. Management of HRH. The management of HRH is as critical as is the training if effective

healthcare delivery and good quality care is to be achieved. Anecdotal observations indicate that

productivity of the staff in public facilities is low. This could be attributed to excessive number of

staff in some facilities and or the lack of motivation. Issues of system organization, clear job

description, career progression and reward systems are important elements for the optimal

performance of the staff. In addition, professional values and behavioral aspects of health staff are

particularly important and can make significant difference in the acceptability and increased

demand for services by the people.

327. An area that has received less attention from ministries of health in the region including

Angola, is the administration and management career in the health sector. Generally all

management positions in the MOH are taken by doctors and or other health professionals with

varying degrees of exposure to management and administration concepts. Improving the

management of the health sector and its programs is warranted to ensure good use of the resources.

328. MOH Strategy for HRH. The MOH has recently developed a strategy for HRH. The

strategy provides the overall direction to improve staffing of health facilities and standardize the

qualifications and careers of health staff in Angola. However the strategy is yet to be translated

into a comprehensive and costed mid-term human resources development plan for the sector.

Developing such a plan is a challenging endeavor, particularly in the context of Angola. The MOH

108

intends to develop the plan but it has limited capacity to do so. The MOH will contract the services

of a consultant to help review its HRH strategy and help the MOH prepare a comprehensive

medium-term human resources development plan.. The Bank can support this process under the

MHSS project. Also the Bank has a comparative advantage in health systems and can also tap on

existing experts and experiences in the region related to HRH.

329. Purpose. The purpose of the consultancy is to facilitate the process and provide analytical

inputs and help prepare a comprehensive, costed HRH development plan for the health sector in

Angola taking into consideration the government reform policy. More specifically the consultancy

will consist of three main stages: (i) assist the MOH in undertaking a thorough and detailed

analysis of the HRH situation in Angola covering the availability, distribution, productivity and

management of health staff; (ii) review and adapt the MOH‘s HRH strategy to formulate a mid-

term HRH development plan and estimate its costs; and (iii) advise on institutional arrangements

needed to strengthen the management of human resources in the MOH.

330. Scope of work. The specific tasks of the consultant would be to:

(i) Undertake a desk review of key policy documentation of the health sector in Angola,

including the overall national health strategy, the HRH strategy, and other relevant

documents.

(ii) Analyze the current availability and distribution of HRH in the country.

(iii) Analyze the factors driving the current distribution of health staff and their productivity

(iv) Review the composition of the health teams in provinces up to the level of health

centers.

(v) Make recommendations to the HRH strategy of the MOH in line with the analysis of the

current HRH situation, in particular regarding staff productivity, posting in remote areas,

and career progression.

(vi) Develop an HRH mid-term plan, with corresponding costs estimates

(vii) Provide 2-3 scenarios for the HRH plan.

331. Process. The consultant will work under the coordination of the Directorate of Human

Resources to whom he/she will report regularly. The consultant should use a participatory process

involving key stakeholders in the health sector and in other line ministries such as MOF, MAPESS,

and other ministries if necessary. A MOH counterpart should be nominated to follow up the

process on a daily basis and to facilitate the work of the consultant‘s team.

332. Two workshops will be held throughout the process. The first will be to present the report on

the analysis of the HRH situation and discuss the strategic diagnosis. This workshop‘s main

objective will be to validate the analysis and the main conclusions. A second workshop will be

held to present and discuss the main components of the HRH strategy and mid-term plan and its

costs implications. The main objective of the second workshop will be to obtain consensus on the

key strategic options to address HRH issues in the sector.

333. Requirements. The consultancy should be done by a multidisciplinary team ideally

composed of: a facilitator or project manager, a senior human resources management expert, and a

health economist and or public health specialist. Other short-term consultants would be used as

needed throughout the process.

109

334. The lead consultant should possess a good track record of similar assignments in developing

countries in the Africa region. Proficiency in Portuguese is a key requirement to allow for

maximum interaction with MOH counterparts. The report should be written in Portuguese, with a

translation in English.

335. Deliverables. The following are the deliverables of the consultancy:

(i) A comprehensive report on the analysis of the HRH situation in Angola with an

executive summary. The report should also be provided in a CD ROM format.

(ii) A Power Point presentation of the main analytical report to be presented at the first

workshop.

(iii) An issues paper for the second workshop.

(iv) A draft HRH mid-term development plan.

(v) The organization and implementation of two workshops.

(vi) A final HRH development plan

336. Time frame. The consultancy would last12 months from the situation analysis to the draft

mid-term HRH development plan. It is expected that the consultancy will be contracted no later

than September 30, 2010.

110

Annex 17: Terms of Reference for the Development of a Health Infrastructure Development

Plan


337. Background. After nearly three decades of war Angola‘s health infrastructure remains

severely damaged or destroyed as a direct consequence of the war and lack of maintenance. In

addition, during that period there were virtually no investments in new health infrastructure, which

has led to the contraction of the health network. The facilities were functioning with inadequate or

deteriorated equipment resulting in reduced quality of health care services.

338. With the advent of peace in 2002, the government started an ambitious reconstruction

program to rebuild the country‘s infrastructure as part of its socio-economic development program.

The reconstruction program includes the reconstruction and expansion of the health network and is

financed by the government and external sources, including significant financing from China, as

well as support from the EU. In the context of the reconstruction program, the Bank supports the

Emergency Multisectoral and Rehabilitation Program (EMRP), which also includes a health

component. The health component of the EMRP contemplated the rehabilitation and reconstruction

of health facilities in the target provinces of Bié, Kwanza Norte, Malange and Moxico. While the

government has succeeded in allocating more funds to rehabilitate and or build new health

infrastructure, the precise status of the country‘s health infrastructure is not fully known.

339. In 2007, the MOH started to undertake a sanitary mapping of the country to better

characterize the situation of the health infrastructure. The aims of the exercise was to: (i) identify

the precise status of each health facility, including its equipment, staff and the population served;

and (ii) to develop an investment program based on the findings of the mapping exercise. The

MOH started the mapping exercise in five provinces supported by the EU, namely Benguela, Bié,

Huambo, Huíla and Luanda. The mapping was implemented between March 2007 and June 2008.

The exercise provided detailed information about the physical status of every facility in each of the

five provinces and allowed the planning of infrastructure investments to rebuild the health facilities

and other related infrastructure in accordance with government plans. These plans have been

discussed with the provincial authorities and have been endorsed by the respective governors.

340. The MOH considers the sanitary mapping a good tool to help make decisions about

infrastructure investments and wants to ensure that the exercise covers the rest of the provinces.

Thus the MOH is seeking support to continue this exercise in the remaining 13 provinces of the

country. In this context it asked the Bank to support the mapping in the five provinces under the

Municipal Health Services Strengthening (MHSS) project financed by the Bank, and Total E&P

Angola.

341. Mapping of health facilities in the five provinces supported by the EU. The sanitary

mapping consisted of an exhaustive assessment of the physical condition, maintenance and

functionality of the equipment, and the staffing pattern for every health facility. To do this task, the

MOH created multidisciplinary teams in each province. Through a competitive process, it

contracted a firm to conduct the data collection and analysis. The role of the firm was to design a

data base for the mapping, supervise the data collection, undertake the analysis of the data, produce

the reports and present the final result to the local government and the MOH at central level. The

process was carried out in a participatory process. Workshops were held to present the results of

111

the mapping and validate the findings. A second workshop was held to discuss the first draft of the

infrastructure investment program.

342. The investment plans were adopted by the provincial governments and will form the basis

for the Public Investment Program of the Provincial Governments and also of the central level

MOH. But developing only a health infrastructure program would not suffice without other critical

inputs such as personnel, medicines and logistics. The MOH has a human resources strategy which

should be taken into account when developing the infrastructure plan. In addition it is necessary to

anticipate the recurrent cost implications of the investment in infrastructure and how this will

impact the budget of the MOH and the government in the medium and long term.

343. Purpose. The purpose of this assignment is to assist the five provinces of the Municipal

Health Service Strengthening (MHSS) project to carry out a health mapping, including the

development of a comprehensive and costed health investment program for the period 2010-2020.

This assignment is a continuation of a similar program carried out under the Health Sector Support

Program (HSSP) funded by the European Commission (EC). Other provinces of the country will

also do the same with support of government and other partners.

344. Scope of Work. The main objective of the consultancy is to undertake the sanitary mapping

of the five provinces of the MHSS with the objective of developing a comprehensive and robust

provincial infrastructure investment program for the period 2010-2019. The investment program

should also contemplate medical and non-medical equipment in accordance with the national

norms and regulations. The consultant should develop criteria to guide investment decisions by the

provincial government that take into account the medium term development program of the

government. In addition, the consultant should, in consultation with relevant provincial authorities

and communities, identify priorities on the basis of other considerations such as disease burden,

population size, access, and equity. In the process, due consideration should be given to economic

efficiency as well as the need to improve the quality of care.

345. The consultant should also develop the first five years implementation plan of the

infrastructure plan, which will subsequently be made operational through government annual work

program.

346. Tasks. The consultant will perform the following tasks:

(i) Review the mapping that has been done with support from the EU. In the process the

consultant will interact with relevant Departments of the MOH, namely the Gabinete

de Estudos Planeamenteo e Estatística (GEPE), Direcção Nacional de Saúde Pública

(DNSP), Direcção Nacional de Recursos Humanos (DNRH) and the Direcção of

Equipamentos and Medicamentos.

(ii) Prepare the health mapping with the relevant provincial authorities, including the

training of provincial and municipal staff to collect, enter, and analyze the data.

(iii) Carry out the health mapping in the provinces of Bengo, Lunda Norte, Malange,

Moxico and Uíge.

(iv) Discuss the work plan with the provincial authorities to whom the consultant should

regularly report.

112

(v) Develop a data base for infrastructure to be regularly updated by the Provincial

Health Directorate and train provincial health staff to manage it.

(vi) Write a report on the mapping and present it to the Provincial Health Directorate and

government in a workshop to get feedback and to validate the findings.

(vii) Develop a draft costed infrastructure investment program for 2010-1019, including 2

or 3 scenarios in line with MDGs and resources available.

(viii) Organize a workshop to present the investment program to the provincial

government and other stakeholders.

(ix) Write reports of the proceedings of the workshops.

(x) Write an investment program document for each of the provinces and prepare power

point presentations.

347. Deliverables. Deliverables will be as follows.

(i) A comprehensive report on the health infrastructure situation of no more than 25

pages plus annexes, with a clear identification of the strategic issues that need to be

addressed. Prepare power point presentations for the consensus workshop.

(ii) Infrastructure Investment Program for each province for 2010-2019.

(iii) Implementation plan of the investment program for the first five years, including a

monitoring and evaluation framework.

348. Timeframe. The consultancy will be done in a maximum of 24 months including the

completion of the report. The consultancy is expected to start around April 2010.

349. Requirements and qualifications. The consultancy will be carried out by a team of experts

consisting of the following professionals:

(i) Public Health Specialists with a Ph.D. or Masters degree and a minimum of 10 years of

experience in health planning. Preference will be given to those with working experience in

a developing country.

(ii) Hospital Architect or Civil Engineering Specialists with 10 years experience in planning and

development of health facilities design and implementation of civil works. Experience of

similar assignments in the region is preferable.

(iii) Medical Engineering or Hospital Equipment Specialists with at least 5 years of experience.

Knowledge and experience of developing countries will constitute an added value.

350. Other relevant information. The consultants will work on the premises of the MOH and

will report directly to the Director of GEPE of the MOH. They will also interact closely with the

Director of DNSP.

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Annex 18: Voucher Scheme to Encourage Institutional Deliveries


351. The MOH will pilot vouchers to pregnant women to deliver in a health facility.

352. Nature of the vouchers. Vouchers would consist of (i) transport vouchers of US$10

equivalent; and (ii) an incentive voucher for the mother of US$15.

353. Eligibility criteria. Vouchers are available to pregnant women living within the selected

municipalities.

354. Geographical scope and duration. The pilot would be implemented in two municipalities

of two provinces in the second year, and then an evaluation will be done to extract lessons learned

that will contribute towards helping the government decide on whether to extend to the other

municipalities in subsequent years – using other funding sources. The pilot could be implemented

first in Uige in the municipality of Negage as the intervention municipality and Sanza Pombo as

the control municipality. Negage has the capacity to do comprehensive EmOnC, because it has a

full team of ObGyn, surgeon, operating theatre, basic blood transfusion capacity and an Angolan

medical doctor as clinical director of the hospital that could help in implementing the voucher at

the hospital level (certification of institutional delivery). For purposes of supervision, both

municipalities are easy to reach. It is also proposed that the second municipality of intervention

would be Caculama, in the province of Malange, with two municipalities serving as control

measures. Piloting the scheme in two different provinces and municipalities should increase the

scalability of the results for the possible future expansion of the program and help understand

better how the different local economic, social, ethnic and cultural conditions impact the scheme.

355. Expected results. With a population of 153,971, Negage can expect 6,929 deliveries (4.5%

of population). If 75 percent of deliveries take place in the municipal hospital, this will amount to

5,196 deliveries.

356. With a population of 43,176, Caculama can expect can expect 1,942 deliveries (4.5% of the

population). If 75% of the deliveries take place in the municipal hospital, this will amount to 1,457

deliveries.

357. Expected cost. The costs of the voucher system would include three types of costs: (i) the

cost of the voucher; (ii) the administrative cost and (iii) the monitoring and evaluation cost. The

cost of the voucher itself would be as follows.

Table 27: Cost of Vouchers

Municipality Population Expected

deliveries

Institutional

deliveries

Cost per

year (US$)

Cost over 2

years (US$)

Negage 153,971 6,929 5,197 129,919 259,838

Caculama 43,176 1,942 1,457 36,143 72,825

Total 197,147 8,871 6,654 166,062 332,663

358. In addition, the social marketing and administrative costs are estimated at US$347,200 and

the monitoring and evaluation cost at US$100,000. Consequently, the total cost of the scheme

would be about US$780,000.

114

359. Social marketing. Communities and hospitals would be sensitized about the scheme to

ensure the support of the male community and local community leaders within the target areas.

The ability of women to redeem their vouchers may be in the hands of other household members,

therefore the target segments for the marketing campaign includes (i) the women between the age

of 15-45 (ii) possible transport providers (iii) health workers (iv) other critical community

members (e.g. fathers and community leaders).

360. The social assessment undertaken in Malange suggests that men, especially husbands of

pregnant women, must be targeted with advocacy and health education activities to make them

more involved in the early stages of the process of birth preparedness.

361. In practice, information sharing meetings for the selected target groups will be organized

and posters about the scheme would be placed in the hospitals and other health facilities in

Portuguese and local language ( Kikongo and Kinbumbo at least).

362. Hospitals will be prepared about the mechanics of the scheme (the need to provide two

copies of a delivery certificate to each woman who delivers), but also about the fact that demand

will increase and thus the need to increase productivity and at least maintain the quality of services.

The hospitals that are impacted by the incentive scheme will also receive support through the first

component of the MHSS project, that will help strengthen the health service delivery.

363. At community level, the role of CHWs and TBAs is very important and their involvement

will be carefully taken into consideration. CHWs and TBAs will be informed about the scheme and

encouraged to accompany pregnant women to the hospital. Creative partnerships with local NGOs,

faith-based organizations, village committees, or women‘s groups when they exist, will help ensure

the availability of local transport.

364. Implementation arrangements. The overall management of the scheme would be

contracted to an NGO. The arrangements for the scheme are illustrated below.

115

Figure 8: Arrangements for Vouchers

365. The management scheme will be the simplest possible, yet robust enough to guarantee that

the vouchers are paid on time and that the risks of fraud at the health facility level and by the

drivers and mothers or their families are reduced.

366. The scheme is based on an administrative approach with mothers receiving the vouchers

when arriving at the facility for delivery and ―paying‖ the driver of the car that has transported her.

The mother then will receive her own voucher after delivering. Delivering will include, for the

objective of this intervention having a live birth, a still birth, or a miscarriage.

367. The voucher will be redeemed for cash at a commercial bank55

in person by the driver and

the beneficiary woman (who has given birth in a health facility), each showing a delivery

certificate from the hospital.

368. Responsibilities of the implementing NGO. The contractor‘s responsibility will be to:

(i) undertake communication activities to promote the transport and mother voucher

schemes to beneficiaries, and explain the rules to health centers, the hospital, and the

municipal administration;

(ii) design the transport voucher ensuring the minimum security features to reduce fraud,

and make it available in health centers;

(iii) help the hospital to design delivery certificates;

(iv) design, in line with the MHSS, the information system to capture information on the

total vouchers, number of users, mothers and drivers, age of users and problems related

to the application of the scheme.

(v) ensure that the municipality opens a bank account where voucher funds will be

transferred from the MHSS project CCU in Luanda or from the DPS;

55

The voucher pilot will be implemented in the towns of Negage (Uige) where there is a commercial bank, and

Caculama (Malange) where there is a commercial bank in Malange, less than an hour away.

Health

center

Transport

Voucher

Mother $15

Voucher

Hospital

Delivery

certificate

to mother

Pregnant

woman

Commercial

Bank

Driver $10

Driver Stamp

Pregnant

Woman

116

(vi) help determine responsibilities for payment of vouchers including appropriate

accounting mechanism, preparation of SOEs, and maintaining of sufficient funds on

account for regular payment of vouchers for transport;

(vii) undertake a risk analysis covering: (i) the cultural factors that could affect the success of

a subsidy scheme; (ii) the legal and regulatory issues that could affect its success; (iii)

the institutional opportunities and constraints; (iv) increase in total pregnancies per

woman; and (v) other types of risks the incentive scheme could face. It would propose

ways of mitigating these risks.

369. Handling of complaints. Errors in the Angola voucher systems could consist of errors of

inclusion or exclusion resulting from errors in the registration process, human errors, or fraud. As a

result, an applicant who is eligible does not receive the voucher or someone has received the

voucher, but cannot exchange it for money. There can also be complaints about the poor quality of

service provision or suspicion of corruption in the system. Thus there is a need for the project to

include a mechanism to address complaints.

370. Complaints will be made in person by the beneficiary (pregnant woman, woman having

given birth in a health facility, or the driver who brought her to the hospital). Complaints will be

made to the Municipal Administrator who will then follow up with the relevant authority (the NGO

administering the scheme, the hospital or health center, or the financial department of the

Municipal Administration) and find a solution. If the complaint is not resolved at this point, it will

go to another level: the Municipal Health Committee. The latter is composed of citizens appointed

by the community, a member from the Municipal Administration, and a member from the

Municipal Health Directorate.

371. The number of complaints is not expected to be large because there is only one simple

eligibility criterion: you must be a pregnant woman to be eligible. Complaints on inclusion or

exclusion tend to be more frequent when there is room for interpretation (level of income, area of

residence, distance from a hospital etc.), which are not criteria in this pilot. However, even if there

are few complaints, the pilot will have a system to deal with them. The possibility to complain

about quality of care is an important means to help improve the quality of care.

372. Legal framework. The Recipient will issue an internal decree (Decreto Executivo) at

Ministry level, regulating the voucher scheme under a pilot approach.

373. Implementation risks. Implementation risks include (i) deviation of funds for private gains;

(ii) a program that does not function well at the beginning and loses credibility; and (iii) program

stimulates demand, but supply does not follow. The first risk will be mitigated by close cash flow

monitoring and control procedures, and audits focused on potentially vulnerable areas. The second

risk will be mitigated by setting up clear institutional responsibilities, a well-designed project

cycle, clear rules for the selection of beneficiaries, and a reliable management information system.

The third risk will be addressed by increasing the existing capacity for institutional delivery. The

overall risk will be mitigated by implementing the pilot in only two municipalities.

374. Monitoring and evaluation. M&E will also be contracted out. For its effective

implementation the pilot will need to be based on a clear picture of the existing provision and its

use, as well as evidence of the current health picture of maternal and neo-natal health in the given

municipality.

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375. The main outcomes of the scheme would be: (i) a decrease in the maternal mortality in the

selected municipalities and a significant increase in institutional deliveries; (iii) a proper response

from obstetric care services, including the provision of quality care; (iii) an efficient administration

of the system; and (iv) no fraud.

376. The evaluation indicators are presented in Annex 3.

377. Voucher Scheme Manual. A Voucher Scheme Manual will be prepared that will, as a

minimum, contain the following information: (a) the eligibility criteria for potential beneficiaries;

(b) detailed conditions to be met by potential beneficiaries in order to receive the proposed

benefits; (c) a mechanism for delivery of the proposed benefits; (d) institutional arrangements,

including the Government of Angola's lines of authority and accountability; (e) the monitoring and

evaluation system, including details on how to audit the scheme and how to handle complaints and

appeals in a timely manner; and (f) information on the legal framework that would underpin the

proposed scheme.

378. Service Agreements. The Government will conclude and thereafter implement, until it has

expired in accordance with its terms, a service agreement, in form and substance satisfactory to

IDA, with one or more Payment Service Providers acceptable to IDA for the payment of Cash

Transfers to Beneficiaries (each a ―Service Agreement‖). The Government will ensure that each

Service Agreement is: (i) submitted to IDA for its review and approval prior to its signature

between the Government and a Payment Service Provider; and (ii) signed and effective

before any proceeds of the Financing is transferred to the Payment Service Provider.

379. Each Service Agreement will include, inter alia, provisions to the following effects.

(i) Unless IDA will otherwise agree in writing, each Payment Service Provider will: (A)

before its first receipt of funds for the payment of Cash Transfers under the Service

Agreement, open and thereafter maintain for a term equal to the term of the Service

Agreement, a separate designated account (the Voucher Scheme Account) for the exclusive

purpose of depositing funds for Cash Transfers and disbursing funds for the delivery of Cash

Transfer in accordance with the provisions of the Service Agreement and the Voucher Scheme

Manual. The Voucher Scheme Account will be opened in a commercial bank acceptable to

IDA, upon terms and conditions satisfactory to IDA, including inter alia a waiver of any rights

said commercial bank or any third party may have to set off, or claim or otherwise appropriate

the payment of, any amount from time to time deposited in the Voucher Scheme Account in

satisfaction of any debt or claim owed to said commercial bank or third party by the Payment

Service Provider, and (B) ensure that all amounts deposited from time to time in the Voucher

Scheme Account are used exclusively to make Cash Transfer payments to Beneficiaries in

accordance with the detailed provisions, procedures, sequencing and timing in relation thereto

as set forth in the Voucher Scheme Manual.

(ii) The Payment Service Provider will maintain records and accounts, in form and

substance satisfactory to IDA, adequate to record all expenditures incurred in the delivery of

Cash Transfer payments, and will retain said records and accounts for at least the term of the

Service Agreement plus two years, and will furnish such records or copies thereof to the

Government and to IDA upon their respective request;

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(iii) The Payment Service Provider will enable the Government and IDA to inspect its

operations, including the Cash Transfers, and the Voucher Scheme Account, and to examine

and make copies of all records and documents relating thereto.

(iv) The Payment Service Provider will prepare and furnish to the Government not later

than six months after the end of their reporting year to which they relate, Financial Statements,

in form and substance satisfactory to the Government, audited by an independent auditor, and

the relevant audit report (with any information reasonably requested by the Government on

the audit and the auditor). The Government will be allowed to communicate all such

information to IDA if IDA will so request.

(v) The Payment Service Provider shall comply with the provisions of the Anti-

Corruption Guidelines.

(vi) The Government will exercise its rights under each Service Agreement in such

manner as to protect the interests of the Government and IDA and to accomplish the purposes

of the Financing. Except as IDA will otherwise agree in writing, the Government will not

assign, amend, abrogate or waive any Service Agreement or any of its provisions.

119

Annex 19: Governance and Accountability Action Plan


1. Country Context. In April 2002, after several failed peace processes, Africa‘s most

protracted conflict, between the União Nacional da Independência Total de Angola (UNITA) and

the Government of Angola ended. Peace appears to be robust, and UNITA has officially ceased to

be a rebel movement and has transformed itself into a legal political party. The potential for Angola

to move beyond reconstruction and to socially inclusive and equitable growth and development is

greater than ever before. However, the country faces a range of challenges and many social and

political risks. After over 30 years of conflict – the war for independence and a civil war - the

country‘s institutional and human resource capacity is weak. Thus, perhaps the single biggest

challenge the country faces is ensuring that the governance system is strengthened, the benefits of

mineral wealth are shared widely, that poverty and inequalities are reduced, and the institutional and

human resource capacities are strengthened so that services can be delivered in a more sustainable

fashion.

2. To address the challenges and consolidate peace and national reconciliation, the government

has started to implement programs aimed at restoring order and security, addressing the needs of

the most vulnerable groups, revitalizing the economy, restarting essential social services, and

reinstating critical infrastructure. The government is undertaking economic reforms and tackling

issues of governance, it is improving oversight over government revenues, and increasing control

over public expenditures.

3. With proper investments, reforms of policies and institutions, and good governance, Angola

will be able to use its rapidly growing wealth to reduce inequities and to improve quality of life for

all its citizens. With a sounder business climate, it will be able to attract private investment in

manufacturing, agriculture, and services – areas of the economy that have seen little investment

since independence. However, to realize its potential, Angola needs improved governance,

focused attention to build institutional capacity, better financial management, and greater

transparency in mobilization and use of public funds. More needs to be done to involve the poor

and socially marginalized groups in decisions on public spending, and in monitoring the use and

effectiveness of funds to ensure that growth is equitable.

4. Political Context. The government has successfully maintained peace in Angola since the

end of the civil conflict. The government is recognized as legitimate by most citizens and has

increasingly brought stability to all regions of the country. In August 2006, the government

signed, a peace agreement with the Cabinda Forum for Dialogue, an umbrella group of civil

society organizations and pro-independence factions, granting the oil rich enclave of Cabinda

special status, but reaffirming Angola‘s territorial integrity. Efforts to clear landmines and rebuild

roads and bridges after 2002 have opened up most of the country‘s main arteries to movement of

people and goods. This has allowed nearly 3.7 million internally-displaced people and refugees to

return home and restart their livelihoods.

5. Progress with demobilization and reintegration has been steady. Nearly 100,000 UNITA ex-

combatants have been demobilized through programs managed and paid for by the government.

The great majority has benefited from training and other types of assistance intended to help them

reintegrate into civilian life. Surveys administered 3 to 6 months after demobilization found that

120

57 percent of former fighters are employed or self employed, 95 percent have access to land for

agriculture, and 90 percent consider themselves socially integrated in their communities.

6. The legislative elections, the second elections during the independence of Angola, took

place on September 2008. The ruling party - MPLA won the elections with 82 percent of the votes.

According to the results of the September 5 legislative elections, the 220-seated Parliament is

composed as follows: ruling MPLA (191), UNITA (16), PRS (8), FNLA (3) and ND (2). The voter

turnout was estimated as high as 87%. The elections took place in a peaceful atmosphere and were

generally considered as free by observers. The new government was appointed in October 2008

with 33 ministers and three new secretaries of state. There were changes in the governance

structure, most notably with the creation of a new Ministry of Economy to lead the coordination

among the economic ministries. Also new positions for secretaries of state were created for higher

education, rural development and water. A new Constitution of the Republic of Angola was

approved by the Parliament with constitutional powers on January 21, 2010, and after the

Constitutional Court Judgement nº 111/2010 of January 30, 2010, on February 3, 2010.

7. The government has made progress with decentralization. The government approved its

national strategy for decentralization in 2001, and is refining a decentralization program which will

be implemented gradually. More recently, the Council of Ministers has revised the decree 17/99,

which sets up the country‘s legal framework for decentralization. The government also approved

Decree-Law nº 2/07 regarding the local governmental structures and Decree nº 9/08 related to the

paradigm of the administrative structures at the level of province, municipality and communes. The

government has expanded the coverage and outreach of a good governance system at the local

level that effectively delivers services.

8. Governance. Between 2002 and 2006, Angola was perceived to be one of the most poorly

governed countries in the world, according to indicators compiled annually by the World Bank

Institute (see Figure 9).56

The lack of transparency and corruption were perceived to be high, but

very recently the President of the Republic did initiate the implementation of a strong policy

against corruption known as ―Zero Tolerance‖ which is expected to introduce significant changes

in the governance‘s transparency. Angola‘s administrative capacity is very low by international

standards, limiting the ability of the state to deliver essential public services. Institutional

fragmentation and complexity also severely impede budget planning, particularly the translation of

strategic policy objectives into budget allocation decisions. However, administrative and financial

reforms are being implemented in order to strengthen the economic and budgetary policies and

practices.

9. Angola‘s governance indicators are still below the African average on most indices. But, the

trend is improving over time, albeit from a very low base. The 2008 Doing Business report ranked

Angola 167 out of 178 countries, while the 2007 Global Competitiveness Report ranked Angola

last (128th

). The Worldwide Governance Indicators for 2008 show a slight decline on three

indicators (i) Political Stability (ii) Rule of Law and (iii) Control of Corruption. It should be noted

that these indicators are not designed to measure minute changes from year to year – but rather

trends over time – and in this respect, Angola has been showing a general improvement on all

indicators since 2002, while still remaining below the Sub-Saharan average (see Figure 10 below).

56

An interactive database of governance indicators for 213 countries is available at

www.worlbank.org/wbi/governance/

121

Figure 9: Angola’s progress on governance, 2002 to 2006

Key: 2005 is the top bar, 2002 is the bottom bar. The thin black line indicates the margin of error.

10. Accountability is upward to the president, not toward public institutions, civil society or

media. Angola is politically stable. The government party enjoys a significant majority in

parliament, with no real challengers.. The public sector is very inefficient: execution rates for

national budget are low. Basic social services are unavailable for a majority of the population with

some of the worst social indicators in the world (HDI). Excessively bureaucratic and time-

consuming regulations stifle private sector development. The supreme audit institution has just

started its work, with significant delays. It was established in 2001 – and only started working on

its first audits in 2006.

11. Despite these perceptions and very real challenges, progress is being made to improve

governance since peace was achieved in 2002. Political stability, government effectiveness, and

voice and accountability in particular have improved substantially (see Figure 10). The

government‘s recent efforts to improve governance include: auditing oil companies, improving the

management of oil revenues, regularly publishing oil company payments, strengthening oil tax

administration, conducting petroleum revenue management workshops, encouraging transparency

in the recent licensing round, adopting oil revenue savings, rolling out an integrated financial

management system, and significantly strengthening the customs service.

12. The government has strengthened the capacity of the Ministry of Finance to control

expenditures and ring-fence the operations of Sonangol on behalf of the treasury, but more needs to

be done. However, due to institutional and technical limitations in the Ministry of Finance and in

the Ministry of Petroleum, the government will need several years before significant changes in the

institutional arrangements can be achieved. Despite some improvements in recent years,

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transparency and accountability in the management of public resources remain low. As a result,

Angola, in 2007, still ranked worse than the Sub-Saharan average on all governance indicators

tracked by the World Bank Institute (Figure 10).

Figure 10: Angola’s governance in relation to the Sub-Saharan Africa average (2007)

Key: Angola is the top bar, Sub-Saharan Africa is the bottom bar. The thin black line indicates the margin of error.

13. Project’s Governance and Accountability Action Plan. The objective of this plan is to

strengthen governance around the project and as a result eliminate corruptive practices, so that the

full impact potential of the project is attained. The proposed plan has been designed specifically for

the Angola Municipal Health Service Strengthening (MHSS) Project. The implementation of this

plan by the Ministry of Health (MOH) would contribute greatly to the overall governance

environment in the sector and would permeate to activities financed by other sources.

14. Action Plan Structure. The plan is essentially a tool to improve the impact of the project

and to transfer a number of methods and practices that may be adopted by Ministry of Health to

improve the efficiency of operations in the sector. The plan will be thus composed of preventive

actions, deterrents, and detection mechanisms. It is organized around mutually agreed upon

objectives and the key actions that are needed to achieve those objectives. The Governance and

Accountability Action Plan was disclosed by the government on April 21, 2010.

15. The supervisory strategy will be the following: (i) the project unit in DNSP will monitor the

activities in the project to determine if the MOH is implementing the plan, through direct

supervision and follow-up of task completion; and (ii) the task team will monitor the plan on the

basis of the periodic reports.

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Table 28: Governance and Accountability Action Plan

Objectives Key Actions to Achieve Objectives Responsible

Party

Target

Start Date

Enhanced public

disclosure program

1. Initiate a program to place posters in

health facilities informing the public that

health services are free, and that no

payment should be made to health

workers.

2. Implement a program involving users‘

reference groups whose advice will be

sought on strategic questions and quality

of care.

3. Issue a notice to the general public

through local media for all new

procurement to invite any interested

party to participate.

4. Make available to any member of the

public promptly upon request all short-

lists of consultants or pre-qualification

of contractors.

MOH/DNSP and

the Provincial and

Municipal

Departments of

Health, with

support from

Central

Coordination Unit

(CCU) and

Regional

Coordination Units

(RCUs)

September

2010

Enhanced compliance

mechanisms

1. At the municipal level, the

Revitalização program will include

community committees who will work

with the municipal health teams, giving

a voice to the public, notably on

community needs and quality of care.

2. Recruit qualified staff for all fiduciary

positions in MOH and in the project

unit.

2. Contract private sector professionals

to staff the CCU – using private sector

salaries to attract better qualified staff.

3. Design and implement regular

training and capacity building programs

for the fiduciary staff.

4. Prepare and use a FM manual and an

appropriately sized accounting software

package.

MOH/DNSP September

2010

Mitigation of collusion

risks

1. The project will contract a consultant

to perform procurement audits every two

years.

2. The project unit will contract qualified

procurement staff to support the MOH

with all project procurement and to

participate in the training and capacity

building programs for the staff in the

CCU..

MOH/DNSP Sept 2010

124

Objectives Key Actions to Achieve Objectives Responsible

Party

Target

Start Date

Mitigation of forgery

and fraud risks

1. Timely payment of interim payments

strictly following the terms and

conditions in the contracts.

2. The use of independent consultants

for both annual external audit and the

internal audits.

3. The use of qualified staff paid

competitive salaries.

4. Use of an accounting software

package with appropriate controls built-

in along with an acceptable Financial

Management and Accounting

Procedures Manual.

5. Regular training and capacity building

programs for management and all

project staff.

6. The attributions of community

committees will include the oversight of

project activities.

MOH/DNSP November

2010

Strengthen human

resource capacity

1. A significant training programs will

be implemented to strengthen the

technical capacity of the staff in the

sector.

2. Transfer of knowledge from the

HAMSET project will be ensured by

aiming at transferring some PIU staff to

MHSS CCU.

MOH/DNSP August

2010

Improve institutional

capacity to manage the

sector

1. The capacity to manage projects will

be addressed by strengthening the

capacity of the CCU as well as that of

provincial and municipal health

departments.

2. Specific training in health system

management will strengthen provinces

and municipalities‘ capacity to manage

the health system.

MOH/DNSP November

2010

125

Annex 20: Availability of Health Workers in the Five Targeted Provinces


16. Availability of nurses. As a result of a significant training program during the years of the

conflict, the MOH currently has a large number of nurses on its payroll, estimated at 36,000.

17. The ―Heath Facility Regulation‖ (REGUSAN) passed in 2003 defines the minimum staffing,

package of services, organization and job descriptions for health facilities. The Regulation uses

two criteria to define the minimum staff required in health facilities at each level: (i) the services

that need to be provided; and (ii) ratios of staff per population. The following table shows the

minimum number of staff per professional category and per Health Facility.

Table 29: Minimum number of professionals per category per health facility Health

Facility

Type

Population

Covered

Health Staff category

Nurse

Midwife

General

Nurse

Auxiliary

Nurse

Medical

Doctor

Laboratory

Technician

Radiology

Technician

Municipal

Hospital

Referral

Health

Center

150.00 –

500.00

2 3 14 2+1* 2*** 2***

Health

Center

75.000 2-3** 3-4** 8 2 2*** 2***

Health

Post type

II

20.000 1 2 5 - 1 1

Health

Post Type

I

5.000 - - 4 - - -

*One of the doctors can be ObGyn or a doctor trained in surgery who can perform C-sections

** One nurse midwife can be substituted by a general nurse trained in EmONC

*** One of them can be an auxiliary technician (basic level)

18. The actual number of staff per facility is available from the 2007 national survey of obstetric

and neo-natal care in Angola. When these are compared to the needs under the regulation, it is

clear that, although the total number of personnel is generally adequate, they are unevenly

distributed, with an excess in provincial and municipal hospitals and a deficiency in more

peripheral facilities. The MOH plans to reallocate the personnel by using non-monetary incentives

such as training, provision of housing, and by providing a more rapid path for career progression

for those who will accept reallocation.

19. A detailed analysis per province was undertaken. The analysis was made using the numbers

of auxiliary nurses because the majority of the new nurse midwives and general nurses to be

trained under the project will come from this category of nurses.

20. Bengo province. In the case of Bengo, the total number of doctors and general nurses are in

line with the minimum requirements. However, the number of auxiliary nurses is more than twice

the amount needed (48 auxiliary nurses in Catete and 32 in Ambriz when there is a need only for

126

14 in the municipal hospital. It is possible to reassign some of these nurses to fill posts in the health

centers in the periphery. It is also possible to train them to specialize as midwifes, notably for the

new delivery rooms to be built by the project. There will be no need for Bengo to recruit a

significant number of new nurse graduates.

21. Uige province. In the case of Uíge, one of the municipal hospitals/referral health centers, in

Negage has 105 auxiliary nurses which is almost 8 times the norm. Thus there is enough capacity

in the municipality to train some of these auxiliary nurses as nurse midwives and in courses to train

them to become general nurses and reassign them to the health centers that will receive the delivery

rooms under the project, and also to fill the needs for general nurses for outreach teams. In the

other municipalities the numbers of existing auxiliary nurses are 2-3 times the existing norm and as

in Negage they can be trained and reallocated. It is even possible for the DPS to reallocate some of

the nurses from Negage to the nearby municipality of Sanza Pombo that has fewer nurses, and

even to staff the municipality of Maquela do Zombo that is more distant.

22. Malange province. When analyzing the situation in Malange, the municipality of Cacuso

has almost 4 times the required number of auxiliary nurses (78), and in the municipality of

Malange the number of auxiliary nurses in the city health centers is also 4 times (71) the minimum.

The municipality of Kalandula has fewer nurses (34), but still has 2.5 times the minimum. Only the

municipality of Caculama has a limited number of nurses. This is because it used to have only one

smaller health facility. Now Caculama has a Municipal Hospital and it will need more staff. These

can be transferred, after training, from the provincial capital, using a rotating scheme to encourage

the nurses and doctors to stay in the municipality.

23. Moxico province. In Moxico, in the case of the 3 municipalities under the Revitalização

program and supported by the project, only the municipality of Camanongue has an insufficient

number of nurses (12), but in Luena, the municipality of the capital, excluding the provincial

maternity, the number of auxiliary nurses (57) in three health centers is almost 3.5 times the

minimum required. The number of general nurses (29) is also 3 times the required amount. The

same is true for the municipality of Luau which has 40 auxiliary nurses and 34 general nurses.

Here again the training of existing nurses and their relocation will help to cover the needs for nurse

midwives and strengthen the new delivery rooms, without the need to contract new nurses.

24. Lunda Norte province. Finally in the Province of Lunda Norte, the picture is very similar.

The municipality of Lucapa with 43 auxiliary nurses, and Cuango with 57, have enough nurses to

be trained as nurse midwives and reallocated to the new delivery rooms. The provincial hospital

with 25 nurse midwives and 203 general nurses can reallocate at least 20 percent of midwifes and

10 percent of general nurses to fill the needs for the health centres with delivery rooms in the

periphery of the Chitato, the capital municipality.

25. Doctors. In the case of medical doctors, the arrival in each municipality of Cuban doctor

teams will solve any existing gap. All the municipalities included in the project will receive or

have already received a Cuban doctor team as well as some expatriate doctors from other

nationalities to strengthen the capacity of municipalities. The movement of Cuban doctors to the

municipalities is expected to continue during 2009, and they will be renewed every three years.

The following table shows the availability of doctors and nurses in three selected municipalities of

the project.

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Table 30: Availability of doctors and nurses in three selected municipalities

Province/Municipality Cuban Teams Other Teams

Uige/Negage

1 ObGyn doctor

1 Internal medicine

Doctor

1 Nurse Midwife

1 Surgeon (Korean)

Uige/SanzaPombo 1 Nurse Midwife ( still

waiting housing)

Malange /Caculama

1 ObGyn

1 Paediatrician

1 nurse midwife

1 Surgeon (Korean)

26. Conclusion. Overall, there are sufficient health personnel for the project. Municipal

hospitals are generally overstaffed either with nurses or doctors, which allows for the training of

personnel to be redistributed to health centers and health posts in peripheral areas.

27. One must be cautious, however, when dealing with these numbers. For the next five years it

makes sense to provide in-service training to the existing nurses and reallocate them within the

provinces and municipalities. However, as the Angolan population grows and the health facility

network expands, the need for nurses and doctors will also be larger. Furthermore, a number of

nurses and doctors will begin to retire or to go to the private sector. Finally, as the health system

stabilizes and the overall country develops, the paradigm will change. The country will be able to

afford larger health staff/population ratios, thereby improving the population‘s access to services as

well as the quality of care. The government will then need to train and contract new nurses and

doctors.

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Annex 21: Availability of Obstetric Care in the Five Targeted Provinces


28. The 2007 national survey of obstetric and neo-natal care in Angola provides data by

provinces, which allowed reviewing the situation of obstetric care in the five targeted provinces.

Table 32 below shows that although there is a reasonably high number of health units with at least

one person who can perform selected procedures, most provinces fare poorly in terms of blood

transfusion and evacuation of retained products. Bengo is the worst performer of the five provinces

in this area.

29. Table 32 provides a good overview of the capacity of health facilities to provide the services

that are the key interventions for EmONC. Malange, Moxico and Bengo lag in the number of health

facilities able to provide blood transfusion, an essential service for comprehensive EmONC with C-

sections. During project preparation visits to the five provinces, it was noted that the majority of the

staff of provincial and municipal hospitals who were providing blood transfusion had received in-

service training, with no quality control from the Luanda National Blood Institute, and were not

specialists in blood transfusion.

30. An analysis of the data from the national obstetric survey shows the lack of skills of the

staff. Less than 50% of basic and general mid-level nurses and only 52% of midwives know that

pregnant women must have at least 4 ANC visits. For other crucial interventions in neo-natal care,

knowledge is even lower: less than 30% of all obstetric care providers had promoted breast feeding.

Also, less than 30% of nurse midwives and basic and mid-level nurses reassessed the physical status

the newborn one hour after delivery or encouraged mothers to initiate breast feeding. Only 50% of

midwifes and almost the same percentage of nurses in general provided eye prophylaxis to the new

born.

31. An analysis of Table 33 shows that there is a serious lack of basic equipment in the five

targeted provinces. This applies to normal delivery kits, C-section kits, and all key equipment

except bi-auricular stethoscopes. Oxygen is strikingly inexistent and this is due to the fact that

medicinal oxygen is only produced in Luanda, and logistical constraints limit the distribution of

oxygen containers. The MOH is considering the production of medical oxygen in some provincial

and municipal hospitals. This will reduce the dependence of the provinces from Luanda. An

additional supply will be provided by the project.

32. Table 33 shows the low percentage of facilities with C-section kits, curettage and forceps

kits, thus their limited capacity to provide quality obstetric care. They also have a limited capacity

to forecast the needs for medical equipment and commodities. Less than 30% of facilities in Bengo

and Moxico and only 50% of those in Malange have normal delivery kits limiting their capacity to

perform quality normal deliveries The project will address this situation by providing delivery kits.

These include magnesium sulfate and oxytocin, two commodities in scarce supply.

33. Table 34 shows that the availability of drugs was usually low, including magnesium sulfate,

oxytocin, hydralazine hydrochloride and antiretrovirals. The lack of magnesium sulfate in more

than 50% of the EmONC facilities is a concern because it is the first-line drug to control eclampsia

and convulsions and is easy to use. The same is true for oxytocin, very useful in the late stage of

labor. It can be administered by trained nurses and provides support to pregnant women in

maintaining contractions.

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34. This analysis shows the importance for the project to finance equipment for obstetric care,

including normal delivery kits and C-section kits, as well as drugs.

Table 31: Percentage of health units with at least one person who can perform selected procedures

Location Antibiotics Oxytocin Anticonvulsants Removal of

Placenta

Evacuation of

Retained

Products

Neonatal

Resuscitation

Blood

Transfusion

National level 92 82 85 92 48 95 18

Bengo 94 50 78 94 33 100 6

Lunda Norte 100 100 100 100 73 91 36

Malange 100 77 100 92 46 92 8

Moxico 100 100 100 100 86 100 5

Uige 100 88 96 100 96 100 32

Table 32: Percentage of health units with selected equipment

Location Biauricular

Stethoscope

Oxygen tank

(full)

Delivery Kit

(complete)

Foley

Catheter

Curettage

Kit

C-Section

Kit

Forceps Kit Suction Kit

Bengo 56 16 28 33 17 6 6 6

Lunda Norte 93 9 73 27 45 27 9 18

Malange 82 0 54 23 46 8 8 8

Moxico 85 5 20 25 20 20 10 10

Uige 83 0 92 44 32 32 12 32

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Table 33: Percentage of health units with selected drugs

Location Magnesium

Sulfate57

Oxytocin58

Hydralazine

Hydrochloride59

Lactated

Ringer's

Solution60

Antiretrovirals

Bengo 28 39 17 89 6

Lunda Norte 45 36 0 64 18

Malange 31 23 0 100 6

Moxico 30 25 10 60 5

Uige 24 20 20 96 28

57

A first-line anti-arrhythmic agent 58

Used to induce labor 59

Used to treat hypertension 60

Used for fluid resuscitation after blood loss

Annex 22: Supervision Plan


35. The project will need intensive supervision given the geographic spread of the proposed

operation (18 municipalities in 5 provinces plus two pilot municipalities in two different provinces),

and given implementation capacity weaknesses at the country and project level. The project will be

implemented at three levels: the central MOH, Provincial departments of Health, and municipalities.

A budget of US$150,000, is needed for the Bank team to supervise the project during the first 12

months of implementation.

36. The supervision by the Bank will be leveraged by the supervision carried out by the Central

Coordinating Unit (CCU) on a regular basis. The MOH will have teams visiting each district four

times a year for a period of about 8 days each and will prepare action-oriented supervision reports

that will be reviewed by the Bank and donors during their bi-annual supervision missions, and

through desk reviews. This system has been used successfully under the HAMSET project. It has

allowed the MOH to distinguish between the better and lesser-performing provinces and provide

more assistance to the latter. Sufficient funds to that effect have been included in the project design

with a total of about US$3.5 million allocated for fuel and per diem over a five-year period (Annex

5).

37. As has been the case for the HAMSET project, some of the skills required by the Bank team

for supervision will be needed on a regular basis while others will be required on an ad hoc basis. It

is therefore proposed to establish a core supervision group, that will emphasize financial,

procurement and operational basic needs, complemented by technical specialists, in particular those

covering monitoring and evaluation, and maternal and child care.

38. While regular Bank (and donors) supervision will take place twice a year, this will be

leveraged by about four visits each per year by the Bank procurement and financial management

specialists who take advantage of their participation in the full supervision of the Bank portfolio (6

projects) to verify progress in the others and provide assistance to the client.

39. A much more intensive than normal supervision program should be carried out during the

first year of the project to put in place a sound institutional base and properly begin interventions to

be undertaken by this complex operation.

40. While the CCU will benefit from the experience of staff recruited from HAMSET, there will

be an incubation period during which they will plan and organize the work with provinces and

municipalities. There may also be some new CCU staff without knowledge of Bank procedures and

standards and there will be a learning curve for the development of a smooth-working team and to

get the supervision program under way. The priority technical specialists will provide support

periodically, as required. The emphasis of the supervision missions will be in getting the MHSS

project up and running, with particular stress on capacity development of provinces and

municipalities.

41. Project supervision will also benefit from the Bank‘s Angola-based operational staff as well

as from Bank specialists form the health, education, and social protection sectors. In addition there

will be (i) a monitoring and evaluation specialist; (ii) an implementation specialist to provide

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longer-term support and to troubleshoot implementation issues at an early stage; and (iii) a maternal

and child health specialist.

42. The supervision team therefore includes the following members: (i) the Task Team Leader

with experience in health systems; (ii) a reproductive health specialist; (iii) a senior implementation

specialist, to help in the critical first half year of project implementation; (iv) a financial

management specialist who will review adherence to Bank procedures with regard to fiduciary

responsibilities; and (v) procurement and implementation specialists, responsible for procurement,

implementation, and institutional issues; and (vi) an environmental specialist.

43. The supervision team will be complemented by representatives of Total E&P Angola, the

Bank‘s financing partner in this operation. As during the preparation process, technical partners,

including UNICEF, WHO, and UNFPA, will be invited to participate in supervision missions to

ensure the good quality of health interventions and project implementation, build strong

partnerships, and facilitate a cross-fertilization of experiences. Areas of technical consultant support

to highlight are monitoring and evaluation (including KAP surveys), and IEC and BCC, and

coordination of returning refugees.