the world bank for official use only...the horn of africa drought is having a major impact on the...

Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No: 65612-KE

PROJECT PAPER

ON A

PROPOSED ADDITIONAL CREDIT

IN THE AMOUNT OF SDR35.9 MILLION (US$56.8 MILLION EQUIVALENT)

FROM THE IDA CRISIS RESPONSE WINDOW RESOURCES

TO THE

REPUBLIC OF KENYA

FOR A

HEALTH SECTOR SUPPORT PROJECT

NOVEMBER 30, 2011

Health, Nutrition, and Population Unit (AFTHE) Human Development Department 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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CURRENCY EQUIVALENTS (Exchange Rate Effective October 31, 2011)

Currency Unit = Kenyan Shilling K.Sh.93 = US$1

US$ = SDR0.6306

FISCAL YEAR July 1 – June 30

ABBREVIATIONS AND ACRONYMS

AF Additional Financing CPS Country Partnership Strategy CRW Crisis Response Window DA Designated Account DANIDA Danish International Development Agency DHMT EMMS

District Health Management Team Essential Medicines and Medical Supplies

FBO Faith Based Organizations FM Financial Management FY Fiscal Year GAM Global Acute Malnutrition GIZ GoK

German International Cooperation Government of Kenya

HSCC Health Sector Coordination Committee HSSF Health Sector Services Fund IBRD International Bank for Reconstruction and Development ICB International Competitive Bidding IDA International Development Association IFR Interim Financial Report IIFRA Independent Integrated Fiduciary Review Agency IPPs Indigenous Peoples Plans IPSAS International Public Sector Accounting Standards KDHS Kenya Demographic Health Survey KEMSA Kenya Medical Supplies Agency KHSSP Kenya Health Sector Support Project MOMS Ministry of Medical Services MOPHS Ministry of Public Health and Sanitation NCB National Competitive Bidding NGO Non Governmental Organizations OP Operational Policy OPRC Operations Procurement Review Committee PDO Project Development Objective RUSF Ready-to-Use Supplementary Food RUTF Ready-to-Use Therapeutic Food SWAp Sector Wide Approach program

UNHCR United Nations High Commission for Refugees UNICEF United Nations Children’s Emergency Fund UOM Unit of Measurement USG United States Government VMPPs Vulnerable and Marginalized People’s Plan WA Withdrawal Application WFP World Food Program WHO World Health Organization

Vice President: Obiageli Katryn Ezekwesili Country Director: Johannes Zutt

Sector Director: Ritva Reinikka Acting Sector Manager: Jean-Jacques de St. Antoine

Task Team Leader: Gandham N. V. Ramana

KENYA

Health Sector Support Project – Additional Financing

CONTENTS

I. Introduction .......................................................................................................................... 1 II. Background and Rationale ................................................................................................... 3 III. Proposed Changes ................................................................................................................ 9 IV. Appraisal Summary ........................................................................................................... 12 Annexes Annex 1: Results Framework and Monitoring ............................................................................. 16 Annex 2: Operational Risk Assessment Framework (ORAF) ...................................................... 23 Annex 3: Detailed Description of New Project Activity ............................................................. 26 Annex 4: Procurement Arrangements ........................................................................................... 29 Annex 5: Map Section ................................................................................................................. 32

List of Figures Figure 1: Trends in Admission of Severely Malnourished Children in Drought Affected ............ 5

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KENYA

HEALTH SECTOR SUPPORT PROJECT- ADDITIONAL FINANCING

ADDITIONAL FINANCING DATA SHEET

Basic Information - Additional Financing (AF) Country Director: Johannes Zutt Acting Sector Manager/Director: Jean-Jacques de St. Antoine/Ritva Reinikka Team Leader: Gandham N.V. Ramana Project ID: P128663 Expected Effectiveness Date: January 15, 2011 Lending Instrument: Investment Lending Additional Financing Type: Financing Gap, Scale-up and Restructuring

Sectors: Health Themes: Child Health, Nutrition, Health System Environmental category: B- Partial Assessment Expected Closing Date: March 31, 2015

Basic Information - Original Project Project ID: P074091 Environmental category: B- Partial

Assessment Project Name: Kenya Health Sector Support Project (KHSSP)

Expected Closing Date: March 31, 2015

Lending Instrument: Specific Investment Lending

AF Project Financing Data [ ] Loan [ x ] Credit [ ] Grant [ ] Guarantee [ ] Other: Proposed terms: Standard IDA terms, 40 years maturity including a grace period of 10 years.

AF Financing Plan (US$m) Source Total Amount (US $m)

Total Project Cost: Cofinancing: Borrower:

Total Bank Financing: IBRD

IDA

New

Recommitted

56.8 0.0 0.0 56.8

from IDA Crisis Response Window Resources

56.8

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Client Information Recipient: Republic of Kenya Office of the Deputy Prime Minister and Ministry of Finance Contact Person: Permanent Secretary Treasury Building P.O. Box 30007-00100, Nairobi, Kenya Telephone No.: +254 (20) 2252299 Fax No.: +254 (20) 2240045 Email: [email protected] Responsible Agencies: Ministry of Public Health and Sanitation Contact Person: Permanent Secretary Afya House, Cathedral Road P.O. Box 30016-00100 Nairobi, Kenya Telephone: +254 (20) 2717077 Fax No.: +254 (20) 2715239 Email: [email protected] Ministry of Medical Services Contact Person: Permanent Secretary Afya House, Cathedral Road P.O. Box 30016-00100 Nairobi, Kenya Telephone No.: +254 (20) 2717077 Fax No.: +254 (20) 2735236 Email: [email protected]

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AF Estimated Disbursements (Bank FY/US$m)FY 2012 2013 2014 2015 Annual 12.8 44.0 0.0 0.0 Cumulative 12.8 56.8 56.8 56.8

Project Development Objective and Description Original project development objective: To support the Program1 and improve: (i) the delivery of essential health services in the Recipient’s territory, especially for the poor; and (ii) the effectiveness of planning, financing and procurement of pharmaceuticals and medical supplies. Revised project development objective: To support the Program and improve: (i) the delivery of essential health services in the Recipient’s territory, especially the poor and the drought affected populations; and (ii) the effectiveness of planning, financing and procurement of pharmaceuticals and medical supplies. Project description: The proposed additional financing (AF) from the IDA Crisis Response Window (CRW) to the Kenya Health Sector Support Project (KHSSP) would support the emergency response to deliver essential health and nutrition services for the drought affected arid and semi-arid regions of Kenya. The AF will include new activities to address the nutrition and health needs of children under five, and pregnant and lactating women as well as scale-up of ongoing activities to improve the supply of essential medicines to mitigate the risk for infections and communicable disease outbreaks. There will be several new indicators added for activities supported under the emergency response and minor refinements to several existing indicators and targets. The project includes two components. Component 1: This component supports the delivery of Kenya Essential Package for Health and Nutrition Services. The proposed AF will support a new activity (US$12.8 million) which complements ongoing efforts by Government of Kenya (GoK) and its partners to deliver essential health and nutrition services to populations affected by the drought. Specifically this involves supply of nutrition commodities to manage acute malnutrition among children under five years, and pregnant and lactating women2. The AF will also provide support for blanket supplementary feeding3, if the need arises, as a part of a wider package of ongoing nutrition interventions. Services of UNICEF will be contracted for the supply of nutrition commodities. Component 2: This component supports increased availability of essential medicines and medical supplies and reinforcement of the supply chain management. The proposed AF will support scale-up (US$44 million) of these activities with an enhanced focus on the drought affected districts with a view to prevent and control infectious and outbreak prone diseases. The AF will also strengthen the ongoing reform to move towards a “pull” system of supply chain management.

1 “Program” means the health sector policy framework, consistent with the Health SWAp, described in the letter dated May 20, 2010 from the Recipient to the Association. 2 Pregnant and Lactating Women with Mid Upper Arm Circumference less than 21 centimeters are identified as moderately malnourished and are eligible for supplementary feeding. When a child less than 6 months is found moderately malnourished then the mother is also eligible regardless of her nutritional status.

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Safeguard and Exception to Policies Safeguard policies triggered: Environmental Assessment (OP/BP 4.01) Natural Habitats (OP/BP 4.04) Forests (OP/BP 4.36) Pest Management (OP 4.09) Physical Cultural Resources (OP/BP 4.11) Indigenous Peoples (OP/BP 4.10) Involuntary Resettlement (OP/BP 4.12) Safety of Dams (OP/BP 4.37) Projects on International Waterways (OP/BP 7.50) Projects in Disputed Areas (OP/BP 7.60)

[x]Yes [ ] No [ ]Yes [x] No [ ]Yes [x] No [ ]Yes [x] No [ ]Yes [x] No [x]Yes [ ] No [ ]Yes [x] No [ ]Yes [x] No [ ]Yes [x] No [ ]Yes [x] No

Does the project require any waivers of Bank policies? Have these been endorsed or approved by Bank management?

[ ]Yes [x] No [ ]Yes [ ] No

Conditions and Legal Covenants: Financing Agreement

Reference Description of

Condition/Covenant Date Due

Section V. Paragraph 3. KEMSA will maintain quality assurance system for procurement and distribution of Essential Medicines and Medical Commodities satisfactory to the Association.

Throughout the Project

3 The Blanket Supplementary Feeding aims to prevent an increase in Protein Energy Malnutrition and micro-nutrient deficiency and reduce excess mortality during droughts. The usual target groups include children under five years, and pregnant and lactating women. This will be complemented by preventive medication such as vitamin A, measles vaccination etc.

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Section V. Paragraph 4 (a) The Recipient shall enter into a contract with UNICEF for the timely provision by UNICEF of an adequate supply and distribution of nutritional supplements and Blanket Supplementary Foods under the Project, including provision for quarterly reports by UNICEF on the costs incurred, quantities delivered, stock status, and compliance with any other contractual obligations in a manner satisfactory to the Association.

Section IV.B.1 Notwithstanding the provisions of Part A of this Section, no withdrawal shall be made for payments made: (a) in respect of expenditures under Category 4 unless a UNICEF contract satisfactory to the Association has been duly executed; and (b) prior to the date of the Original Financing Agreement.

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I. Introduction 1. This Project Paper seeks the approval of the Executive Directors to provide an additional credit of US$56.8 million from the IDA Crisis Response Window (CRW) to the Republic of Kenya for the Kenya Health Sector Support Project (KHSSP) (P074091), and introduce changes to the Project’s legal documents to revise the project’s objectives, include a new activity to deal with the emergency nutrition and health needs of the drought affected populations, and scale-up an ongoing activity to enhance access to essential medicines and supplies. Further, the Additional Financing (AF) proposes to simplify the results framework of the original project, strengthen the focus on reforms, and maintain attention on governance. 2. Kenya is experiencing an unprecedented drought and requires urgent support to complement ongoing government efforts to address the needs of vulnerable populations. The Horn of Africa drought is having a major impact on the populations residing in the arid and semi-arid regions of Northern Kenya. The global acute malnutrition levels among children under five are unacceptably high (over 20 percent) and hospital admissions of severely malnourished children nearly tripled compared to previous years. Furthermore, the drought has affected some of the most impoverished areas of Kenya populated by nomadic and semi-nomadic pastoralists and subsistence farmers. Sixteen counties are entirely or partially affected by the drought and many have the highest levels of poverty in Kenya4. While the worst part of the drought appears to have passed with the onset of short rains, the coping mechanisms of these populations have been severely eroded and it will take longer to recover. Therefore, there is a critical need to ensure that these vulnerable populations receive similar support to the refugees residing in the camps who received priority attention so far.

3. The proposed Additional Financing will help Kenya to address more effectively the emergency health and nutrition needs of most vulnerable populations, especially pregnant and lactating women and children under five, among more than 3.7 million people in the drought affected northern arid and semi-arid regions. The expected key outcomes from the AF are: (a) increased direct project beneficiaries (using the outpatient services of the primary health care facilities in the drought affected areas); (b) improved recovery of severely malnourished children through “therapeutic nutrition” and “micronutrient support” complemented by treatment and prevention of co-morbidities; and (c) improved coverage of moderately malnourished children under five, and pregnant and lactating women in the most affected counties through “supplementary feeding” programs. The AF will support the GoK to effectively address the most urgent nutrition needs of young children, and pregnant and lactating women who are most vulnerable. It will also ensure adequate supply of essential medicines to prevent and control infectious diseases among vulnerable groups and the spread of communicable diseases. More importantly, by addressing the critical needs of the host populations in the drought affected areas who are equally vulnerable as the refugees, the proposed AF will complement the Horn of Africa Emergency Health and Nutrition Response Project approved by the Bank from the IDA CRW to support health and nutrition services for the refugee populations. The proposed AF is part of the 2011 Drought Response Financing Plan and fully in line with the Bank’s strategy to provide immediate relief while the original Credit will

4 Turkana, Mandera, Marsabit, Garissa, Wajir, Isiolo and Tana River have poverty levels much higher than the national average (79 percent vs. 47 percent).

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continue to contribute to the ongoing health systems strengthening as part of the broader health sector-wide approach. 4. The proposed additional financing is consistent with CRW objectives of enhancing IDA capacity to offer rapid response and providing additional and predictable financing to countries hit by crises. The Project is the ideal vehicle for providing a quick and well coordinated response to support the emergency health and nutrition needs of vulnerable groups in Kenya for the following reasons:

Being a part of the sector-wide program, the Project remains the main vehicle for coordinated response by government for public health emergencies.

The AF will enable the Bank to promptly respond to the GoK’s request for meeting the financing gap to provide urgently needed health and nutrition support for the vulnerable groups among populations affected by drought.

The original Project Development Objectives (PDOs) of delivering essential packages for health services and supplying essential medicines and medical supplies is fully aligned with the proposed AF for the drought affected areas.

The drought affected regions have the highest levels of poverty in Kenya and therefore remain the most important target group for the Project.

5. The original project which supports the Kenya sector-wide program has two components. The first component finances the effective and transparent delivery of the Kenya Essential Package for Health through the Health Sector Services Fund (HSSF) grants and Performance Based Financing to increase access to quality basic health and nutrition services. The grants aim to enhance citizen ownership and participation in the delivery of health services. The second component funds the increased availability of essential health commodities and strengthening of supply chain management. Both components support improvements in health sector governance, accountability and performance. The proposed AF will complement the original project by adding a new activity of supplying nutrition commodities under Component 1 and by scaling-up the ongoing Kenya Medical Supplies Agency (KEMSA) reforms to effectively put in place a strong “pull system” for the supply of essential medicines under the Component 2. Both activities proposed to be financed by the AF will focus on expanding access to essential medicines and nutrition supplements, enabling government to effectively address the emergency health and nutrition needs of populations residing in the 16 drought affected counties. The original project has disbursed 10 percent of the Credit with another 40 percent of the Credit already committed with procurement underway. There is thus a need for additional financing to scale up the emergency response. 6. The original design and implementation arrangements will be further strengthened to more effectively respond to the emergency situation. The KEMSA will procure the essential medicines and medical supplies following the Bank’s International Competitive Bidding (ICB) procedures and services of the United Nations Children’s Fund (UNICEF) will be used as a supplier of ready to use supplemental and therapeutic nutrition supplements. To respond promptly the scope of the ongoing ICB procurement under the original project by KEMSA will be increased by 20 percent and supply of essential drugs and supplies will be accelerated by shortening the currently planned 18-month period and planning for staggered

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deliveries. Use of UNICEF as a specialized agency in procurement of health sector goods will accelerate the delivery of urgently needed nutrition commodities. The standard Bank contract agreed for UN agencies will be used by the government to contract UNICEF. Both UNICEF and KEMSA will be delivering the commodities at the facility level under the oversight of the facility staff and the management committee comprised of civil society representatives. Health and nutrition services will be delivered by public health services in partnership with UNICEF (which has 18 nutrition support officers in the affected counties) and the World Food Program (WFP) which have a strong field presence and are supported by other partners. 7. Although the proposed AF would not involve co-financing, it will complement ongoing drought mitigation efforts and health systems development reforms of GoK and its development partners, especially UNICEF, WFP, World Health Organization (WHO), German International Cooperation (GIZ), Danish International Development Agency (DANIDA) and the United States Government (USG) through their implementing partners in arid and semi-arid regions of Kenya as well as other national and international Non Government Organizations (NGOs) such as Kenya Red Cross, Save the Children, and World Vision International. The Nutrition Technical Forum co-chaired by the Division of Nutrition and UNICEF ensures effective coordination among partners supporting nutrition interventions. The overall scope of support has been endorsed by the Steering Committee of the Health Sector Coordination Committee (HSCC). The AF will complement the first Project approved by the Bank from the IDA CRW to the United Nations High Commission for Refugees (UNHCR) for the Horn of Africa Emergency Health and Nutrition Response, which specifically targets the refugee camps in the drought affected areas. II. Background and Rationale 8. The ongoing drought along with escalating food prices puts Kenya’s renewed economic growth at risk. In 2010, the economy grew by 5.6 percent, in part as a result of declines in inflation (i.e. below 5 percent) and in debt (i.e. from 60 percent during the past decade to 38 percent) as well as implementation of a fiscal stimulus package. The ongoing drought in Horn of Africa combined with other shocks, especially the steep increase in food prices by 130 percent compared to the past five-year average, has the potential of slowing down Kenya’s developmental progress. The inflation rate has tripled in the past year reaching 18.9 percent by October 2011. 9. More than 3.7 million people residing in arid and semi-arid northern and eastern regions of Kenya are directly affected by the drought. The most seriously impacted are those residing in the counties of Turkana, Mandera, Marsabit, Garissa, Wajir, Isiolo, Tana River, Samburu and most of Baringo, Laikipia, Kajiado and West Pokot as well as the eastern parts of Kitui, Makueni, and Machakos, and the hinterlands of Kwale and Kilifi which are some of the most impoverished parts of Kenya. The Ministry of Public Health and Sanitation (MOPHS) estimates that around 385,000 children and 90,000 pregnant women suffer from acute malnutrition in the affected areas.

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10. Global Acute Malnutrition (GAM) rates in children under five as well as numbers of severe acute malnutrition cases are soaring in the affected areas. Annual nutrition surveys were carried out by the MOPHS and partners in the first five months of 2011 and showed GAM rates above 20 percent among children under five in Turkana, Mandera, Wajir, Marsabit, Isiolo and Samburu. There also has been a steep increase in the number of admissions for severe acute malnutrition in these areas with new admissions of around 6,000 per month in September 2011 (Figure 1). Based on these findings, blanket supplementary feeding has been recommended by the Nutrition Technical Forum and WFP is providing blended products for this program. The need for continuation of blanket feeding will be reassessed in December 20115. Programs to treat severe acute malnutrition have been scaled up in 18 districts. The scarcity of safe water, food and animal feed is further compounded by the influx of migrants, increasing the risk for communicable disease outbreaks, such as measles and cholera, both of which require prompt attention and adequate supply of essential medicines. In addition, internal migration in search of scarce water and food is affecting the delivery of essential health services. Over 80 percent of the country’s strategic grain reserves have been used for emergency food distribution and are rapidly depleting. Half of the 8 million cattle in severely drought affected areas have died or are beyond recovery, seriously threatening the livelihoods of these pastoral communities. The August 2011 Long Rains Assessment Report indicates that the situation has worsened in the entire country and regions previously classified under the alert group have now been moved to the crisis level. The Bank’s crisis response to Kenya includes a comprehensive cross-sectoral financing plan covering water supply and sanitation, social protection, and agriculture, in addition to the proposed emergency support for health through this AF.

5 The need for ongoing blanket feeding will be assessed and decided upon following nutrition surveys in November 2011 and the Short Rains Assessment in December 2011. If GAM rates remain above 20-30 percent, there is a possibility that the Nutrition Technical Forum may consider continuing blanket feeding and using RUSF.

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Figure 1: Trends in Admission of Severely Malnourished Children in Drought Affected Arid and Semi-Arid Lands (ASAL)

Source: Integrated Management of Acute Malnutrition Data, MOPHS.

11. Rapid implementation of Kenya’s package of proven high impact nutrition interventions in a coordinated manner through the health sector program will prevent deaths and help minimize the impact of the drought on women and young children. The Ministries of Health6 are working closely with their partners in responding to the current emergency in a timely, adequate and coordinated manner to minimize the consequences of drought particularly on the health and nutritional situation of young children and women. In 2010, Kenya adopted a package of 11 High Impact Nutrition Interventions focusing on infant feeding, micronutrient supplementation and management of acute malnutrition7. These essential nutrition services – proven to be efficient in preventing and addressing malnutrition and mortality in children – have a potential to prevent nearly a quarter of deaths if the full package is effectively implemented in an integrated manner. 12. A partnership framework was developed in March 2011 and used to estimate funding needs and gaps based on partner interventions. Partners are supporting the

6 The MOPHS is responsible for the delivery of primary care including provision of Kenya’s essential package for health services at the community level and through outreach. The Ministry of Medical Services (MOMS) is responsible for hospital services, including the operation of Stabilization Centers for severely malnourished children. 7 These interventions include: (1) Promotion of Exclusive Breast feeding for the first 6 months of life; (2) Promotion of optimal complementary feeding for infants after the age of 6 months; (3) Vitamin A supplementation (2 doses per year for children 6-59 months); (4) Zinc supplementation for diarrhea management; (5) Multiple micronutrients for children under 5 years; (6) De-worming for children (2 doses per year for children 12-59 months); (7) Iron-folic acid supplementation for pregnant mothers; (8) Prevention or treatment of severe acute malnutrition and moderate acute malnutrition; (9) Promotion of improved hygiene practices, including hand washing; (10) Salt Iodization; and (11) Iron fortification of staple foods.

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government to: (i) scale-up delivery of essential nutritional services to affected populations at health facility and community levels with a goal of maximum coverage of services; (ii) put in place efficient coordination mechanisms at decentralized levels; (iii) maintain efficient nutrition surveillance and reporting systems; and (iv) ensure timely and adequate supplies of essential food and non-food commodities. In October 2011, a total funding need of US$44.8 million was estimated to meet emergency nutrition needs for a six month period. The donors have pledged US$28.5 million, leaving a funding gap of US$17.3 million. In addition, there is a great need for essential medicines and medical supplies for preventing and promptly responding to communicable disease outbreaks at the community, primary health care facility and hospital levels. These needs are reported to be on the rise due to reduced availability of safe water and migration of vulnerable populations. The Ministries of Health have therefore proposed procurement of additional essential medical supplies estimated at US$40 million. 13. The KHSSP, approved by the Board of Executive Directors on June 29, 2010, is the optimal instrument for addressing the health and nutrition needs of vulnerable groups as it directly supports health service delivery closest to the community. The Project’s original PDOs are to support the Program and improve: (i) the delivery of essential health services in the Recipient’s territory, especially for the poor; and (ii) the effectiveness of planning, financing and procurement of pharmaceuticals and medical supplies. The Project, in the original amount of US$100 million, supports the broader Sector-Wide Program of the government by strategically pooling resources with the GoK and DANIDA and has two Components. The first Component (US$46 million) supports the effective and transparent delivery of Kenya’s Essential Package for Health Services at the primary care level through the Health Sector Services Fund (HSSF) and the second Component (US$54 million) seeks to increase availability of essential health commodities and strengthen supply chain management. Both Components support improvements in health sector governance, accountability, and performance. 14. The KHSSP became effective on time on September 30, 2010 and is performing satisfactorily. Implementation performance and progress towards the development objectives are both satisfactory. Nearly 35.8 million individuals used outpatient services during FY 2010-2011 and more than half of them (56 percent) were women according to data from the Health Management Information system of the Ministries of Health. Moreover, close to one million children were fully immunized before completing their first year (64 percent coverage). Under the HSSF, primary health facilities received funding to deliver the essential package for health services. In 2011, close to 650 government health centers (level 3) and nearly 4,500 facility committee members and health staff received training in planning and managing HSSF funds. In addition, 265 District Health Management Teams (DHMT) received HSSF funds for providing supportive supervision. 15. Reforms related to procurement and supply of Essential Medicines and Medical Supplies (EMMS) are underway with good progress. KEMSA reforms are progressing and the new Board is providing more effective oversight. Recently several senior level management positions have been filled through competitive recruitment. With support from the USG, a comprehensive Enterprise Resource Planning system has been made operational which is helping to improve KEMSA’s operational effectiveness. As agreed, consultants have been contracted to prepare Standard Operating Procedures and procurement and logistics manuals and performance

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based Memoranda of Understanding with Ministries of Health which will foster mutual accountability. KEMSA has also introduced Bar Coding for all supplies to track leakages.

16. KEMSA is currently finalizing contract awards for EMMS being procured following the International and National Competitive Bidding procedures. The Ministries of Health have established "drawing rights" for health facilities to move towards the "pull system of supply" where facilities order required supplies based on actual need rather than receiving centrally determined numbers of medicine kits (push system). Expeditious replenishment of the EMMS pool by the Ministries of Health based on quarterly invoices received from KEMSA remains critical to sustain this important reform. The implementation of pilots on "Social Accountability" to enhance transparency, promote user participation, and address complaints, has started in nine representative locations. In addition, "Performance Based Financing" has been initiated in Samburu County. A situational analysis of health facilities built under the Constituency Development Fund has been concluded and options for making non-functional facilities operational through public-private partnerships are being discussed. The Bank has recently approved the concept note shared by the Ministry of Medical Services (MOMS) on proposed pilots for health insurance and implementation is expected to start soon. 17. Governance and fiduciary measures are also being effectively implemented. The original project supports enhanced attention to improve governance and strengthen fiduciary systems in the health sector. The Steering Committee of the HSCC which provides overall oversight for the Sector-Wide Program and the HSSF have strong representation of NGOs and private sector. The releases of HSSF funds are widely disclosed in the newspapers and health facility management committees are now taking charge of planning, implementation, and reporting on their respective activities and finances. Quarterly Interim Financial Reports (IFRs) are being shared on time with the Bank and recently a review of fiduciary systems has been undertaken jointly by the internal audit department of the Ministries of Health and the Bank. The key findings of the review are that all facilities sampled received money as well as medicines and have established facility management committees. The review identified the need for strengthening accounting capacity at the facility level and acknowledged the role of county accountants supported by DANIDA in providing such support. The HSSF has now allowed the facilities to hire an accounts clerk and discussions are under way to provide sustained support through ongoing technical assistance from other bilateral partners. An Independent Integrated Fiduciary Review Agency (IIFRA) has been selected through competitive bidding to systematically undertake fiduciary, performance and value for money audits. The scope of work will include the activities being supported under the AF as well. To bolster the government’s efforts to strengthen governance, especially for the decentralized activities, a strong and sustained oversight will be required, including strong support from the Bank’s country office in Kenya. 18. The most recent Implementation Status Report of August 2011 rates overall implementation progress of the project satisfactory. The project is in compliance with its legal covenant and the IIFRA, selected through quality and cost based criteria, is now up and running after a slight initial delay. The overall strategy for implementing the vulnerable and marginalized groups’ plan and health care waste management pilots in five locations have been agreed upon and procurement of consultant agencies and goods is underway. The Sector-Wide

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Approach Secretariat is being strengthened by providing additional senior staff and consultants. The Project has disbursed about 10 percent of the original Credit and procurements amounting to 40 percent of the Credit are in the pipeline with the contracts under evaluation by KEMSA. 19. The proposed AF is fully consistent with the Country Partnership Strategy (CPS) 2010-2013 for Kenya. The CPS aims to support government efforts to unleash Kenya’s growth potential. It also seeks to ensure that growth contributes to reduce inequality and social exclusion, including increasing access of the poor to basic health services. By specifically targeting the arid and semi-arid regions of Kenya and most vulnerable groups of children under five and pregnant and lactating women in these drought affected regions for nutrition services, the Project will help Kenya to address immediate adverse effects of malnutrition and ill health while the original Credit continues to contribute improvements to the system capacity to respond to various emergency shocks and protect vulnerable populations. The AF is also well aligned with the Bank’s 2007 Health, Nutrition and Population Global strategy which aims to help client countries to achieve sustainable improvement in their health outcomes, especially the poor focusing on areas where Bank has comparative advantage. Finally, the AF is fully consistent with the “Africa Regional Strategy” which aims to enhance governance and public sector capacity to improve systems for delivering basic health services and manage accounts.

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III. Proposed Changes 20. The proposed AF for US$56.8 million is to support effective delivery of the Kenya Essential Package for Health Services8 for poor and vulnerable populations affected by the drought. The AF will primarily support: (i) supply of nutrition commodities to manage severely malnourished children under five and provide supplementary feeding to moderately malnourished children, pregnant and lactating women in most drought affected districts of Northern Kenya (US$12.8 million), as a newly proposed activity under Component 1; and (ii) increase in the availability of essential medicines and medical supplies in the drought affected areas and further strengthen the ongoing reform to move towards a pull system of supply (US$44 million), as scale-up of the original project activities under Component 2. 21. The PDOs remain relevant with a small proposed change to include a special focus on urgent health and nutrition needs of the drought affected populations. The revised PDOs will be to support the Program and improve the: (i) delivery of essential health services in the Recipient’s territory, especially the poor and drought affected populations; and (ii) effectiveness of planning, financing and procurement of pharmaceuticals and medical supplies. The original closing date of March 31, 2015 will remain unchanged. 22. Governance arrangements for the original Credit will apply for the AF. The governance risks identified for the original project will remain valid for the AF as both activities being supported need to ensure effective delivery of essential health and nutrition services at health facility and community levels. UNICEF will supply nutrition commodities directly to the health facilities as per the consignee list provided by the MOPHS while KEMSA will continue its current distribution cycles9 gradually moving towards a pull system. At the facility level, the health management committees will monitor the receipt and use of both nutrition supplements and essential medical supplies. In addition, the district nutrition officers of MOPHS and 18 Nutrition Support Officers of UNICEF and its implementing partners supported by other donors will also monitor the delivery and effective use of the nutrition supplements. The practice of making available health facility grants released in the public domain will continue and more emphasis will be given to disclosure of information at the facility level in a simple and understandable way. The ongoing social accountability pilots will guide this process. These demand side governance initiatives will be further strengthened by comprehensive independent reviews to be undertaken by IIFRA and activities supported by the AF will be included in the scope of the IIFRA reviews. 23. The original Project design and implementation arrangements will be strengthened. Procurement under the proposed AF would be carried out in accordance with the World Bank’s “Guidelines: Procurement under IBRD Loans and IDA Credits” dated January 2011, “Guidelines: Selection and Employment of Consultants by World Bank Borrowers” dated January 2011, “Guidelines on preventing and combating Fraud and Corruption in projects financed by IBRD Loans and IDA Grants” dated October 15, 2006 (the Anti-Corruption Guidelines), revised in January 2011 and the provisions stipulated in the Legal Agreement. The

8 The Kenya Essential Package for Health Services includes essential and evidence-based health and nutrition services. 9 Once in two months for hospitals and once in three months for health centers and dispensaries.

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new procurement guidelines will be applicable for all new procurements initiated under the project after approval of the AF. Services of UNICEF will be used by the MOPHS for procurement and distribution of nutrition supplements through its established global contracts to ensure timely supply of quality products. UNICEF will be contracted directly pursuant to the provisions of Paragraph 3.10 of the Consultants Guidelines to supply the nutrition supplements and provide additional services for in-country logistics and distribution of the supplements to health centre facilities level 2 and 3 to be identified by the Borrower. Given the relatively high value of the contract and that the contract will be procured through direct contracting, procurement clearance for award of contract will be provided by Operations Procurement Review Committee (OPRC). More details on procurement arrangements are provided in Annex 4. 24. The concerns of Sector-Wide Approach Program (SWAp) Secretariat capacity building are being addressed. There are increasing demands on the SWAp Secretariat to ensure effective donor coordination and to support the implementation of the New Constitution. There will be additional capacity building both through dedicated staff and through additional consultants to accelerate implementation and ensure an expeditious response to the current crisis. A senior officer has been posted to provide dedicated support to KHSSP and Bank has issued no objection to the Terms of Reference for the additional consultants. The financial management arrangement will be the same as for the original Project and procurement and distribution arrangements for essential medicines through KEMSA will remain unchanged.

25. Delivery of nutrition supplementation services will be done with support of implementing partners of Ministries of Health to address the concern of capacity limitations in the drought affected areas. The MOPHS has been working with its implementing partners to support the delivery of outpatient and supplementary feeding programs at community level through their community health workers. The Ministry of Medical Services (MOMS) is operating stabilization centers for managing severely malnourished children with medical complications. The proposed scope of coverage for nutrition commodities will also include the facilities managed by Faith Based Organizations (FBOs) which have very strong presence in the drought affected areas. UNICEF and WFP have already positioned additional staff on the ground in drought affected districts for providing oversight along with the district nutritionists during the emergency period. 26. Key outcome indicators and targets for the activities proposed to be supported under the AF are agreed. Three additional indicators are proposed for the activities included under the AF. These are summarized in the following table and cover the (a) Direct Project beneficiaries using the outpatient services of primary health facilities, (b) Recovery among severely malnourished children on treatment, and (c) Number of beneficiaries (moderately malnourished children under five, pregnant and lactating women) receiving the supplementary foods. The Division of Nutrition has a well established surveillance reporting system institutionalized in partnership with UNICEF which will provide regular updates on coverage for therapeutic and supplementary nutrition and blanket feeding. The Project will support and strengthen nutrition treatment and supplementation at outpatient level, and nutrition rehabilitation of medically complicated cases at inpatient services.

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Indicator Original target Changes with AF Revised targetPOI# 1 Direct project beneficiaries disaggregated by females and drought affected areas (Number of outpatient visits to health facilities at levels 2& 3). 10

Total: 29,300,000Females:

16,100,100

Drought Affected Populations: 332,500

Total: 29,300,000Females: 16,100,100

Drought Affected Populations: 332,500

POI# 7 Severely malnourished children under five receiving treatment recovered (Percent).

NA >60% >60%

IO1# 6 Number of beneficiaries receiving supplementary feeding (children under 5, pregnant and lactating women).

NA 285,210 285,210

27. It is also proposed to modify some indicators and revise targets for the original project to ensure better focus on the reform process and ability of the existing monitoring and evaluation system to generate the required information on a sustained basis. The key reform supported by the project is moving towards a pull system of supply which empowers the health facilities to order medicines based on their actual needs within the drawing rights provided by the Ministries of Health and responsiveness of KEMSA to effectively supply the requested essential medicines in time. To better reflect this process, the Project Outcome Indicator (POI)#2 has been revised to “Value fill rate of commodities on KEMSA Essential Drug list” which better captures the new accountability relationship KEMSA will have with its client (the health facility) under the pull system. Similarly the past experiences suggest that failure to make timely payment to the KEMSA by the Ministries of Health is the main reason for KEMSA not being able to make payments to its suppliers. Therefore, the POI# 5 has been changed to timely reimbursement of KEMSA documented claims by Ministries of Health. A new indicator (POI#5) is proposed to monitor the actions taken by Ministries of Health and KEMSA on fiduciary irregularities reported by IIFRA and KEMSA complaints redress system. More details of proposed changes are presented in Annex 1.

10 Drought affected areas are the 16 counties which are covered by the AF.

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28. The revised costs by Component are shown in the Table below. Component Original

Financing (US$ million)

Additional Financing

(US$ million)

Revised cost (US$ million)

1: Effective and transparent implementation of Kenya Essential Package for Health through HSSF grants and performance strengthening.

46.0 12.8 58.8

2: Availability of essential health commodities and supply chain management reform.

54.0 44.0 98.0

Total 100.0 56.8 156.8 IV. Appraisal Summary 29. The existing design of the Project is appropriate for the AF. The main new activity proposed under the first Component is to bridge the financing gap during the next 12 months for the targeted delivery of essential nutrition and health services to populations affected by drought to: (a) manage severe malnutrition among children under five by providing Ready-to-Use Therapeutic Food (RUTF); and (b) manage moderate malnutrition among pregnant and lactating women through providing Ready-to-use Supplementary Food (RUSF). These additional nutrition commodities will be supplied to health facilities (levels 2-3 and 4) and will be limited to counties affected by the drought. The primary responsibility to deliver services will be with the MOPHS at facility and community levels supported by UNICEF and its implementing partners. Under the second Component, the proposed AF will support scaling-up of ongoing reform to improve availability of essential medicines with special focus on responding to the increased needs of the health facilities in the drought affected areas operated by both Ministries of Health and further complement the ongoing supply chain management reforms to move towards the pull system of supplying essential medicines. 30. Addressing acute malnutrition makes strong economic sense especially in drought situations where there is a rapid increase in levels of acute malnutrition. Malnutrition is an important underlying factor for child mortality causes. Inpatient treatment for severe acute malnutrition is associated with high opportunity and economic costs for affected families and health service providers. Community-based therapeutic care maximizes population-level impact through improving coverage, access, and cost-effectiveness of treatment and provides effective care to the majority of acutely malnourished people as outpatients, using techniques of community mobilization to engage the affected population and maximize coverage and compliance. People with severe acute malnutrition without medical complications will be treated in an outpatient therapeutic program, using RUTF and routine medication. Those suffering from severe acute malnutrition with medical complications will be treated in an inpatient stabilization center, according to standard WHO protocols, until they are well enough

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to be transferred to the outpatient therapeutic program11. The support for prevention and control of infections and outbreak prone diseases will play a complementary role to supplementary feeding. While the Bank’s support for nutrition will be limited to mitigate the immediate emergency needs identified by the Ministries of Health, there is a very high risk of relapse among those children who recovered. This concern requires more comprehensive understanding of factors contributing to unacceptably high levels of chronic malnutrition in Kenya. The ongoing comprehensive nutrition Analytical Advisory Activity12 will guide the Bank’s longer term engagement in Kenya which could subsequently be supported either through a new operation or AF. 31. The proposed AF by preserving or restoring the essential health and nutrition services complies with the objectives of Bank Rapid Response Policy (OP 8.00). The policy envisages the Bank to work in close coordination with appropriate development agencies including the United Nations in line with comparative advantage and core competencies of each such partner. UNICEF will be contracted directly as a "Supplier" of nutrition supplements pursuant with the provisions of Paragraph 3.10 of the Consultant Guidelines. This has been considered given that: (a) nutritional supplements are specialized products with limited number of suppliers internationally, (b) the commodities are critical for the management of the drought crisis in the country and a rapid response is required, and (c) UNICEF is a specialized agency in the procurement of health related goods. Given the relatively high value of the contract and that the contract will be procured through direct contracting, procurement clearance for award of the contract will be provided by the Operations Procurement Review Committee (OPRC). Building on existing practices, the funds will be directly transferred from IDA to UNICEF upon the request of the GoK, and UNICEF will provide quarterly reports on supplies made while GoK will provide monthly updates on number of beneficiaries covered under the program. 32. The procurement will be carried out in accordance with the World Bank’s “Guidelines: Procurement under IBRD Loans and IDA Credits” dated January 2011, and “Guidelines: Selection and Employment of Consultants by World Bank Borrowers” dated January 2011; and the provisions stipulated in the Financing Agreement. Part of the funds under the additional financing (US$12.8 million) will be used for the procurement of essential health and nutrition supplements through UNICEF. The remaining funds under the AF will be used in the procurement of Essential Medicines and Medical Supplies (EMMS) using International Competitive Bidding (ICB) and National Competitive Bidding (NCB) methods through Kenya Medical Supplies Agency (KEMSA) to replenish the supplies that will be used for emergency interventions from the ongoing procurement under the original project. The

11 An impact assessment of twenty-one (21) community-based therapeutic care programs implemented in Malawi, Ethiopia, and North and South Sudan between 2000 and 2005 treating 23,511 cases of severe acute malnutrition, achieved recovery rates of 79.4% and mortality rates of 4.1%. Coverage rates were approximately 73%. Of the severely malnourished children who presented, 76% were treated solely as outpatients. Initial data indicate that these programs are affordable, with the cost-effectiveness of emergency community-based therapeutic programs varying from US$12 to US$132; Steve Collins, Kate Sadler, Nicky Dent, Tanya Khara, Saul Guerrero, Mark Myatt, Montse Saboya, and Anne Walsh; Key issues in the success of community-based management of severe malnutrition, WHO, UNICEF, and SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children, SCN Nutrition Policy Paper No. 21, Food and Nutrition Bulletin, vol. 27, no. 3 (supplement), The United Nations University, 2006. 12 Kenya Nutrition Multi Sector Gap Analysis.

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Procurement Plan for activities to be undertaken under the additional financing has been prepared by KEMSA and has been reviewed by the Bank and accepted. The overall risk for procurement is assessed as “substantial” and the proposed mitigation measures are detailed on the ORAF and in the Annex 4. 33. The support for EMMS through KEMSA will focus on providing additional supplies to the drought affected areas to ensure prompt treatment and control of disease outbreaks. In addition to enhancing the drawing rights ceilings for, and/or the number of, essential medicine kits to level 2 and 3 health facilities in the drought affected areas, targeted supplies will also be made available to district and provincial hospitals through the AF. The scope of AF will include US$4 million (10 percent of the US$44 million) to KEMSA to cover their handling, storage and distribution costs of the commodities. 34. A Financial Management assessment of KEMSA showed that the agency has extensive past experience in handling similar operations and adequate financial management capacity to manage the AF. The financial management assessment of the implementing entities for the original KHSSP rated the overall risk as substantial. 35. Disbursement to UNICEF for the procurement and distribution of nutrients to health facilities in arid and semi-arid (US$12.8 million) will be made on the basis of six-month cash forecasts prepared by UNICEF. The cash forecast would be prepared on the basis of the budget, work-plan and procurement plan and submitted to MOPHS (with copies thereof) in support of the Withdrawal Application (WA) which would be submitted to the Bank (with copies of the cash forecast, budget, work-plan and procurement plan) for review and disbursement of funds through direct payment. No Designated Account will be opened by GoK as the funds will be paid directly to UNICEF. However, GoK needs to ensure the amount to be disbursed (on the basis of UNICEF budget, work-plan and procurement plan) is reflected in the MOPHS supplementary budget for FY11/12. UNICEF will provide the Bank with a bank account into which these funds will be deposited. Replenishment of funds to UNICEF would be done on quarterly basis on submission of Interim un-audited Financial Report (IFRs) accounting for the use of funds previously disbursed and a six-month cash forecast based on the budget, work-plan/procurement plan. The IFR will disclose both the amount and quantities delivered per quarter and cumulatively. A detailed breakdown of the deliveries to the health facilities showing the names, location, dates delivered, quantity and amount will be submitted as part of the quarterly IFR. The format and content of the IFR has been discussed and agreed with UNICEF and will be shared with the Bank within 45 days after the end of each quarter. Expenditure related to the essential nutrients will be recognized and reported in quarterly IFR only upon delivery of essential nutrients to the respective health facilities duly acknowledged by a receipt in an acceptable form. Nutrition commodities procured by UNICEF but not distributed and received by the relevant health facilities will not be treated as an eligible expenditure. The audit of this Component will be done by Kenya National Audit Office as part of the annual audit of MOPHS KHSSP Component in the International Public Sector Accounting Standards cash basis of accounting financial statements format applied by GoK for donor projects.

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36. Disbursements to KEMSA for the supply of EMMS will be made on the basis of existing arrangements. KEMSA is already executing Component II of the KHSSP and the financial management arrangements are deemed to be adequate. There are no material changes in the Project design and implementation arrangements for Component II. 37. No new safeguard policies are triggered under the proposed AF and thus the environmental category of the KHSSP will not change. The environmental category of the KHSSP is currently rated ‘B’, as a result of triggering Environmental Assessment (OP/BP 4.01) and Indigenous Peoples (OP/BP 4.10) safeguards. No exceptions to Bank policies are required. An expression of interest was issued by the MOPHS for the development of the Vulnerable and Marginalized People’s Plans13 for three Bank-financed health related projects, namely KHSSP (P074091), the Kenya Total War Against HIV and AIDS Project (P081712) and the Kenya East Africa Public Health Laboratory Networking Project (P111556). While the scope is national, the assessment will be conducted in ten sites, clustered into five groups spread across the country in mapped areas home to indigenous people. The Plans will cover three of the seven districts hardest hit by the drought (Garissa, Marsabit, and Wajir14) and will include recommendations on how to target these hard-to-reach and underserved groups. 38. The risks relating to the AF have been identified and mitigation measures are planned to address these. These are outlined in the Operational Risk Assessment Framework in Annex 2. To manage the risks the project will strengthen the SWAP secretariat, particularly with the view of improving coordination and minimizing duplication of efforts. The project will also monitor the implementation of the governance action plan and will enhance social accountability and transparency. Specific risks include poor coordination of drought relief and potential diversion of nutrition supplies. This will be mitigated by working closely with other partners, delivering supplies direct to facilities by UNICEF, and by positioning additional staff on the ground to monitor the nutrition supplementation services. The limitations of institutional capacities of executing agencies are also recognized as a risk particularly for (i) district and facility levels to effectively administer HSSF and (ii) the management of the supply chain with potential diversion of essential drugs and supplies. The project aims to address these risks through handholding and capacity building at lower level facilities, with the support from other bilateral partners. The implementation risks rating is substantial.

13 Equivalent to the World Bank’s Indigenous Peoples Plans. 14 Vulnerable and Marginalized People’s Plans will be conducted in ten sites in seven districts (Garissa, Marsabit, Wajir, Moyale, Narok, Lamu, and Koibatek) with areas mapped as home to Indigenous People. The AF will focus on Turkana. Garissa, Wajir, Mandera, Marsabit, Isiolo and Tana River which are the hardest hit areas.

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Annex 1: Results Framework and Monitoring

KENYA: Health Sector Support Project - Additional Financing

Revisions to the Results Framework Comments/ Rationale for Change

PDO

Current (PAD) Proposed To support the Program and improve: (i) the delivery of essential health services in the Recipient’s territory, especially the poor; and (ii) the effectiveness of planning, financing and procurement of pharmaceuticals and medical supplies.

To support the Program and improve: (i) the delivery of essential health services in the Recipient’s territory, especially the poor and the drought affected populations; and (ii) the effectiveness of planning, financing and procurement of pharmaceuticals and medical supplies.

The PDOs remain relevant for the AF and only a minor change is proposed to specifically include the drought affected populations. The poverty levels in the seven counties most affected by the current drought is much higher compared to rest of Kenya and therefore relevant for the poverty targeting envisaged by the Project.

PDO indicators

Current (PAD) Proposed change* POI#1 Direct Project Beneficiaries (Disaggregated by females).

Revised: Direct Project beneficiaries (Disaggregated by females and drought affected areas).

To assess the use of health services in areas affected by drought.

POI#2 Health facilities that experience essential drug stock-out for than two weeks (Percent).

Revised: POI#3 Value fill rate of commodities on KEMSA Essential Drug List (Percent).

Provides better reflection of effectiveness of pull system and improved KEMSA efficiency which are the core reforms being supported by the project. This will be complemented by a new IOI # 9 indicator - Facilities under the pull system sending their order refill requests in the previous quarter (Percent).

POI#3 Children immunized (Number, disaggregated by Northeast Province).

Revised and end of the project target value changed. Now POI#2.

To clarify that this indicator actually provides information on children less than one year and immunization actually means “fully” immunization including revised targets accordingly both for National and drought affected areas.

POI#5 Timely payment of suppliers by KEMSA based on agreed procurement contract.

Revised. Timely reimbursement of KEMSA documented claims by Ministries of Health (Percent).

Failure to make timely payments to KEMSA is the main reason for KEMSA not being able to pay its suppliers. Prompt payment will replenish EMMS financing basket and suppliers can offer more competitive prices. Made an IOI # 10 indicator.

New. Fiduciary irregularities reported from HSSF and KEMSA acted upon (during previous quarter).

This new indicator captures the action taken by Ministries of Health and KEMSA on any irregularities reported. Made new POI#5

POI# 6 Facilities displaying Revised. Level 2 and 3 HSSF facilities Ensure compliance with evolving

17


quarterly information on funds received and availability of drugs at facility level.

disclosing information as per GoK guidelines.

disclosure requirements based on Social Accountability pilots.

POI #7 New. Severely malnourished children under five treated and recovered (Percent).

Reflects the coverage and effectiveness of the therapeutic feeding program on severely malnourished.

Intermediate Results indicators

Current (PAD) Proposed change* IOI#3 Health Personnel receiving training.

End of the project target value changed.

To reflect annual targets rather than cumulative number. IOI#4.

IOI#6 Level 2 and 3 facilities providing reports on services OVC to department of Social Services where OVC Project is being implemented.

Dropped. Information being collected under another project.

IOI #7 Successful completion of innovative initiatives to improve referral to district hospitals and for improved heath financing.

Dropped. Number of pilots limited and may not effectively reflect outcomes.

IOI#8 Level 2-3 facilities implementing results based financing initiatives (number, percent).

Revised and end of the project target value changed. Now IOI# 6.

Reflect the time needed for piloting the results based financing and the policy changes required.

IOI #9 New. Facilities under pull system sending their orders during the previous quarter.

Reflects the capacity built at the facility level to place orders under the pull system

IOI #11 Complaints reported and actions taken through an accessible complaints mechanism on service delivery, fraud and corruption a quarterly basis (number)..

Revised: Fiduciary irregularities reported from HSSF and KEMSA acted upon (within one quarter) (percent).

To shift the focus on action when a fiduciary irregularity is reported. Given the importance this indicator has been lifted up to POI level # 5.

IOI#11 Tenders and awarded contracts advertised on the KEMSA website and meeting national and international standards for dissemination (percent).

Dropped. KEMSA is disclosing information at their website and most procurement under the project is being done through ICB following World Bank Procedures and disclosure requirements.

IOI#12 On-time delivery of drugs and medical supplies to level 2 and 3 facilities.

Dropped. Revised POI#2 reflects this indicator.

IOI#13 Availability of pre-shipment inspection certificate with KEMSA.

Dropped. KEMSA has established a system of batch testing by WHO pre-qualified laboratories. Maintaining this system will be a legal covenant.

IOI #14 Timely completion of Annual Procurement Plan.

Dropped. Already a requirement for the rating the project procurement performance.

IOI#7 New. Number of beneficiaries receiving supplementary feeding in the drought affected areas (moderately

Provides the total number of beneficiaries receiving supplementary feeding.

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malnourished children under 5, and moderately malnourished pregnant and lactating women).

NOTES *Indicate if the indicator is Dropped, Continued, New, Revised, or if there is a change in the end of project target value

In total 5 POI level indicators have been revised and two at IOI level. This is to tighten up the definition of the indicators, to allow the project to use data which is more readily available, to ultimately improve the measurement of progress. One new POI level indicator and two new IOI level indicators are proposed (two of which are specific to measuring progress on malnutrition). Seven IOI level indicators have been dropped to focus in on measuring the key components of the project.

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REVISED PROJECT RESULTS FRAMEWORK

Project Development Objective (PDO):

To support the Program and to improve (i) the delivery of essential health services in the Recipient’s territory, especially for the poor and the drought affected populations; and (b) the effectiveness of planning, financing and procurement of pharmaceuticals and medical supplies.

PDO Level Results Indicators15

Cor

e

UOM16

Baseline Original Project Start

(2008-09)

Progress To Date

(2010-11)17

Cumulative Target Values18

Frequency

Data Source/ Methodology

Responsibility for Data

Collection Comments

2012 2013 2014 2015

1. Direct Project Beneficiaries (Number of outpatient visits to levels 2&3).

Number

25,896,000

26,500,000 27,000,000 28,000,000

29,300,000

Annual HIS Division of HMIS

Disaggregated by females and drought affected areas.

2. Children fully immunized. Number 1,188,698

NE Province:

1,200,000 1,230,000 1,250,000 1,298,058 Annual

HIS/Kenya Demographic & Health Survey/MICs

Division of HMIS

Disaggregated by drought affected areas.

3. Value fill rate for commodities on KEMSA Essential Drug List. Percent 73% 75% 80% 85% 90% Quarterly KEMSA ERP

KEMSA Operations Director

4. HSSF facilities meeting the core financial management requirements of the fund.

Percent 0% 20% 70% 85% 90% 90% Annual

Quarterly reports of Independent Integrated Fiduciary Review Agency

SWAp Secretariat

5. Fiduciary irregularities reported from HSSF and KEMSA acted upon (during the previous quarter).

Percent 0% 80% 90% 95% 100% Quarterly/ annual

Ministries of Health based on IIFRA reports and KEMSA complaints database

SWAp secretariat and CEO KEMSA

15 Please indicate whether the indicator is a Core Sector Indicator (for additional guidance – please see http://coreindicators). 16 UOM = Unit of Measurement. 17 For new indicators introduced as part of the additional financing, the progress to date column is used to reflect the baseline value. 18 Target values should be entered for the years data will be available, not necessarily annually. Target values should normally be cumulative. If targets refer to annual values, please indicate this in the indicator name and in the “Comments” column.

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6. Level 2 and 3 HSSF facilities displaying information as per GoK guidelines.

Percent 0% 70% 80% 85% 90% Annual

Project data, DHMT facility supervision reports,

Division of Primary Health Care Operations Director

7. Severely malnourished children under five receiving treatment recovered.

Percent 60% 60% 60% 60% Monthly Nutrition Monitoring Reports

Division of Nutrition, MOPHS and UNICEF

Baseline to be established January 2012.

Beneficiaries19

Project beneficiaries.

Number

25,896,000 26,500,000 27,000,000 28,000,000 29,300,000 Annual HIS Division of HMIS

Covered under POI#1.

Of which female (beneficiaries). Number

14,229,369 14,500,00 15,00,000 15,800,000 16,100,100 Annual HIS Division of HMIS

Will be a sub indicator of POI#1.

Of which from drought affected areas.

Number

280,000 300,000 310,000 332,500 Annual HIS Division of HMIS

Will be a sub indicator of POI# 1.

Intermediate Results and Indicators

Intermediate Results Indicators

Cor

e

Unit of Measurement


(2008)

Progress To Date (2011)

Target Values Freque

ncy Data Source/ Methodology


Collection Comments 2012 2013 2014 2015

Intermediate Result 1: Effective and transparent implementation of Kenya Essential Package for Health through HSSF grants and performance Strengthening

1. People with access to a basic package of health nutrition and population services.

Number 0 25,500,000 27,000,000 28,000,000 30,495,000

2. Facilities receiving HSSF funds within 15 days of beginning of quarter.

Percent 0% 0% 50% 60% 70% 90% Quarterly

HMIS, Reports of HSSF Secretariat

Division of HMIS and HSSF secretariat

While HSSF funds were released for all 4 quarters of FY 2010-11, none of the releases were made within 15 days of beginning of quarter.

19 All projects are encouraged to identify and measure the number of project beneficiaries. The adoption and reporting on this indicator is required for investment projects which have an approval date of July 1, 2009 or later (for additional guidance – please see http://coreindicators).

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Cor

e

Unit of Measurement


(2008)






3. Facilities management committees having quarterly meetings with minutes of meetings.

Percent

Level 2: 27%

Level 3: 46%

(2004)

80% 85% 90% 90% Quarterly Program data HSSF Secretariat

4. Health Personnel receiving training.

Number 0 4,648 5,500 6,000 6,500 6,500 Annual Project data HSSF Secretariat

Number of health staff trained in HSSF procedures.

5. Level 2 and 3 facilities meeting minimum staffing norms.

Percent

Level 2: 3%

Level 3=34%

30% 40% 40% 40% Annual HIS and HRH data base

Division of HMIS

6. Level 2-3 facilities implementing results based financing initiatives (number).

Number 0% 25 50 200 250 Annual HIS and HRH data base

Division of Primary Health

Subject to the findings of ongoing pilot in Samburu and required policy changes.

7. Number of beneficiaries receiving supplementary feeding in the drought affected areas. (Moderately malnourished children under five and moderately malnourished pregnant and lactating women).

Number 157,413 285,210 285,210 Quarterly

Nutrition reporting and UNICEF reporting

Divisions of. Nutrition Ministries of Health and UNICEF

The Baseline is for 2011.

Intermediate Result 2: Availability of essential health commodities and supply chain management reform

8. Performance contract between KEMSA and MOMS and client service agreement between KEMSA and MOHS, established and monitored on a quarterly basis.

Yes/No No In

progress Yes Yes Yes Yes Quarterly Project data

Project M&E officer, SWAp secretariat

Consultant selected to prepare the performance contract.

9. Facilities under pull system sending their orders during the previous quarter.

Percent TBD TBD Quarterly

KEMSA ERP and , DHMT facility reports

KEMSA Operations Director

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Cor

e

Unit of Measurement


(2008)






10. Timely reimbursement to KEMSA documented claims by Ministries of Health (Percent).

Percent 50% (2

quarter)

75% (3

quarter)

75% (3

quarter)

100% (4 quarter)

Quarterly

Project data Project M&E officer

To start from October 2011.

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Annex 2: Operational Risk Assessment Framework (ORAF)

KENYA: Health Sector Support Project - Additional Financing

Stage: Board

Project Stakeholder Risks Rating HighDescription: Inability of the partners and government of Kenya to effectively coordinate their support for drought relief resulting in duplication of activities and wastage of precious resources.

Risk Management : The Health Sector Coordination Committee will coordinate and provide oversight to the drought response of Ministries of health and partners in the health sector. The Steering Committee has strong representation of non‐government organization and private sector. Resp: Client| Stage: Implementation | Due Date : January 15, 2012| Status: Meetings being held regularly Risk Management : Being part of the sector‐wide program, the Project is an ideal vehicle for a coordinated response by the Government for emergency public health responses. The monitoring of the Joint Financing Agreement will be done during semiannual Joint supervision missions. Resp: | Stage: Implementation | Due Date : December 9, 2011 and once every 6 months| Status: Ongoing

Implementing Agency Risks (including fiduciary)Capacity Rating: Substantial Description: The HSSF involves a major change in the way that the level 1‐3 services are provided. Limitations of institutional capacities of Responsible agencies, especially at the district and facility levels to effectively administer the HSSF may adversely affect the achievement of PDO on delivering Kenya Essential Package for Health. Risks include those associated with poorly trained human resources, inefficient deployment of human resources and lack of motivation among staff. There are also capacity risks associated with the management of the supply chain.

Risk Management: The Ministries of Health are in the process of establishing mechanisms for continuous handholding and capacity building at district and facility levels with support from its bilateral partners.

‐ Resp: Client | Stage: Implementation| Due Date : January 31, 2012| Status: Not yet due Risk Management : Strengthening of the SWAp Secretariat by providing additional senior staff and consultants. A Senior officer has been posted to provide dedicated support to KHSSP and additional consultants are being recruited

‐ Resp: Client| Stage: Implementation| Due Date : January 31, 2012| Status: Not Yet Due Risk Management : UNICEF and WFP have positioned additional staff on the ground in the drought affected areas for providing oversight along with the district nutritionists during the emergency period. Resp: Partner| Stage: Implementation| Due Date : November 7, 2011| Status: Completed

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Risk Management: Delivery of nutrition supplementation services will be done with support of implementing partners of Ministries of Health to address the concern of capacity limitations in the drought affected areas. Facilities managed by FBOs which have a very strong presence in the drought affected areas will be included in the coverage of nutrition activities.

‐ Resp: Client | Stage: Implementation | Due Date : February 29, 2012| Status: Not yet due

Governance Rating: HighDescription: The implementation of the governance action plan (oversight by independent steering committee, access to information, citizen’s monitoring and KEMSA reforms) may slow down, during 2012 elections. Citizens may take longer time to play active participatory role, especially in the rural areas. Consequently, there could be risks of misallocations, leakages and physical losses of commodities during the elections. The proposed changes in the roles and responsibilities of Health Ministries and Counties in delivering essential health services and policy making under the New Constitution may also affect the project governance. The role of KEMSA and composition of its Board may also change based on decisions made by Counties. Also, there may be risks of diversion or interruption of project inputs during the 2012 elections.

Risk Management: The Ministries of Health have prepared a position paper on implementation of the Constitution in clarifying their stand on addressing the right for health and positions on 43 critical issues relevant for the devolved governance.

‐ Resp: Client| Stage: Implementation | Due Date : June 30, 2012| Status: In progress

Risk Management: To reduce the potential risks of diversion of medical supplies, the Social accountability and transparency will be enhanced. The facility management committees will certify the receipt of money and medicines every quarter and all health facilities will be required to display information on commodities received and dates. The risks of diversion of nutrition supplies will be mitigated by delivering the supplies direct to the facilities by UNICEF and ensuring sustained oversight by district nutrition officers supported by 18 UNICEF nutrition officers posted to the drought affected areas.

‐ Resp: Client | Stage: Implementation | Due Date : February 29, 2012| Status: Not yet due

Project Risks Design Rating: Substantial

Description: The SWAp secretariat capacities are already overstretched and may not be able to effectively coordinate the implementation of emergency drought relief measures.

Risk Management : The SWAp secretariat will have additional staff and consultants and UNICEF with its implementing partners will support the districts to implement the emergency drought relief measures coordinated by 18 staff fully embedded with the district health management teams in the districts worst affected by drought.

‐ Resp: Client | Stage: Implementation| Due Date : January 31 , 2012 | Status: In progress Social & Environmental Rating: LowDescription: The vulnerable and marginalized groups may be excluded or may not optimally benefit from the improved health and nutrition services. The implementation of the health care

Risk Management: The SWAp secretariat is in the process of issuing Expression of Interest to select an appropriate agency for undertaking a comprehensive assessment of vulnerable and marginalized groups covering all Bank supported operations in Kenya and will help in developing a

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waste management may get further delayed. country relevant plan to improve services for this important group.

‐ Resp: Client | Stage: Implementation | Due Date : December 15, 2011 | Status: In progress Risk Management: Demonstrate operational feasibility of full package of activities for effective health care waste management in 5 locations.

‐ Resp: Client | Stage: Implementation| Due Date : March 31 , 2012| Status: in progress Program & Donor Rating: LowDescription: As no co‐financing is considered for activities planned, there are no risks associated with other donor contributions. However, prompt replenishment of the pool for essential medicines and medical supplies by GoK including support from DANIDA remains critical for sustaining the reforms in procurement and supply of essential commodities through establishment of drawing rights.

Risk Management: The Ministries of health have established drawing rights and protocol for replenishing the pool for essential medicines and medical supplies every quarter.

‐ Resp: Client | Stage: Implementation | Due Date : every quarter starting from third quarter of 2011| Status: in progress

Delivery Monitoring & Sustainability Rating: LowDescription: Monitoring the implementation and timely reporting of the results could be constrained due to capacity constraints and inadequate supportive supervision by districts.

Risk Management: New Computerized District Health Information Management system is being introduced and new supervision tools are being developed to objectively assess the performance. The District Health Management Teams will be paid based on their supervision outputs.

‐ Resp: Client| Stage: | Due Date : March 31, 2012| Status: In progress Implementation Risk Rating: Substantial

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Annex 3: Detailed Description of New Project Activity

KENYA: Health Sector Support Project-Additional Financing Background 1. The failure of the long rains in 2011 has affected livelihood productivities of many household and negatively impacted on household food security. The rains were highly depressed and poorly distributed with some parts of the country experiencing late onset of the rains. Significant parts of Marsabit, Moyale, Mandera, Wajir, Isiolo and Tana River received less than 10 percent of normal rain. Other pastoral areas as well as the south eastern and coastal lowlands received only 20-50 percent of normal rains. The impact of the rains on food security is further worsened by the persistent high food and fuel prices, thereby increasing vulnerability of many households. It is now estimated that 3.7 million people have been affected by the drought and in need of food assistance. 2. According to nutritional surveys conducted in 2011, levels of acute malnutrition have significantly increased as a result of the deteriorating food security. This is particularly significant for Turkana, Wajir, and Marsabit districts where Global Acute Malnutrition (GAM, Weight-for-Height <-2 z-scores) rates are above 25%, with Turkana North having a GAM rates of 37.4%. Admissions for management of severe and moderate acute malnutrition have increased by 80% and 35% respectively when compared to 2010. The monthly caseloads for severe acute malnutrition increased from 8,000 to 17,000 between January and July 2011 and are expected to increase further in the coming 12 months given the current forecast. With acute malnutrition being a significant underlying factor to increased morbidity and mortality in young children, immediate measures have to be taken to ensure access to quality and timey preventive and curative interventions.

3. The Nutrition Sector identified key actions to be implemented and scaled-up immediately to respond to the current emergency. These actions include: scale-up access to critical services at health facility and community levels, scale-up technical support through additional human resources to ensure quality service delivery, support and scale-up coordination mechanisms and information management to enable adequate and timely response as well as blanket supplementary feeding to reverse current trends in the most affected areas (i.e. Turkana, Marsabit, Mandera, Wajir). While the focus is on treatment of acute malnutrition other high impact nutrition interventions (infant and young child nutrition, micronutrient supplementation, deworming) remain part of the package of interventions to be scaled-up. The revised funding needs for the nutrition sector are about US$44.8 million out of which a there is a financing gap of US$17.3 million.

4. Given the increasing caseloads immediate funding is needed to procure additional essential commodities for the treatment of severe and moderate acute malnutrition and ensure sustained technical and logistic support in the next twelve months. In addition, funding is required for the procurement of Ready-to-Use Supplementary Food (RUSF) and Ready-to-Use Therapeutic Food (RUTF).

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General and Specific Objectives 5. The overarching objective of the proposed nutrition intervention is to support ongoing efforts of Government of Kenya and its partners to prevent and increase the coverage of treatment for high levels of acute malnutrition in children below 5 years old and pregnant and lactating mothers in the affected areas. Program Strategy 6. The overall strategy is to bridge the gaps in the supply of essential nutrition commodities to support existing local structures and systems to deliver essential nutrition services, such as treatment of acute malnutrition. The response will be primarily undertaken through Ministry of Public Health and Sanitation (MOPHS), with full support of UNICEF and implementing partners. UNICEF already has partnerships with NGOs to ensure technical and logistic support with regard to prevention and treatment of acute malnutrition in the targeted districts; therefore the funding will be used in the scale-up of activities to reach more children and women. Key Activities 7. Provision of essential nutrition supplies for management of acute malnutrition - through the proposed Additional Financing which will complement the following ongoing activities supported by MOPHS and its implementing partners:

Community systems: Support to community and outreach systems to deliver nutrition interventions in the target districts.

Coordination: Support the coordination mechanisms for emergency nutrition interventions at both national and sub-national level.

Nutrition Information: Provide technical support to partners and government to ensure that there is readily available emergency nutrition information.

Monitoring 8. The government and its partners will monitor the implementation of nutrition interventions through existing monitoring system which provide weekly and monthly reports. Expected Results

Indicators Target Sources of verification % of severely malnourished children <5years admitted and recovered.

>= 60% (60,000)

Number of moderately malnourished children under 5 years and moderately malnourished pregnant and lactating women receiving supplementary nutrition in drought affected areas.

280,000 Monthly program reports.

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Resources

Cost Breakdown Cost (USD) Supply of 1,140 MT RUSF @ USD 2000 4,560,000Supply of 1,300 MT of RUTF @ USD 4400 5,720,000Logistic (transport, storage, communication) @ 15% of supplies value 1,542,000Program support cost 7% (UNICEF Service Charge) 827,540Total cost 12,649,540Treatment: 6.5 Kg (75 sachets) of RUSF per person (one sachet of 92 g is required daily)

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Annex 4: Procurement Arrangements

KENYA: Health Sector Support Project-Additional Financing

1. The proposed AF for preserving and restoring the essential health and nutrition services is in compliance with the Bank Rapid Response Policy OP 8.00.

2. Procurement under the proposed AF would be carried out in accordance with the World Bank’s “Guidance: Procurement under IBRD Loans and IDA Credits” dated January 2011, and “Guidelines: Selection and Employment of Consultants by World Bank Borrowers” dated January 2011; and the provisions stipulated in the Legal Agreement. For each contract to be financed by the Credit, the different procurement methods, estimated costs, prior review requirements, and time frame for implementation will be agreed between the Borrower and the Bank in the Procurement Plan (PP). The PP will be updated at least annually or as required to reflect the actual Project implementation needs and improvements in institutional capacity. The proposed Project will carry out implementation in accordance with the “Guidelines on preventing and combating Fraud and Corruption in projects financed by IBRD Loans and IDA Grants” dated October 15, 2006 (the Anti-Corruption Guidelines), revised in January 2011 and provisions stipulated in the Financing Agreement.

3. The AF applies to an ongoing original project and the procurement arrangements described in the original project documents would apply in as far as the ongoing procurement activities are concerned. All new procurement activities both under the original project and the additional financing will be carried out in accordance with the new Guidelines dated January 2011.

4. Part of the funds under the additional financing in the amount of US$12.8 million will be used for the procurement of essential health and nutrition supplements through UNICEF. This has been considered given that: (a) nutrition supplements are specialized products with limited number of suppliers internationally; (b) there is a weak procurement capacity in the country to respond to such emergency; (c) the commodities are critical for the management of drought crisis in the country and a rapid response is required; and (d) UNICEF is a specialized agency in the procurement of health related goods. Given the specialized nature of the commodities to be supplied and urgency in responding to the crisis, it was agreed that UNICEF will be contracted directly pursuant to the provisions of Paragraph 3.10 of the Consultants Guidelines. UNICEF will supply the nutrition supplements and provide additional services for in-country logistics and distribution of the supplements to health centre facilities level 2 and 3 to be identified by the Borrower. Given the relatively high value of the contract and that the contract will be procured through direct contracting, procurement clearance for award the contract will be provided by Operations Procurement Review Committee (OPRC).

5. The remaining funds under the AF will be used in the procurement of Essential Medicines and Medical Supplies (EMMS) using International Competitive Bidding (ICB) and National Competitive Bidding (NCB) methods through Kenya Medical Supplies Agency (KEMSA) to replenish the supplies that will be used for emergency interventions from the

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ongoing procurement under the original project. KEMSA was established in 2000 as an autonomous state corporation with the mandate to procure, warehouse and distribute EMMS to the public health facilities in Kenya. KEMSA’s performance and procurement capacity in the procurement of EMMS under the original project is considered satisfactory.

6. The original project is financing the procurement of Essential Medicines and Medical Supplies at an estimated cost of US$40 million which are at different stages of implementation. The Borrower has sought and obtained the Bank’s “no objection” to increase the orders by twenty (20) percent to meet the emergency needs. For the ongoing procurements, the Guidelines published in May 2004, and revised in October 2006 and May 2010 will apply. The supplies from ongoing procurement is intended to cover a period of 18 months requirements and hence will not affect the supply situation in non-drought affected areas and supplies from the proposed next round of ICB and NCB procurement through the additional financing will replenish these stocks.

7. Operating Costs. Similar to the arrangements agreed for the original project documents, the AF will support KEMSA’s administrative costs for customs clearance and forwarding, warehousing and distribution of commodities procured by them to the recipient districts at the rate of up to ten (10) percent of the cost of goods and commodities procured through it.

8. Procurement Plan. The Procurement Plan for activities to be undertaken under the additional financing has been prepared by KEMSA and has been reviewed by the Bank and accepted as indicated in the table below. This plan will be updated annually to reflect the latest circumstances. The World Bank Standard Bidding Document for procurement of goods will be used for all ICB and NCB contracts.

List of Contract packages to be procured following ICB, NCB and Direct Contracting procedures:

Ref No.

Contract Description Cost Estimate in ‘000,000’ USD

Procurement Method

Prequalification Yes / No

Domestic Preference Yes / No

IDA Review

Submit/ Open Bids

Comments

1 Nutritional Supplements

12.8 Direct Contract

No N/A Prior Nov 2011

2 First line anti TB drugs 2.27 ICB No Yes Prior July 2012 3 Second line anti TB

drugs 1.58 ICB No Yes Prior Jul 2012

4 Dispensary Kit I 0.98 ICB No Yes Prior July 2012 5 Dispensary Kit II 0.89 ICB No Yes Prior July 2012 6 Dispensary Kit III 1.07 ICB No Yes Prior July 2012 7 Dispensary Kit IV 0.13 NCB No No Post July 2012 8 Dispensary Kit V 0.68 ICB No Yes Prior July 2012 9 Health Centre Kit I 0.33 NCB No No Post July 2012 10 Health Centre Kit II 0.30 NCB No No Post July 2012 11 Health Centre Kit III 0.32 NCB No No Post July 2012 12 Health Centre Kit IV 0.28 NCB No No Post July 2012 13 Health Centre Kit V 1.46 ICB No Yes Prior July 2012 14 Pharmaceutical (lots) 2.70 ICB No Yes Prior 15 Pharmaceuticals

(Loose) 1.4 ICB No Yes Prior Jan 2012

16 Pharmaceuticals (oral dosage)

9.82 ICB No Yes Prior Aug 2012

17 Pharmaceuticals 1.52 ICB No Yes Prior Aug 2012

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Ref No.

Contract Description Cost Estimate in ‘000,000’ USD

Procurement Method

Prequalification Yes / No

Domestic Preference Yes / No

IDA Review

Submit/ Open Bids

Comments

(Injectables) 18 Pharmaceuticals

(Packaging Materials) 0.55 ICB No Yes Prior Aug 2012

19 Non Pharmaceuticals (Lots)


20 Non Pharmaceuticals (Loose)


21 Non Pharmaceuticals (Loose)

0.60 ICB No Yes Prior Jan 2012

9. Risks and mitigation measures. The overall risk for procurement is assessed as “substantial”. The proposed mitigation measures are summarized here below. After the measures have been implemented, the residual risk rating would be “moderate”.

Supply of nutrition supplements by UNICEF directly to health facilities.

Monitoring of receipt and use of nutritional supplements and essential medical supplies by facilities management committees for enhanced social accountability.

Use of district nutrition officers and UNICEF nutrition support officers in the field to provide sustained oversight in the supply and use of nutritional supplements.

Use of the Independent Integrated Fiduciary Review Agency (IIFRA) engaged under the original project to cover all activities supported by the additional financing.

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Tana

Mara

Galana

Athi

Ewaso

Thua

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Loga Bogal

Lak Dera

Lak Bor

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Marsabit

Turkana

Kitui

Garissa

Isiolo

Nakuru

Kajiado

Tana River

Mandera

Kilifi

Narok

Samburu

Taita/Taveta

Baringo

Meru

Kwale

Laikipia

LamuMakueni

West Pokot

Homa Bay Nyeri

Machakos

Tharaka-Nithi

Nandi

Embu

Siaya

MigoriBomet

Kiambu

Kericho

Kisii

Busia

Bungoma

Nyandarua

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Kisumu

UasinGishu

Murang'a

Trans Nzoia Elgeyo/Marakwet

Kirinyaga

Nyamira

Nairobi

Vihiga

Karungu

Lokichar

Kangatet

Butere NyahururuFalls

Lolgorien

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Bodhei

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Garba Tula

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El Wak

Tarbaj

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MoyaleSololoNorth Horr

South Horr

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Marigat

Archer’sPost

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NakuruGarissaNyeri

Kakamega

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Mandera

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Isiolo

Embu

Kitui

Machakos

Lodwar

MaralalKitale

Eldoret

Nanyuki

Narok

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NAIROBI

Wajir

Marsabit

Turkana

Kitui

Garissa

Isiolo

Nakuru

Kajiado

Tana River

Mandera

Kilifi

Narok

Samburu

Taita/Taveta

Baringo

Meru

Kwale

Laikipia

LamuMakueni

West Pokot

Homa Bay Nyeri

Machakos

Tharaka-Nithi

Nandi

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MigoriBomet

Kiambu

Kericho

Kisii

Busia

Bungoma

Nyandarua

Kakamega

Kisumu

UasinGishu

Murang'a

Trans Nzoia Elgeyo/Marakwet

Kirinyaga

Nyamira

Nairobi

Vihiga

Mombasa

Karungu

Lokichar

Kangatet

Butere NyahururuFalls

Lolgorien

Magadi

Namanga

Konza

Kibwezi

Tsavo

Shimoni

Malindi

Garsen

Bodhei

KolbioBura

Nguni

Ikutha

MackinnonPark

Lokichokio

Karungu

Kakuma

Thika

Gilgil

Mbalambala

Garba Tula

MandoGashi

El Wak

Tarbaj

Ramu

Buna

MoyaleSololoNorth Horr

South Horr

Kapedo

Marigat

Archer’sPost

Kisumu

NakuruGarissa

Mombasa

Nyeri

Kakamega

Kwale

Lamu

Voi

Wajir

Mandera

Marsabit

Isiolo

Embu

Kitui

Machakos

Lodwar

MaralalKitale

Eldoret

Nanyuki

Narok

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NAIROBI

E T H I O P I A

SOMALIA

TANZANIA

UGANDA

SOUTH SUDAN

Ng’iro M

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Loga Bogal

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INDIANOCEAN

Lake

Victor ia

LakeTurkana

To Murle

To Juba

To Dila

To Imi

To Kismaayo

To Bur Gavo

To Dar Es Salaam

To Moshi

To Arusha

To Seronera

To Musoma

To Kampala

To Mbale

Yat ta P lateau

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34°E 36°E 38°E 40°E 42°E

34°E 36°E 38°E 40°E

2°S

0°

2°N

4°N

4°S

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KENYA

0 40 80 160120

0 40 80 120 Miles

200 Kilometers

IBRD 33426R2

JULY 2011

KENYACITIES AND TOWNS

DISTRICT CAPITALS*

NATIONAL CAPITAL

RIVERS

*not all District Capitals are shown.

MAIN ROADS

RAILROADS

DISTRICT BOUNDARIES

INTERNATIONAL BOUNDARIES

This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, o r any endo r s emen t o r a c c e p t a n c e o f s u c h boundaries.

the world bank for official use only...the horn of africa drought is having a major impact on the...

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