ON FEDERAL NIGERIA

Document o f The World Bank

FOR OFFICIAL USE ONLY

Report No: 37299-NG

PROJECT APPRAISAL DOCUMENT

ON

PROPOSED CREDIT

IN THE AMOUNT OF SDR 121.70 MILL ION (US$180 MILL ION EQUIVALENT)

TO THE

FEDERAL REPUBLIC OF NIGERIA

FOR A

MALARIA CONTROL BOOSTER PROJECT

November 14,2006

Human Development I11 Country Department 12 Afr ica Regional Office

This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. I t s contents may not otherwise be disclosed without World Bank authorization.

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CURRENCY EQUIVALENTS (Exchange Rate Effect ive November 13,2006)

Currency Unit = Na i ra 1 Na i ra = US$128.35

U S $ 1 = 0.00779120

ACT

AL ANC CBO CFAA

CPAR

DFID

DALY DHS DPT3

EPI

FBO FMOF F M O H HFA FMR FMS HMIS

I C B IDA IDF IEC

I M C I

IPT IRS ITN IVM L C B

CQ

FISCAL YEAR

January 1 - December 3 1

ABBREVIATIONS AND ACRONYMS

Artemisinin-based Combination Therapy ArtemetherILume fantrine Ante-Natal Care Community-based Organization Country Financial Accountability Assessment Country Portfolio Assessment Review Chloroquine Department for International Development Disability Adjusted L i f e Year Demographic and Health Survey Third Dose o f the Diphtheria-Pertussis- Tetanus Expanded Programme on Immunization Faith-based Organization Federal Ministry o f Finance Federal Ministry o f Health Health Facility Assessment Financial Monitoring Report Financial Management System Health Management Information System International Competitive Bidding International Development Association International Development Fund Information, Education and Communication Integrated Management o f Childhood Illnesses Intermittent Preventive Therapy Indoor Residual Spraying Insecticide-Treated mosquito Nets Integrated Vector Management Local Competitive Bidding

LGA LLIN L M I S

LQAS M C H MCP MDG M&E MICS M I S MPP NGOs NMCP OPT P A U PEMFAR

P F M U PIF P I U PMVs PRSP PSI RBM RDT SMOH SP SPAR SWAP USMR UNICEF USAID

W H O WHOPES

Local Government Authority Long-Lasting Insecticidal Nets Logistic Management Information System Lo t Quality Assurance Sampling Maternal and Child Health Malaria Control Program Millennium Development Goal Monitoring and Evaluation Multi-Indicator Cluster Survey Management Information System Malaria Plus Package N o n Governmental Organizations National Malaria Control Program

Project Accounts Unit Public Expenditure Management and Financial Accountability Review Project Financial Management Unit Project Implementation Facilitators Project Implementation Unit Patent Medicine Vendors Poverty Reduction Strategy Paper Population Service International Ro l l Back Malaria Rapid Diagnostic Test State Ministry o f Health Sulphamethoxazole-P yrimethamine State Portfolio Assessment Review Sector-Wide Approach Under-Five Mortality Rate United Nations Children’s Fund United States Agency for International Development World Health Organization WHO Pesticides Evaluation Scheme

Vice President: Gobind T. Nankani Country ManagerDirector: Hafez Ghanem

Sector Manager: Laura Frigenti Task Team Leader: Ramesh Govindaraj

NIGERIA Malaria Control Booster Project

CONTENTS

Page

STRATEGIC CONTEXT AND RATIONALE ................................................................. 1 Country and sector issues .................................................................................................... 1

A . 1 . 2 . 3 .

Rationale for Bank involvement ......................................................................................... 4

Higher level objectives to which the project contributes .................................................... 4

PROJECT DESCRIPTION ................................................................................................. 5 B . 1 . 2 . 3 . 4 . 5 .

Lending instrument ............................................................................................................. 5 Project development objective and key indicators .............................................................. 5 Project components (see Annex 5 for detailed breakdown o f project costs) ...................... 6

Lessons learned and reflected in the project design ............................................................ 8 Alternatives considered and reasons for rejection .............................................................. 9

C . IMPLEMENTATION ........................................................................................................ 10 Partnership arrangements .................................................................................................. 10 1 .

2 . Institutional and implementation arrangements 10

3 . Monitoring and evaluation ................................................................................................ 12

4 . Sustainability 13

5 . 6 .

................................................................

. . . ..................................................................................................................... Crit ical r isks and possible controversial aspects ............................................................... 14

Credit conditions and covenants ....................................................................................... 15

APPRAISAL SUMMARY ................................................................................................. 15 D . 1 . 2 . 3 . 4 . 5 . 6 . 7 .

Economic and financial analyses ...................................................................................... 15

Technical ........................................................................................................................... 15

Fiduciary ........................................................................................................................... 16

Social ................................................................................................................................. 17 Environment ...................................................................................................................... 18

Safeguards Policies ........................................................................................................... 19

Policy Exceptions and Readiness ...................................................................................... 19

Annex 1: Country and Sector or Program Background ............................................................ 20

Annex 2: Major Related Projects Financed by the Bank and/or other Agencies ...................... 22

Annex 3: Results Framework and Monitoring .......................................................................... 23

Annex 4: Detailed Project Description ..................................................................................... 39

Annex 5: Project Costs .............................................................................................................. 50 Annex 6: Implementation Arrangements .................................................................................. 51 Annex 7: Financial Management and Disbursement Arrangements ........................................ 57

Annex 8: Procurement Arrangements ....................................................................................... 66

Annex 10: Safeguard Policy Issues ........................................................................................... 91

Annex 1 1 : Project Preparation and Supervision ....................................................................... 93

Annex 9: Economic and Financial Analysis ............................................................................. 75

Annex 12: Documents in the Project File ................................................................................. 94

Annex 13: Statement o f Loans and Credits .............................................................................. 95 Annex 14: Country at a Glance ................................................................................................. 97

Map : IBRD 33458

NIGERIA

BORRO WER/RECIPIENT INTERNATIONAL DEVELOPMENT

MALARIA CONTROL BOOSTER PROJECT

80.00 0.00 80.00 30.00 150.00 180.00

PROJECT APPRAISAL DOCUMENT

ASSOCIATION Total:

AFRICA

110.00 150.00 260.00

AFTH3

Date: November 14,2006 Country Director: Hafez M. H. Ghanem Sector Managerhlirector: Laura Frigenti Project ID: PO97921

Lending Instrument: Sector Investment Loan (SIL)

Team Leader: Ramesh Govindaraj Sectors: Health (1 00%) Themes: Health system performance (P) Environmental screening category: Partial Assessment

1 ,

[ ]Loan [XI Credit [ ] Grant [ 3 Guarantee [ 3 Other:

For Loans/Credits/Others: Total Bank financing (US$m.): 180.00 Proposed terms:

Borrower: Government o f the Federal Republic o f Nigeria Plot 223D, Cadestral, Zone 6, Mabushi, Utako Distr ict Abuj a Nigeria Tel: 234-09-882-105 1 Fax: 234-09-523-5685 PCUHQ@PCUAGRIC. ORG

Responsible Agency: Federal Ministry o f Health Federal Secretariat Nigeria Tel: 234 9 5238367

Project implementation period: Start March, 2007 End: September, 201 1 Expected effectiveness date: March 15, 2007 Expected closing date: March 3 1 , 2012 Does the project depart f rom the CAS in content or other significant respects? Re$ PAD A.3 [ ]Yes [XINO

Does the project require any exceptions from Bank policies? Re$ PAD D. 7 [ ]Yes [XINO

[ ]Yes [ IN0 [ ]Yes [ IN0 Have these been approved by Bank management?

1s approval for any pol icy exception sought from the Board?

Does the project include any critical r isks rated “substantial” or “high”? Re$ PAD C.5 [XIYes [ ] N o

Does the project meet the Regional criteria for readiness for implementation? Re$ PAD D. 7 [XIYes [ ] N o

Project development objective Re$ PAD B.2, Technical Annex 3 The Project Development Objectives are: (i) to ensure that the target population will have improved access to, and utilization of, a well-defined set o f Malaria Plus Package interventions (MPP); and (ii) to strengthen Federal and States ability to manage and oversee delivery o f malaria plus interventions.

Project description Re$ PAD B.3.a, Technical Annex 4 The project has two main components and is further divided into nine subcomponents.

Component 1 : Strengthen the capacity o f the Federal Government to provide malaria control leadership and coordination over the medium and long-tern. To support the ability o f the Federal Ministry o f Health (FMOH) staff to undertake these essential functions, the project will support:

Strengthening procurement and logistics o f commodities for accelerated implementation o f the malaria plus interventions; Improving National Monitoring and Evaluation for evidence-based management; Coordinating program activities at the national level and across programs.

Component 2: Strengthening the health system to improve delivery o f the Malaria Plus interventions in the target states. The Project will expand the capacity o f the State Ministry o f Health (SMOH) and the Local Government Authorities (LGAs) in the target states, so as to rapidly expand the Malaria Plus services at both the facility and the community levels. The project wil l provide appropriately tailored support to the states to help them improve their planning, implementation, coordination and supervision capacities. They include among other things the following:

Increasing access to, and utilization o f preventive measures; Expanding access to, and utilization o f effective diagnostic and treatment services; Strengthening community mobilization and Communication for Behavior Change; Improving state-specific M&E for evidence-based management; Strengthening partnerships for resource mobilization and implementation; Enhancing capacity o f the states for oversight and project coordination.

Which safeguard policies are triggered, if any? Re$ PAD D. 6, Technical Annex 10 Two safeguards policies are triggered by this project: Environmental Assessment (OPBP 4.01) and Pest Management. The Integrated Vector Management Plan and the Medical Waste Management Plan were disclosed in-country and the Bank's Info Shop prior to appraisal.

Significant, non-standard conditions, if any, for: Re$ PAD C.7

Board presentation / Credit effectiveness: There are no conditions for Board presentation or effectiveness

Covenants applicable to project implementation: Standard Financial Covenants

Disbursement conditions: All participating States to sign: (a) subsidiary credit agreement with the Federal Government; and (b) contracts with a Service Delivery Agency.

A. STRATEGIC CONTEXT AND RATIONALE

1. Country and sector issues

1. (WHO) estimates that there are more than 1.1 m i l l i on deaths per year f rom malaria, mostly among children less than five years o ld (WHO 2002). Although the disease i s preventable and curable with available technologies, in the absence o f strong and sustained malaria control efforts, coverage with effective interventions i s low, particularly among the poor.’ At least 85 percent o f deaths f rom malaria occur in Afr ica (Arrow, Panosian, and Gelband, 2004).

Malaria afflicts mill ions in low- and middle-income countries. The Wor ld Health Organization

2. Nigeria. The majority o f cases are due to Plasmodium Falciparum, the life-threatening form o f the disease. Malaria accounts for about 110 mi l l ion clinical cases annually, including 60 percent o f a l l outpatient attendances and 30 percent o f a l l hospital admissions. Although the entire population i s at risk, severe morbidity and mortality i s usually seen in children under five and in pregnant women. Malaria i s responsible for nearly 29 percent o f estimated deaths among children and 11 percent among pregnant mothers. The northern states in Nigeria suffer some o f the highest ch i ld mortality rates in Africa.

Malaria i s a major public health problem, and both a cause and a consequence o f poverty, in

3. and effective treatment i s extremely low. Only 34 percent o f febrile children receive anti-malaria treatment (chloroquine). Only one percent o f pregnant women received Intermittent Preventive Therapy (IPT) (NDHS, 2003), although this has recently improved to 17 percent. Despite being a country where malaria i s endemic, the use o f long-lasting insecticidal nets (LLINs), which i s one o f the main preventive interventions against malaria, remains rare. Only 6.8 percent o f households own at least one Insecticide Treated Ne t (ITN) (NMCP, 2005), about one percent o f households own more than one ITN, and only one percent o f children under five sleep under I T N s (NDHS, 2003). Similarly, only 1.3 percent o f pregnant women sleep under an ITN (NDHS, 2003). On the whole, because o f poor malaria control, Nigeria i s significantly off-track in reducing the prevalence o f malaria and reducing chi ld and maternal mortality - al l o f which are health-related Mi l lennium Development Goals (MDGs).

Progress to date in combating malaria has been slow, and the coverage o f prevention measures

4. Geographical, income, and ethnic differentials a l l contribute to the substantial inequities in access to health services and health status prevalent in Nigeria. One o f the major challenges faced by the National Malaria Control Program (NMCP) i s the l o w utilization o f public health care services. This has l ed the Government to consider seriously involv ing other segments o f the health delivery system -- the private sector, N o n Governmental Organizations (NGOs), and community-based organizations -- as channels for essential public health commodities and services, including for the prevention and treatment o f malaria.

Mos t o f Nigeria’s social indicators fa l l below the average o f sub-Sahara Afr ican countries.

5. system, and the private system, including both non-profit and for-profit providers. All three systems are actively involved in the delivery o f health care in Nigeria and their capacity varies significantly among and across states. The public health delivery system coordinates closely with the faith-based organization in terms o f policy, management, and reporting. The faith-based system consists of: the Christian faith- based mission networks, which provide a significant portion o f the secondary health services, and some primary-level facilities, and the Muslim-based health networks, which operate primarily in northern states. Private health care providers are heterogeneous, ranging from patent medicine vendors, dental and

There are three health delivery systems in Nigeria: the public health system, the faith-based

World Bank. 2005. “Rolling back Malaria - the World Bank Global Strategy and Booster Program.” Human Development 1

Network, Washington.

2

medical clinics, to tertiary hospitals. Most o f these are registered by the government, but there are also unregistered clinics, drug shops and numerous drug hawkers. In 2003, there were 2,751 registered pharmacies, but there were an estimated 36,000 or more patent medicine vendors in the country. The National Association of Patent Medicine Vendors coordinates the worlung framework and guidelines for Patent Medicine Vendors who are a legally recognized category o f drug sellers. There are far more numerous than registered pharmacies and are significant providers o f “informal” care. They are widely present in the southern states, and in urban areas in al l parts o f the country, including in the northern states.

6. L i k e other sectors, the health system i s recovering f rom a period o f poor governance and corruption. Governance and accountability are particularly weak at the local level, partly because o f capacity constraints, which are further exacerbated by the proliferation o f Local Government Authorities (LGAs), spreading capacity even more thinly. Governance and accountability issues are also related to inadequate funding and poorly trained, equipped, and motivated staff, in part due to very l o w and irregularly pa id salaries. There are also problems with planning, budgeting, and financial management at a l l levels o f government.

7. 1998 to provide a coordinated global approach to fighting malaria and halve the burden o f malaria by 20 10. Nigeria’s RBM was supported by a five-year Strategic Plan for the period 200 1-2005. Nigeria i s a signatory to the Abuja Declaration which commits the country to deploy a l l necessary resources and raise funds to achieve the program’s overall objective and the Abuja targets. However, none o f these targets were close to being met by end o f 2005, and coverage o f key preventive and curative interventions remains low. With the change in leadership at the helm o f Nigeria’s National Malaria Control Program (NMCP), and significant support for malaria control f rom the Office o f the President, the program has received a fresh impetus.

Government malaria control strategy. The R o l l Back Malaria (RBM) Partnership was launched in

8. Program (NMCP) has led a process to develop a new Country Strategic Plan for 2006-20102. The Plan reflects Government strategy to accelerate and intensify efforts o n malaria control. I t was developed in partnership with the RBM Partners, States’ Ministries o f Health and their LGAs, and other stakeholders. The collaboration and involvement o f a l l these partners i s expected to enable a national scale-up o f key preventive and curative interventions.

With the Country Strategic Plan for 2001-2005 n o w at a close, the National Malaria Control

9. The program aims to halve the burden o f malaria by 2010, which i s expected to reduce all-cause chi ld mortality by 20 percent. T o achieve this objective, the program envisages a massive scale-up o f vector control interventions for a l l at-risk population and a strong focus on preventive measures, coupled with the introduction o f more effective case management, including the use o f artemisinin-based combination therapies (ACT) for treatment o f uncomplicated malaria cases, with an init ial focus o n children under five.

10. The National RBM Program scale-up will support a l l 36 States, plus the Federal Capital Territory, to achieve results at national, regional, and community levels, using a phased approach. Coverage o f interventions will be scaled up in two phases. Phase One, which corresponds to the 2006- 2008 period, will be a rapid catch-up phase, focusing o n increasing coverage to levels close to 80 percent among vulnerable groups. Phase T w o will consolidate these achievements and extend coverage to the general population at risk.

* Government o f Nigeria, Federal Ministry o f Health, A 5-year Strategic Plan: 2006-2010: A Road Mat, for Impact on Malaria in Nigeria.

3

1 1. The Country Strategic Plan builds o n a set o f core as wel l as cross-cutting interventions:

Case management: Diagnosis: to ensure that at least 80 percent o f suspected malaria patients are correctly diagnosed by 2010. Laboratory diagnosis using microscopy method will be extended progressively to al l health facilities whi le rapid diagnostic test k i t s (RDTs), will be used o n a p i lo t basis for malaria diagnosis before large deployment. RDTs are not recommended for children under five. Treatment: Children under f ive will receive free Artemether-Lumefantrine (AL) through public sector and faith-based health facilities. Malaria component o f the Integrated Management o f Childhood Illnesses (IMCI) wil l be strengthened. A home-based management o f malaria strategy wil l be developed to increase access to effective treatment for under-fives. T h i s strategy wil l uti l ize Patent Medicine Vendors (PMVs) as wel l as expand the highly successful mother model system that has been piloted in Nigeria. Integrated Vector Management, to ensure that at least 80 percent o f the population at risk sleeps under insecticide treated nets. For children under five, there will be free distribution o f LLINs through: (i) public campaigns, as part o f Immunization Plus Days (IPD) and measles campaigns; and (ii) public sector and faith-based health facilities. A free LLIN i s given to pregnant women attending f irst Ante-Natal Care (ANC) and to children under five who complete the third dose o f the Diphtheria-Pertussis-Tetanus (DPT3) vaccination. In addition, experimentation with voucher systems and social marketing has been successful and will be explored further. Selected areas with suitable epidemiological characteristics will be covered by I R S interventions with a goal to achieve 85 percent coverage in al l eligible households. Criteria o f eligibil i ty are being finalized. Prevention duringpregnancy, at least 90 percent o f women have access to directly observed IPT with Sulfamethoxazole-Pyrimethamine (SP) twice during the second and third trimesters o f pregnancy, through public and faith-based antenatal facilities. Effective program management, to strengthen the capacity o f program management systems at a l l levels o f the health system.

Partnerships and Donor support

12. Plan (2006-10) and o f the Operational Plan (2006-8). RBM partnership serves as an advisory body including development agencies (both multilateral and bilateral), private sector companies and NGOs. It also includes representatives f rom large corporations such as Exxon Mobi l , and UBA (United Bank Africa). Through the monthly meetings coordinated by the NMCP, partners provide technical support o n pol icy issues, strategic operational plans development, implementation, monitoring and evaluation o f RBM interventions. They also facilitate effective collaboration o f NMCP with other programs in the context o f integrated disease control and serve as advocates for resource mobilization.

Nigeria’s partners were actively engaged in the development o f the Malaria Control Strategic

13. Since the launch o f the RBM initiative, there has been a steady increase in the national malaria control budget and release o f funds, growing f rom US$0.4 mi l l ion (2004) to US$2.4 m i l l i on (2005) and subsequently to US$18.2 m i l l i on in 2006. With the change to ACTS and adoption o f LLINs in Nigeria, it i s estimated that approximately US$ 845mill ion i s needed over the next 5 years to implement the 5-year national plan for malaria control. The Global Fund rounds two (2004-2006) and four (2005-2007) contributed US$41.5 mi l l ion to this financing gap. UNICEF continues to support related activities in l ine with the National RBM Strategy with around U S $ l M annually and WHO with a similar budget. Similarly, U S A l D i s a long term partner that supports RBM interventions in several States and i t s annual contribution i s projected to increase f rom US$2 mi l l ion in 2006 to US$6.65 mi l l ion in 2007.

14. DFID has outlined a National Malaria Project implementation strategy for assistance worth about US$lOO mi l l ion but the approval o f this project has been pending for almost two years. Investments in areas such as immunization will however significantly contribute to the outcomes pursued by the malaria

4

specific interventions, thus projects such as the DFID supported Routine Immunization should be equally recognized in this context. There are also other donors e.g. the Chinese government who has made donations in I T N s . Whereas this proposed project (US$180M) would alleviate some o f the existing funding deficiencies, the gap none the less remains significant despite potential future successes with the DFID and Global Fund proposals.

2. Rationale for Bank involvement

15. In 2005, the Bank launched a new Booster Program for Malaria Control to increase coverage o f malaria-specific interventions with effective service delivery, broader health-system development, and capacity building across multiple sectors. The Bank’s program to control malaria i s intended to support country-led programs with an emphasis o n outcomes, flexibil i ty in approaches, and partnerships with c i v i l society organizations and partner agencies.

16. Through the proposed project, the Bank intervention will add value by:

scaling up access to effective diagnosis and case management; ensuring access to the most effective prevention measures and tools at household and community level; reinforcing and expanding effective distribution and operational delivery mechanisms through public- private partnerships; strengthening procurement, financial, and logistics management systems; building technical and operational capacity at federal, state, and local government levels for monitoring and evaluation; and strengthening the implementing capacity o f State and LGA.

17. program, the Bank will also bring financial assistance to complement programs and projects f rom other donors, notably DFID and the Global Fund, although the size o f assistance may s t i l l fall short.

In addition to providing strategic and technical support to the Government to implement i t s

3. Higher level objectives to which the project contributes

18. Morbidi ty and mortality caused by malaria are significant obstacles to achieving the Government’s poverty reduction strategy, as the direct costs o f malaria treatment and lost economic productivity constitute a financial burden on the economy. The Government’s 2004 National Economic Empowerment and Development Strategy (NEEDS) includes developing strategic plans for malaria as a specific action o f the health component o f the poverty-reduction strategies. The Presidential Initiative for Accelerated Achievement of the MDGs outlines the way to achieve the health-related MDG and includes malaria control as a key component. Finally, Nigeria’s 2004 National Health Policy identifies malaria control as a priority health program. T h i s Project i s consistent with the objectives and approach o f the Country Partnership Strategy (CPS) that supports Nigeria’s NEEDS. The CPS aims to achieve the following results: (i) improved service delivery for human development; (ii) improved environment and services for non-oil growth; and (iii) improved transparency and accountability for better governance. The proposed Project supports pr imari ly results packages (i) and (iii).

Several Government policies recognize malaria as both a health and a development priority.

5

B. PROJECT DESCRIPTION

1. Lending instrument

19. The lending instrument i s a Sector Investment Loan (SIL).

2. Project development objective and key indicators

20. improved access to, and utilization o f well-defined set o f Malaria Plus Package o f interventions (MPP); and (ii) to strengthen Federal and States abil ity to manage and oversee delivery o f malaria plus interventions.

The Project Development Objectives are: (i) to ensure that the target population will have

21. will be used during project implementation to measure the extent to which coverage o f key interventions and impact are achieved:

The MPP i s described in detail in a matrix at the end o f Annex 4. The fol lowing key indicators

Percentage o f children < 5 years with fever treated with an effective antimalarial within 24 hours f rom onset o f symptoms. Percent o f infants aged 0-6 months that were fed breast milk only in the last 24 hours. Percentage children < 5 years who slept under an ITN the night preceding the survey. Percentage o f pregnant women who received two or more doses o f IPT. Percentage o f pregnant women who slept under an ITN the night preceding the survey. Percentage o f States regularly using M&E data to manage malaria and or Maternal and Chi ld Health (MCH) Programs.

Target population and geographical coverage:

22. The project gives priority for pregnant women and children under five and i s expected to have significant spill-over effects f rom the improvements in maternal and chi ld health. I t wil l target seven o f the thirty-six states allowing for a significant scale-up effect in each state. The selection o f these states was the result o f a consultative process in which due consideration was given to one or more o f the following criteria (details in Annex 4):

Mortal i ty rate among under-fives exceed 260/1000. Access to effective primary health care services i s poor to non existent (based on access within 5 kilometers. Access to secondary facilities i s very poor or non existent (based o n required travel time exceeding ha l f a day). The States have demonstrated commitment to implement (i) large scale campaigns to cut child- mortality andor (ii) a comprehensive malaria booster program. Documented Plasmodium Falciparum resistance to chloroquine and SP (the f i rst l ine treatments in use) exceeds 85 percent. An implementable State-Level RBM Strategic Plan for malaria control (based o n federal guidelines and internationally recommended best practices) exists. No other significant donor aid for malaria control i s currently available.

Selected states are: Northern states: Kano, Jigawa, Gombe, Bauchi; Southern states: Akwa Ibom, Rivers, and Anambra.

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3. Project components (see Annex 5 for detailed breakdown of project costs)

Component 1: Strengthen the capacity of the Federal Government to provide malaria control leadership and coordination over the medium and long-term. (US$86.5 million).

23. requires additional support to develop necessary policy, to coordinate the efforts o f donor agencies and funding streams, to engage in a meaningful way with the private sector including NGOs, to implement procurement strategies to ensure continuous availability o f key commodities, to monitor and evaluate program performance and to plan and commission operational research. T o support the abil ity o f FMOH staff to undertake these essential functions, the project will support:

The Federal Government i s committed to delivering the Abuja targets o n Malaria Control but

(a) Strengthening procurement and logistics of commodities and promoting their use through social marketing for accelerated implementation of the malaria plus interventions The project will support strengthening the procurement systems that ensures continuous supply o f central procurement o f key commodities. The fol lowing commodities will be carried out at the Federal level: Long lasting Insecticide treated nets (LLINs), ArtemethedLumefrantine (AL), Sulphadoxine- pyrimethamine (SP), spray pumps and insecticide for the indoor residual spraying. The project will not finance RDTs as, according to Government Strategy, RDTs will not be used for children < 5 and will be used on a pi lot basis for other groups. In addition, given the possible bottlenecks involved in procuring malaria commodities and distributing them to the states and LGAs, either directly or through the Project Implementation Facilitators (PIF) (See Component 2 below), the Project will finance technical assistance to the NMCP in procurement and logistics management o f malaria commodities. Technical assistance in the form o f a Technical Specialist, who will assist the FMOH and the SMOHs in the evaluation o f bids and proposals will also be provided, o n an as-needed basis. Finally, a Social Marketing Agent will be recruited to assist the FMOH and the States in promoting the use o f the relevant commodities.

@) Malaria control i s an outcome-driven program and thus the FMOH will need systematic and regular M&E aggregate data f rom the States to assess the status o f the overall process, introduce program changes as needed, and pol icy making. This component i s aimed at strengthening the national M&E Unit o f the NMCP by establishing a results-based monitoring system to track both process and outcome indicators. The project will finance a contract with a specialized M&E firm to support the NMCP in undertaking effective M&E.

Improving Monitoring and Evaluation for evidence-based management

(c) The project will strengthen the capacity o f the N M C P in program coordination and oversight. I t will support close collaboration among relevant programs and departments within the FMOH, as wel l as an annual review o f the project through a “Results for Health” Forum.

Coordinating program activities at the national level and across programs

Component 2: Strengthen the health system to improve delivery of the Ma lar ia Plus interventions in the target states (US$71.5 million).

24. The Project will strengthen the capacity o f State MOH and LGAs in the target states to rapidly expand the Malaria Plus Package at both health facility and community levels. The project will provide support to the states and LGAs to help them improve their planning, implementation, coordination and supervision capacities. The project will provide support either directly through the FMOH and RBM partners, and, where deemed appropriate, through Project Implementation Facilitators (PIFs), using service contracts between the selected States and PIFs. A decision on what services the PIF would provide in each state will be based o n a detailed implementation capacity assessment that will be carried out prior to project effectiveness by the FMOH with assistance, as required, f rom IDA and other RBM partners. Selection o f the PIFs will fo l low an international competitive process. Where PIFs are

7

contracted, their main purpose wil l be to assist authorities on one or more o f the fo l lowing functions: (i) to develop and assure the implementation o f state-wide (including LGAs) plans for delivering decentralized Malaria Plus Package (MPP); and (ii) identify and allocate resources and monitor the effectiveness o f implementation. Throughout this process, the PIFs wil l strengthen state, LGA and community ownership, as we l l as their technical and managerial capacity, t o ensure sustainability o f efforts. They are expected to play a supportive and collaborative role vis-&vis State and local health authorities, as wel l as private and faith-based organizations. Special attention will be given to the LGAs to deliver the MPP and to strengthen public-private partnership. The objectives o f the component are summarized below. They include:

(a) The selected states will receive comprehensive support in scaling-up the preventive measures identified in the Malaria Plus Package (Annex 6). State and local authorities, with the support o f the FMOH, RBM partners and the PIFs, where such entities are contracted, will be encouraged to use a variety o f delivery routes to maximize coverage as quickly as feasible. Activities to achieve this objective include: (i) rapid scale-up o f coverage and uti l ization o f LLIN through a variety o f delivery mechanisms, i.e. through campaigns, health facilities and social marketing (including building o n the successful p i lot ing o f voucher systems). L L I N S financed through this project will be free to children <5 and pregnant women. Furthermore, states either directly or with assistance from the PIFs, as appropriate, will: (i) support local authorities and will coordinate with the Social Marketing Agent to put in place mechanisms that will ensure financial accessibility o f the poor and vulnerable population to LLINs; (ii) increase utilization by pregnant women o f Ante-Natal Care (ANC) and free IPT; (iii) identify eligible areas for I R S and implement I R S accordingly; (iv) mobil ize communities and families to reinforce utilization o f prevention tools; and (v) enhance social accountability between the States, LGA, and the communities.

Increasing access to, and utilization of preventive measures

@) Expanding access to, and utilization of effective diagnostic and treatment services The selected states and LGAs will receive comprehensive support in the scaling-up o f effective diagnostic and treatment services as part o f the Malaria Plus Package. The specific activities include: (i) identifying and assessing the health conditions o f populations living in rural or remote areas with l o w access to MPP, and proposing strategies to reach them; (ii) increasing access to diagnostic services, i.e. enhancing clinical diagnostic sk i l l s through the strengthening o f I M C W M strategy, expand microscopy, and introducing RDTs o n a pi lot basis; (iii) increasing access to ACT (Artemether-Lumefantrine) for uncomplicated malaria in the target population; (iv) strengthening referral o f severe cases for appropriate case management; (v) ensuring that the state and LGA public and private health system has the tools and competencies to assure the delivery o f quality MPP; (vi) strengthening in-service training and supervision geared to develop or improve sk i l ls in priority technical areas; and (vii) improving home-based management o f malaria and other maternal and chi ld interventions identified in the Malaria Plus package. The states will also work with various partners to ensure proper disposal o f biomedical waste. Depending o n the results o f the implementation capacity assessment, PIFs wil l be contracted to assist the states in one or more o f the above activities.

(c) The Project recognizes the need for community mobilization and the involvement o f the political, traditional and religious leadership in project activities for achieving rapid improvements in malaria control. The states will be supported, either directly or through the PIFs, o n community mobilization and for behavior change communication (BCC) initiatives to improve coverage o f the Malaria Plus interventions.

Strengthening community mobilization and communication for behavior change

(d) The States, supported if required by PIFs, will develop effective linkages with other initiatives in the health sector and work across ministries and in partnership with the private sector in order to maximize

Strengthening partnerships for resource mobilization and implementation

8

project impact. The project wil l tap into additional sources o f funding such as the Community Social Development Project, to finance directly community-based initiatives linking with malaria control.

(e) This component wil l provide technical assistance and capacity-building activities (either directly or through the PIFs) to strengthen the M&E technical and training skills o f stakeholders in the target states. The objective i s to introduce the decentralized M&E system as a results-based management tool to assess the status o f the overall process and introduce program changes as needed. The project will support the following activities: (i) developing an information system to measure output and outcome indicators, based o n the project’s indicators (Annex 3). Outcome indicators will be collected and reported on a biannual basis and output indicators o n a routine basis. State and local authorities, community leaders and health personnel will be trained to interpret health indicators and use them for decision malung, establishing a project logistic management i n fomat ion system (LMIS) data (collecting three essential data: stock o n hand, consumption and losses and adjustments) in close coordination and collaboration with the Federal level procurement team. The state L M I S needs to be standardized in al l states and by a l l public and private implementation partners. When contracted for this function, the PIF will assess the state and LGA storage and delivery capacity; identi@ bottle-necks and propose solutions and assist in implementation to improve access to commodities and medicines, and assisting the State health system in assessing the performance o f campaigns, other community mobilization activities, and community-based health workers.

Improving state-specific M&E for evidence-based management

( f ) As necessary, PIFs wil l assist, and build the capacity of, the participating S M O H and LGAs in technical, financial, operational, and management functions. This will ensure maximum coordination within the states and between S M O H and the NMCP, strengthen quality control and build state and local level accountability.

Enhancing capacity o f the states for oversight and project coordination.

4. Lessons learned and reflected in the project design

25. malaria control projects, and the implementation o f the 2001-2005 Country Strategic Plan to Ro l l Bank Malaria.

The design o f the proposed project takes into account lessons from international experience, other

26. stories o f countries where malaria has been successfully controlled:

The fol lowing lessons from international and regional experiences are based o n the success

Strong leadership and commitment to malaria control at a l l levels o f government which recognizes malaria as a barrier to economic development. A targeted technical approach using a package o f effective tools to control malaria, combining effective case management with preventive measures, such as targeted use o f IRS, integrated vector management, and distribution o f LLIN. A strong results-based M&E system to drive decision-making and implementation to achieve set targets, including a baseline assessment and well-defined and measurable performance indicators. Partnership with private sector and community-based organizations to achieve large-scale, sustainable impact. Decentralized implementation and control ofjhances to promote program ownership by local governments, with the national malaria control programs retaining leadership in specific aspects o f implementation, such as procurement o f essential commodities.

9

27. The main lessons from implementation of previous and ongoing projects3 in Nigeria are:

The need to strengthenprogram ownership and commitment at federal, state, and local levels and to develop greater engagement with states, stakeholders, and partners. The need to link annual work programs and resources with targets for results. The need to strengthen institutional capacity at Federal, state and LGA levels through the recruitment, facilitation and management support o f a significant technical assistance mandated to work with al l partners to produce results and to ensure sustainability. The need to address governance issues at al l levels o f government. The need to assess in the pharmaceutical sector the private legal and illegal sub-sectors, as wel l as the appropriate roles for the States. An environment that supports regulation and enforcement i s required if intervention through the private sector i s t o succeed. Tools to deal with these issues need to be developed and tested. The need to address the issue o f how to deal with port officials and suppliers for internationally procured commodities (Global Fund experience). The need to assess the dynamics o f the private pharmaceuticals sector, i l legaldrug flows, and their relationship with Bank-financed programs and regulatory and enforcement bodies.

28. Strategic Plan for 200 1-2005 was implemented through strong partnerships, but these were relatively small projects and pi lot programs. Nonetheless, they provided valuable lessons to help design the next phase, in terms o f strategic focus and implementation arrangements. A review o f the Country Strategic Plan concluded that overall coverage level o f key activities remains extremely low, far beneath the thresholds required for effective control. The review recommended strengthening program management at a l l levels, designing and implementing a comprehensive IEC strategy and delivery mechanisms, developing the National M&E capacity, and building the capacity o f health staff as wel l as that o f community-based health workers.

Lessons from implementation of the 2001-2005 Country Strategic Plan: The Country

5.

b

b

b

Alternatives considered and reasons f o r rejection

A Sector-Wide Approach (SWAP) versus intervention-specific vertical investments. Whi le the project does not involve pooling o f financing with other partners, i t i s guided by the common framework for malaria control adopted by the NMCP. The project also takes into cognizance the contributions to malaria control o f the other development partners in Nigeria in i t s selection o f states, and thereby complements the funding and activities being provided by other partners. Sole responsibility of the Federal Government. An alternative design was one in which malaria control would have been the sole responsibility o f the Federal Government. This was rejected because o f Nigeria’s federal system and decentralized structure. Whi le the National Malaria Control Program i s responsible for the national strategy, state governments will be responsible for funding and implementing the project’s interventions through an on-lending scheme with the Federal Government, in collaboration with the local governments. State executing all activities. An assessment o f the implementation capacity o f the public sector at the States and particularly LGAs level suggested that health authorities need a great deal o f support to p lay the role o f oversight and to have in place the necessary systems for accountability. Projects that did not consider that important aspect in their design have failed to have an impact, even though they ultimately managed to disburse. Therefore, the project wil l adopt the “contracting out” approach whereby the state contracts with a Project Implementation Facilitator to strengthen their capacity to manage for results, in those areas where such capacities are weak. The determination o f the areas o f

Lessons are from Bank-financed projects as well as f rom projects financed by other donors. The Bank Team worked closely with partners managing the Global Fund Project, DFID, COMPASS, and others.

C.

1.

10

need will be made based on a detailed capacity assessment to be made by the FMOH prior to project effectiveness. Geographic coverage. Although the 36 states and the Federal Capital Territory (FCT) o f Nigeria are a l l malaria endemic, to varying extents, funds available in the context o f the proposed project could not support the Government’s strategy on a nationwide scale. In addition, experience o f project implementation in Nigeria shows that projects that target a l l or a large number o f states are slow to be implemented. Therefore, the project will adopt a phased approach which could expand to non- participating states based o n experience obtained during implementation and the availability o f funding.

IMPLEMENTATION

Partnership arrangements

29. R o l l Back Malaria (RJ3M) partnership in Nigeria i s quite solid and therefore, it i s expected that project implementation wil l benefit f rom contributions o f several key partners, particularly WHO, UNICEF, U S AID, DFID, the Global Fund, international and national non-governmental organizations, particularly faith-based organizations. In addition, the project will re ly o n private organizations currently supporting health coordination systems, supply logistics, and health care delivery through the three established health delivery systems.

The proposed project was prepared in close cooperation with a l l key development partners. The

2. Institutional and implementation arrangements

30. Given the decentralized nature o f the Project, the implementation arrangements have been designed to offer a balance between effective overall supervision and monitoring o f activities at the Project level, as wel l as reinforcing the management and institutional responsibilities o f individual states.

The Project will be implemented over a period o f f ive years f rom March 2007 to September 201 1.

3 1. Federal Minister o f Health (FMOH) (or hisher representative). The PSC will consist o f a balanced representation f rom the FMOH, the Federal Ministry o f Finance (FMOF), states and LGAs, other development partners, faith-based organizations active in delivery o f health services at the primary level, and the private sector. The PSC will be responsible for ensuring timely implementation o f the project by the N M C P and various contracting agents. It will convene quarterly to: (i) review progress reports prepared by the NMCP and states MCP Focal Person and clear the forwarding o f these reports to IDA with comments; (ii) review and approve annual work programs and budgets; (iii) ensure that agreed performance targets and timelines for activities under the different components are met; and (iv) proactively address critical issues that could hinder Project implementation.

Project Steering Committee (PSC). The Project wi l l be overseen by a PSC chaired by the

32. coordination o f project activities, specifically with other Ministries, other FMOH departments and SMOH, and federal representatives o f the faith-based and private sector health delivery systems. The NMCP Director will act as the project coordinator. In addition to overall coordination, the N M C P will be responsible for: (i) overall technical management; (ii) procurement arrangements o f malaria commodities; (iii) overall accountability for the financial management o f the credit at the Federal level. Specifically, i t will be responsible for (a) preparing activity budgets, monthly S A reconciliation statement, quarterly SOE Withdrawal Schedule, quarterly Inter im Financial Reports (IFRs), and annual financial statements, and (b) ensuring that the project financial management arrangements are acceptable to the Government and IDA. I t will also forward the reports and statements to the Federal Ministries o f Health and Finance and

At the Federal Level, the NMCP, within the FMOH, wil l be responsible for the overall

11

IDA; and (iv) monitoring, evaluation and reporting o n progress. The Assistant NMCP Director will coordinate activities for the Federal component o f the project.

33. With respect t o procurement and financial management, the N M C P has obtained the transfer o f a procurement staff and a project accountant f rom other parts o f the Ministry to focus solely o n this project. The designated project accountant, who will be a professionally qualified accountant, will work under the technical guidance, support and quality control o f the Head o f Finance o f the Health Sector Development Project (HSDP) I1 , using i t s existing systems and procedures as a basis for the design and implementation o f an accounting and financial management system for this project. The staff will be accountable to the NMCP Coordinator for the financial management o f the project, with the Head o f Finance HSDP I1 tahng responsibility to oversee the technical quality o f service delivery by such staff. T h i s arrangement will strengthen the capacity o f the NMCP and permit quick implementation o f a financial management system for the project under experienced guidance and quality control. In addition, a Technical Assistant specialized in procurement, and another one specialized in logistics management will be recruited to assist with the procurement strategies and implementation o f the specific malaria commodities and related logistics. The Bank team assessed these arrangements and found them adequate. These arrangements wil l be reviewed periodically by IDA as part o f regular project supervision.

34. A financial management assessment o f the HSDP I1 FM Unit had been undertaken and the existing financial management arrangements are acceptable to IDA. The financial management arrangements will be reviewed periodically as part o f regular project supervision missions. A procurement and logistics assessment has been finalized during appraisal.

35. At the State Level, the SMOH o f each participating state will be responsible for implementing project activities at state and local levels. The S M O H will be supported in i ts technical and operational functions by the PIF, as deemed necessary. In each o f the participating states, a State MOH Focal Unit, supported by a technical team, wil l be in charge o f implementing project activities at the state and local levels. I t also serves as the liaison between state and federal levels. In addition, the Project Financial Management Unit (PFMU) o f the Off ice o f the State Accountant-General will be tasked to provide the required Financial Management services to the State MOH Focal Unit responsible for implementing project activities at the state and local levels.

36. As the procurement o f malaria commodities i s done by the Federal level, the S M O H wil l undertake only l imi ted procurement, which they wil l either carry out o n their own, or where such capacities need strengthening, with the assistance o f the PIF based o n the stipulations o f TORS. Staff o f the S M O H will participate in this procurement process as part o f capacity building and institutional strengthening. The State MOH Focal Unit for MPP, supported by the PFMU, will have overall accountability for the financial management o f the credit at the participating State level. Specifically, i t will be responsible for: (i) preparing activity budgets, monthly S A reconciliation statement, quarterly SOE Withdrawal Schedule, quarterly Inter im Financial Reports (IFRs), and annual financial statements; and (ii) ensuring that the project financial management arrangements are acceptable to the Government and IDA. I t will also forward the reports and statements to the State Ministries o f Health and Finance and IDA. As workload necessitates, additional professionally qualified Project Accountants and Internal Auditors will be recruited for the duration o f the project. A financial management assessment o f the respective PFMUs had been undertaken and the existing financial management arrangements are acceptable to IDA. The financial management arrangements wil l be reviewed periodically as part o f regular project supervision missions.

37. levels and will coordinate project activities at this level, reporting back to their respective SMOH.

At the Local level, LGA health authorities will have implementation oversight at LGA and Ward

12

38. At state and local levels, the project will be implemented through, and maximize the use of, the three existing health delivery systems: the public health delivery system, the faith-based health delivery system, and theprivate sector, including the Patent Medicine Vendors (PMV), as wel l as the affected communities themselves.

3. Monitoring and evaluation

39. A robust project management and monitoring system will be implemented by the N M C P to monitor implementation progress and provide continuous feedback to strengthen and refine delivery mechanisms. T o achieve this objective, the project’s MdLY activities emphasize: (i) program management using results; (ii) spatial mapping o f the location o f key commodities; and (iii) decentralized M&E to the State and LGA levels to measure outcomes and the quality o f services. The project’s M&E system, which has been developed following extensive consultations with the N M C P and the concerned RBM partners in Nigeria, will have four components:

40. A Logistic Management Information System (LMIS) will be created to track a l l project commodities, such as ITN and ACT from their point o f entry into Nigeria through to the decentralized distribution points in the states and LGAs (public health facilities, FBO and private sector). The L M I S wil l use a standardized form that record the transmission o f the quantity o f ITN and A C T at each point where an organization takes delivery or delivers these commodities. The L M I S tracks the distribution o f the ACT and ITN down to the lowest level service delivery point. Each state, with assistance from the PIF if required, will be responsible for traclung i t s own allotments but will be required to use one reporting system and forward this information to the federal level, assisted by a logistic support specialist and a M&E Agent. The L M I S will show the spatial distribution o f I T N s and ACTs in the project area, and provide the project management to determine commodities’ stock-on-hand, consumption and losses, and adjustments. The system wil l use a set o f standardized forms and records to track the commodities’ storage and distribution. These records will provide information on stock-keeping, transaction and consumption records.

41. Each SMOH, with the assistance o f the PIF where such entities need to be contracted, will be responsible for using the L M I S data to monitor the stock levels and forecasts for the state and LGA. The L M I S will show the spatial distribution o f I T N s and ACTs in the project area, and provide the project management to determine whether any area i s deprived o f needed commodities. The M&E Agent wil l biannually sample the L M I S data and verify the chain o f transactions f rom the port down to the lowest level service delivery point to authenticate the information.

42. coverage and use o f ACT and ITN at the LGA level o n an annual or biennial basis. I t can also be used to assess I R S coverage. The L o t Quality Assurance Sampling (LQAS) method will be used to measure the key outcomes listed in the results matrix. These include coverage and use o f ITN and use o f A C T at the LGA level. LQAS i s a rapid survey that wil l determine whether LGA are reaching pre-established targets for key project indicators. The same data will a l low calculation o f point estimates for outcome indicators for State and Project levels. The project will experiment with the use o f PDA and or optical readers for rapid data entry and to avoid information bottlenecks. A data for decision-making component will be established to determine underlying program problems identified with LQAS. All data will be used during annual work planning sessions to restructure and improve the project, as wel l as to set targets for the subsequent year. T o ensure the accuracy o f the information collected a small sample o f questionnaires will be sampled and the corresponding interviewee, interviewed again. By counting the concordant pairs, the reliabil i ty o f the data can be established. - T h i s M&E work will be managed by the M&E Agent who will be responsible for M&E capacity building in each State. Small data collection teams wil l be formed in each State and in each LGA consisting o f SMOH, private sector members, and

A rapidpopulation-based survey system will be established in each participating State to track

13

supported by the PIF, where such an entity i s contracted. The LQAS i s being used because it requires the least amount o f information to judge whether outcomes are on track at the LGA level. A baseline survey, using the LQAS methodology, i s currently underway in the seven participating states as we l l as in two control states. The complete results o f this survey are expected to be ready in early December, 2006 and will be used to measure progress in project implementation and support local and national level decision- making over the l ifetime o f the project through the proposed annual follow-up surveys. As a direct consequence o f the baseline survey, capacities have been built up in the participating and the control states to undertake the annual surveys using the LQAS methodology.

43. f rom the PIF, to determine the quality o f care at a sample o f health facilities in each participating State. A similar tool will be used to assess the quality o f care o f PMV. These data will be used to strengthen capacity building activities for health facilities and PMV. This M&E work wil l also be managed by the M&E Agent at the Federal level who will build the capacity o f the S M O H and the private sector to carry out the assessment on a small sample o f facilities.

44. Special studies will be carried out as a means o f enhancing rapid M&E approaches. For example, b lood pooling methods will be assessed as a rapid means to detect ACT drug resistance. Another special study will apply methods used to manage pol io campaigns to ITN campaigns developed under the project. The purpose i s to rapidly identify areas that were not fully covered during the campaign and to rectify problems before the campaign leaves an area.

Health Facility Assessments (HFA) will be implemented by the states, with assistance i f required

45. As indicated above, two control states (north and south) have been selected f rom a set o f alternate states that could be funded in the project at a later date. Their presence in a baseline and final assessments are expected to help in the measurement o f exogenous influences o n key program indicators.

46. potentially used by the project to measure all-cause mortality in children under 5 years o f age. In Nigeria, the latest D H S was carried out in 2003 and the next one would not be due until 2008 at the earliest, but there i s n o certainty o f i t s occurrence, or which survey methodology will be chosen. Nevertheless, if D H S or a similar study i s carried out around the end o f the project, project managers wil l discuss the possibility o f sub sampling the project states to examine changes in the under fives mortality rate.

The national population surveys, such as D H S and M I C S or Malaria Indicator Survey, can be

47. will be reviewed annually in a Forum for Health Results that brings together both levels o f government, to identify priorities as wel l as to problem solve.

In order to ensure that the States and the Federal government are wel l coordinated for M&E, data

4. Sustainability

48. results in the areas o f technical assessment, planning, training, implementation, monitoring and evaluation o f malaria control interventions. It will also strengthen the coordination and delivery capacity o f each o f the three main health delivery systems to adopt and implement effective new malaria case management and prevention tools and strategies, particularly t o achieve effective malaria control across some o f the country’s most at-risk community targets. The project also proposes to complement other ongoing projects that support malaria control and system strengthening in order to build sustainable technical and implementation capacity in these systems. The support required by FMOH and SMOHs to maintain the delivery systems and new technical capacity established by the project should also be significantly less after f ive years o f transmission reduction and community capacity-building. Coupled to this, the basic cost o f essential commodities, including recommended case management and prevention, i s expected to

The project will progressively build the capacity o f the Federal MOH and the SMOHs for lasting

14

Risks To project development objectives

Institutional and implementation capacity constraints result in bottlenecks for program and project implementation.

Project may not expand at the rate proposed and therefore may not be implemented on the scale intended.

Project Financial Management

fa l l significantly over that period with increased global production and competition. The level at which the project will procure and implement i s not sustainable without external donor support and commitment. However, i f coverage targets are met in the supported states, significant reduction will occur in the incidence o f uncomplicated and severe malaria cases and in the corresponding burden currently placed o n the three main health systems.

Risk rating with

Risk mitigation measures mitigation

Project w i l l finance capacity strengthening through training, contracting wi th project implementation facilitators, as and where required, who will help develop procedures and resource mobilization for sustained program development and implementation.

S

Selected states w i l l benefit from project support to M strengthen their capacity to deliver a comprehensive package o f malaria plus services. Other states could be included in the program, as their readiness for implementation improves.

supervision. Adequate FM arrangements, external audit and IDA M

49. The full involvement o f the PMVs and the faith-based sectors, and their adoption o f new protocols and tools, will help ensure the sustainable delivery o f services to affected communities during and after the project.

Delays in procurement w i l l hinder effective Direct payment and early tendering are expected to respond response. to this risk o f non-availability.

50. result in reduction o f clinical infections per year, and days o f f sick, among school children and adults. This will increase family and community productivity and improve fami ly income-generation capacity. Increased malaria awareness, increased demand for services, and increased economic capacity will help ensure the maintenance o f the ongoing malaria control services established through the public, faith-based and private sectors when, in the future, a greater degree o f cost-sharing wil l be required.

At the community level, investments made through the project t o achieve effective coverage will

S

5 1. Progress towards ensuring sustainability will be assessed during the Project’s Mid-term Review.

Poor coordination among various partners results in

Increasing resistance will alter the national malaria inefficiency and duplication o f efforts.

program’s focus to short-term responses, including indoor residual spraying.

Di f f icul ty in inducing data use and performance- based culture. Overall Risk

5. Critical risks and possible controversial aspects

Annual program and project reviews w i l l be conducted with

The national program will carefully monitor resistance.

M

M all financing and implementing partners.

Annual program will help guide major changes and ensure that short-term responses are consistent with longer-term objectives.

to conditions and implementation capacity at this level. The national program provides enough flexibil i ty to adapt M

M

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6. Credit conditions and covenants

52. Disbursement conditions: All participating States to sign: (i) subsidiary credit agreement with the Federal Government; and (ii) contracts with a Project Implementation Facilitator to support the state in technical and fiduciary areas where the FMOH assessment reveals a significant need for capacity building.

D. APPRAISAL SUMMARY

1. Economic and financial analyses

53. in Nigeria and for involvement o f the public sector in the fight against the disease. Malaria i s a major public health problem, accounting for 40 percent o f the burden o f disease and responsible for an estimated 300 000 chi ld deaths each year. The economic and social burden o f the disease i s also substantial at a l l levels. At the macroeconomic level, the economic growth penalty o f malaria endemicity over the period 1980 - 1995 was estimated at US$17 billion, which represents a per capita loss o f US$156, or 18 percent o f actual 1995 income. Market failures and the poverty dimensions o f malaria control are a strong justification for public sector involvement. Indeed, the costs o f technologies available to prevent or treat malaria can represent an insurmountable barrier for poor households. For example, the ACT, adopted by the Government as first-line treatment cost roughly 10 times more than current monotherapy and subsidy can not be avoided if these drugs are to be used at large scale by the population, particularly the poorest.

There i s strong economic and public health rationale for investing in malaria control intervention

54. Malaria control interventions have proved to be highly cost-effective in many settings and studies, exhibiting cost-effectiveness ratios inferior to US$ 100 per Disabil ity Adjusted L i f e Year (DALY) saved. Estimation o f the Project potential impact, using the Marginal Budgeting for Bottleneck tool, showed that we can expect substantial reduction in chi ld and maternal mortality at impressive cost- effectiveness ratios i f the project reaches i t s coverage targets. Our analyses also showed that delivering malaria-specific interventions, along with other effective health interventions that can be delivered through the same mode, and are already present in the country, will have a higher impact but at a negligible increase in cost, when compared to combinations o f pure malaria-specific interventions.

55. care and especially to fighting malaria, and the country’s potential to significantly increase public resources allocated to primary health care, the project financial sustainability i s considered very l ikely. Firstly, the public health expenditure have increased substantially over the past three years and the Government’s effort t o mobilize more domestic revenues has translated into a draft Health Bill submitted to Assembly in 2004 that designate a source o f financing for primary health care. Secondly, the pattern o f public health expenditure, considerably skewed toward hospitals, suggests that more resources can be made available for primary health care in the medium and long term by reprioritizing expenditure among the different level o f care. Finally, the recent debt-relief granted by the Paris Club o f creditor countries guaranties some permanent and predictable stream o f resources that can possibly benefit the health sector, especially malaria control interventions.

Based upon the Government’s strong commitment in the recent past to improving primary health

2. Technical

56. depth analysis o f the sector summarized in a “Country Status Report o n Health” (CSR). T h i s analysis helped to bring to the fore the key issues plaguing the sector, such as the heavy burden o f disease,

This project’s priority areas were tailored to respond to the essential issues identified in the in-

16

particularly malaria, and an alarming picture with respect to chi ld mortality more broadly. This project seeks to reduce Nigeria’s malaria burden to more manageable levels and thereby free-up health system capacity to grapple with other pressing needs and priorities. The project i s also embedded within the Afr ica Regional Malaria Control Booster Program and adheres to technical focus areas outlined in the Booster Program for Malaria Control in Afr ica Framework for Act ion Paper (Working Paper for Donor’s Conference, Paris, September 8-9,2005). Likewise, the project f i t s within the broader framework o f the RBM partnership and builds o n the recent progress in Afr ica to increase coverage o f essential interventions.

57. The project design i s also consistent with the fol lowing findings: (i) an analysis o f bottlenecks that hinder increases in the coverage o f selected interventions; and (ii) a cost-effectiveness analysis that showed that malaria-specific interventions, along with non malaria-specific interventions, have a much higher impact o n chi ld and maternal mortality than the malaria-specific package alone. The analysis used data o n effectiveness f rom the Lancet Series o n chi ld survival and o n neonatal survival and the Cochrane Review and the British Medical Journal paper o n maternal survival. For this analysis, a l l interventions were classified according to the mechanism by which they are delivered and thus according to the inputs and strategies needed for their delivery. Given the context o f Nigeria and the bottlenecks identified, i t was concluded that results would be achieved faster by focusing o n family service and o n outreach or scheduled clinical services. The detailed analysis and findings are in Annex 9.

3. Fiduciary

58. capacity in the Public Sector as weak. Since then, substantial progress has been made, both at the Federal and at the State level, to improve this weak capacity. Through an IDA Credit, the Economic Reform and Governance Project, which has a substantial component o n procurement reforms, and an IDF Grant, the Bank i s currently assisting the Government address this weak capacity and build appropriate partnership with the private sector. Though most o f the required tools (the procurement codes and implementing regulations, national procurement manuals, national standard bidding documents,) are being finalized, most o f the elements therein are being implemented using the provisions o f the revised Financial Regulations. Improvement in public procurement practice has been noticed, and public expenditure has been more efficient and cost-effective.

Procurement. The 2000 Country Portfolio Assessment Review has identified procurement

59. i s currently implementing the Second Health System Development, Polio Eradication and Avian Flu Projects. Therefore, the sector has built some level o f procurement capacity over the years. The Unit managing the ongoing Health System Development in the Federal and selected State Ministry o f Health wil l be responsible for the proposed project fiduciary task, including procurement functions. Therefore the project will benefit f rom the experience already acquired by the personnel o f the unit. However, identif ied areas o f weakness in the health sector included lack o f effective and efficient storage and distribution capacity because o f the size o f the country, when procurement activities were centralized. Annex 8 outlines an action plan and procurement arrangements to address the above and other r isks. They include among others: (i) the recruitment o f organized private sector delivery/logistic organizations and/or PES, where necessary, with proven experience in this area, for the distribution o f LLIN, I R S and SP for IPT; (ii) hiring o f a Procurement and a Logistic Consultant o n a competitive basis where necessary; (iii) to minimize undue interference in procurement process, the Generic Procurement Manual developed for IDA-financed projects in Nigeria and the Bank’s Standard Bidding Documents, will be adapted for use by the project, pending the finalization o f National Procurement Manual and the Bank’s Standard Bidding Documents; and (iv) store records will be computerized, and Project officers will be trained to build their capacity in contract and store management.

The Health sector has had a long history o f implementing various Bank-financed projects, and it

17

60. Assessment (CFAA) (2000) recommendations in January 2005, further supported by a recent PEMFAR, observed that the Federal Government o f Nigeria (FGN) has made a significant effort t o advance reform o f the PFM system since 2003. Major achievements so far have been: (i) the adoption o f an oil-based fiscal rule that has greatly improved the quality o f macroeconomic management; (ii) launching o f significant steps toward increased transparency o f the budget process; (iii) more efficient cash management; (iv) procurement reforms; (v) updating the legal framework for PFM; (vi) reallocation o f budget resources in support o f MDG-related government functions; (vii) strengthening monitoring and evaluation (M&E); and (viii) introducing a more strategic longer-term focus in budget management. This has clearly helped to reduce waste o f public resources, particularly on the capital budget and payroll sides. The impact o f these early measures i s also evident in significantly improved fiscal and broader macroeconomic outcomes. There i s nevertheless s t i l l a long way to go and PFM initiatives and reforms are articulated in the Government’s PRSP - NEEDS, which are supported under the Country Partnership Strategy Cjointly developed by IDA and DFID) specifically through three Bank assisted projects - Economic Management Capacity Building Project (EMCAP), State Capacity Building and Governance Project (SCBGP) and the Economic Reform Governance Project (ERGP).

Financial Management. A review o f implementation o f the Country Financial Accountability

61. Financial management services to the Federal and State level un i ts responsible for the implementation o f the project will be provided respectively through the FM Unit o f the HSDP I1 project and the respective State PFMUs. At the federal level, the Head o f Finance o f the H S D P I I project will provide the technical guidance, support and quality control for effective financial management to the N M C P designated project accountant who will be accountable to the project coordinator o f NMCP. The State PFMUs will designate appropriate professionally qualified accountant with responsibility for the NMCP. As workload necessitates, additional professionally qualified Project Accountants and Internal Auditors will be recruited for the duration o f the project. The FM arrangements for the project are designed to: (i) ensure that funds are used for the purpose intended; (ii) ensure production o f t imely information for project management and government oversight; and (iii) to facilitate compliance by the N M C P and State Focal MPP Units with IDA fiduciary requirements. The overall FM risk in the project i s moderate. Various measures to mitigate FM risks have been agreed, including resolution o f the significant financial management weaknesses tabulated in Annex 7 and implementation o f the actions outlined to strengthen the financial management system. Such measures are also elaborated in the Governance Note for the project prepared by the Project Team and the CMU.

4. Social

62. Malaria afflicts more poor and middle-income households with human suffering causing significant negative impact o n the local economy and community health services. The project design strongly mainstreamed social development issues, while maintaining the agreed national priorities (i.e,, NMCP) in the context o f the Booster Program for Malaria Control. As a country-led project, there was consultation (via meetings, workshops, dialogue, VC, phone calls, etc.), and strong partnerships with a wide range o f stakeholders such as CBOs (Community Based Organizations), NGOs and private sector at a l l levels during the project preparation and more are planned in the future. One major outcome o f the multi-stakeholders consultation which was incorporated in the design o f the project was the strong emphasis o n strengthening efforts to extend care to poor rural areas o f Nigeria.

63. critically about different ethno-medical perceptions and practices; local sociocultural beliefs/perception and the behavioral aspects that influence health and sickness-related issues; the crit ical role c iv i l society could play in al l areas o f service delivery; and the absolute need to engage community members meaningfully in the design and implementation o f the project. Therefore, the project i s designed to strengthen institutional capacity o f the state, as wel l as allowing local government and communities to

The framework that underlies the design o f the project includes the importance o f thinking

18

participate effectively and implement evidence-based and cost-effective malaria interventions. It incorporates various dimensions o f social class, gender, ethnicity and age.

64. The project i s structured to add value and increase efforts o f other human development and Community Dr iven Development (CDD) projects in the country portfolio, since Nigeria has made significant progress in the implementation o f a series o f CDD harmonization policies directed primarily at effective social service delivery, which i s positively imparting poverty reduction including other communicable diseases. I t i s also envisaged that a C iv i l Society Organization (CSO) toolkit and/or project implementation manual would be developed to provide guidance on the choices available to users and the objectives the project wishes to achieve. The project address three key issues o f community participation and sustainability by: (i) promoting accountability and institutional change through civ ic engagement and internalizing participation approaches via robust participatory M&E system; (ii) preserving community and societal strengths by using existing social capital, local institutions and uti l izing community values in promoting equitable and inclusive distribution o f malaria prevention and care products; and (iii) strengthening government capacity to implement socially responsible development policies that link national, states and local economics in health care delivery system.

5. Environment

65. Management. The project has been classified as category B indicating l imi ted adverse environmental and social impacts; given the r isks associated with Indoor Residual Spraying (IRS) o f DDT and other pesticides, and with the handling and disposal o f health care waste.

T w o safeguards policies were triggered by the project: Environmental Assessment and Pest

66. T o address potential negative impact consistent with the requirements o f these safeguard policies, the NMCP has prepared the key safeguard instrument i.e. an Integrated Vector Management Plan (IVMP). In the absence o f a national health-care waste management p lan for Nigeria, an addendum to the harmonized medical waste management plan o f Abidjan-Lagos Corridor H IV /A IDS project was prepared. The additional medical waste expected to be generated i s that related to the diagnosis and treatment o f malaria but i s not exclusive to malaria: needles and syringes, gloves, and glass slides. Although malaria i s not transmitted v ia unsafe handling o f medical waste, the material may be co-infected with HIV, viral hepatitis, etc, so needs to be handled with care.

67. options that are available in accordance with the l i fe history o f the traits o f vector and human activities. The Plan also determines that DDT use for I R S i s an integral part o f the IVMP Program and i s allowed by WHO and the Stockholm Convention. The Bank allows for purchase o f DDT if safeguard policies are complied with. Records also show that I R S can have an impact o n malaria transmission. However, environmental factors, endemicity, costs and limited resources make I R S less than ideal when used alone. Therefore, other vector management methods, including the use o f LLIN and larvicidal agents, will be included in the Plan and evaluated.

In addition to describing the environmental and human health aspects, the IVMP helps select the

68. awareness building to ensure proper and effective implementation. Also important to emphasize are the consultative processes that need to be put in place to ensure that the potentially affected persons and communities are wel l informed, and in a timely manner, as part o f the screening process that will take place at the time o f implementation. The safeguards instruments have been reviewed and approved by Sector Manager (following advice f rom ASPEN staff o n the project team). Disclosure in Nigeria took place o n August 10,2006 and at the Bank’s Infoshop a few days later.

Finally, the Plan makes recommendations regarding capacity-building needs, training, and

19

69. vector-borne diseases within a given locality. In Nigeria, the IVMP Initiative will be applied within the context o f the Health Sector Reform Program and the Init iative will move f rom the older vertical programs to broader systems: grafting specific aspects on to the existing health system. The organizational structure focuses heavily o n "inter-sectoral" collaboration within the public sector and partnership building with others including NGOs, the private sector, and the commercial sector. In parallel with organizational development i s the legislative and regulatory framework for vector control, both o f which are key to ensuring that IVMPs are properly implemented. The IVMP will be implemented by the National Malaria Control Program (NCMP) and the Environmental Health specialists at the Federal, State and local levels, in collaboration with Federal and States' ministries o f environment. The Bank supervision team wil l be monitoring the implementation.

The IVMP works within an integrated disease management framework, dealing with multiple

6. Safeguards Policies

70. and Pest Management. The Integrated Vector Management Plan and the Medical Waste Management Plan were disclosed in-country and the Bank's In fo Shop.

T w o safeguards policies are triggered by this project: Environmental Assessment (OP/BP 4.01)

Safeguard Policies Triggered by the Project Yes N o Environmental Assessment (OPBP 4.01) [X 1 [I Natural Habitats (OP/BP 4.04) [I [XI Pest Management (OP 4.09) [X 1 [I Cultural Property (OPN 1 1.03, being revised as OP 4.1 1) [XI Involuntary Resettlement (OP/BP 4.12) [I [XI Indigenous Peoples (OP/BP 4.10) [I [XI Forests (OP/RP 4.36) [I [XI Safety o f Dams (OPBP 4.37) [I [XI Projects in Disputed Areas (OP/BP 7.60)' [I [XI Projects o n International Waterways (OP/BP 7.50) [I [XI

[I

7. Policy Exceptions and Readiness

71. There i s n o pol icy exception sought. The project complies with al l applicable Bank policies.

* By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas

20

Under-5 mortality rate (per 1,000)

Maternal mortality rate (per 100,000 live buths) % children underweight (under 5 years old)

Annex 1: Country and Sector or Program Background NIGERIA: Malaria Control Booster Project

168 201 151 159 85 39

800 704 800 700

1. Health Outcomes and Performance4

Nigeria i s one o f the poorest countries in Africa, with a GNI per capita o f US$390 (2004). The country ranks at the lowest scale o f the 2005 UNDP Human Development Index, where it places it 158* out o f 177 countries. Despite recent economic growth, largely based o n windfall f rom high o i l prices, around h a l f o f the total population, estimated at 139.8 mill ion, remains poor.

Table 1. Nigeria: Human Development Indicators

Most o f Nigeria’s social indicators fa l l below the average o f low-income and sub-Sahara Af i ican countries (Table 1). At present, one out o f 10 children dies before reaching the age o f one, and one out of f ive before the age o f five. Given the country’s large population, this high Under-Five Mortal i ty Rate (U5MR) implies that about one m i l l i on children under five dies each year, many f rom preventable diseases or f rom diseases treatable at l o w cost. The high MMR and IMR are indicative o f the continuing poor coverage and access to health care in Nigeria. Geographical, income, and ethnic differentials a l l contribute to the substantial inequities in access to health services and health status prevalent in Nigeria.

Communicable diseases, often in association with malnutrition, are the major causes o f chi ld mortality and morbidity and they represent a major health burden for the country. These causes, which are for the most part preventable or treatable at l o w cost, include malaria, neonatal causes, diarrhea, pneumonia, measles, and HIV/AIDS.

Table 2. Malaria-related key indicators, 2003

Number o f reported malaria cases 2,608,479

Number o f households owning at least one ITN

Number o f Under-5s sleeping under ITN

540,278 2.2%

244,486 1.2 %

Source: Nigeria: Health, Nutrition, and Population, Country Status Report, 2005.

This annex i s largely based on the “Country Status Report on Nigeria: Health, Nutrition, and Population,” Report No. 34177-NG, draft. November 2005.

21

2. The Health System

The Nigerian health system i s decentralized under a federal structure. The federal level i s responsible for overall pol icy and tertiary services, the state level for,secondary services, and local governments for primary services. These health responsibilities are tied to funding flows, leading to poor coordination and integration o f the referral program, impeding the connection between primary and f i rst referral services.

Government resources come essentially f rom o i l revenues to the Federation Account, which i s shared between levels o f government based on an allocation formula. However, these resources are not earmarked on a sector-by-sector basis, and state and local governments are not required to provide budget and expenditure reports to the federal government. This considerably limits the effective influence o f the Federal MOH over primary and secondary health services, and state Ministries o f Health (SMOH) over PHC services. Poor coordination between state and local governments, fluctuating funding levels, poor management, and polit ical interference has prevented parastatal agencies and vertical programs to function effectively. Uti l ization o f public health care services i s very low, and there are considerable disparities among regions and between urban and rural areas.

The private health care sector i s a major component o f the health care delivery system, operating about 66 percent o f higher-level medical services and 15 percent o f primary health care services. Although the majority o f private facilities are for-profit, many are not-for prof i t and are mostly faith-based. The Government has recognized the importance o f engaging the private sector in service delivery and i s promoting public-private partnerships, although many challenges remain.

3. Health financing and budgeting

The federal government finances tertiary services, state governments finance secondary hospital services, and local governments support primary health care services. Most offederalfunds are allocated to the main areas o f federal responsibility. Around 66-75 percent o f total expenditures are to cover personnel costs, suggesting that most drug costs are borne by patients. Health spending at state level represents a l o w proportion o f total state spending and seems to be unevenly distributed among regions. Total spending at local level accounts for 10-15 percent o f total government expenditures. L i ke the other two levels o f government, most health spending by local governments i s o n personnel.

Total annual health spending in Nigeria i s estimated at around US$30 per capita, which i s somewhat higher than other countries o f similar GDP per capita. The largest share comes f rom private out-of- pocket spending. Due to the ineffective use o f public health expenditures, public health services re ly heavily o n private financing and household out-of-pocket spending. Private expenditures o n health are very large. They have been estimated at almost US$30 b i l l ion a year, or more than US$23 per capita. Expenditure o n drugs represents the largest share o f household spending, about two-thirds o f per capita expenditure o n health.

Nigeria’s health outcomes are not commensurate with i t s high health expenditures. Most health spending does not go to primary health care and preventive services which provide the most cost-effective means o f improving the population’s health status. Around two-thirds o f federal and state government spending i s allocated to hospitals. I t i s l ikely that most private spending i s not allocated to public health care and preventive services.

22

ACTIVITIES

Annex 2: M a j o r Related Projects Financed by the Bank and/or other Agencies

NIGERIA: Malar ia Control Booster Project

AGENCIES

I. BANK-FINANCED PROJECTS

1 Development o f guidelines for malaria in pregnancy

1 Technical partner leading on case management

Latest Supervision Ratings (Bank-

USAID

WHO

SECTOR ISSUES

9 Health Systems Development I1

o o

Strengthen system management at state level Improve the delivery o f primary health care services, with a particular focus on maternal and child health Strengthen policy formulation and develop a system to monitor health sector performance

o

Economic Reform and Governance Project

o

o

Improve the federal government's economic and financial management systems and processes Establish a reform process o f the federal c iv i l service to improve professionalism and the government's ability to deliver services

H I V A I D S Program Development

Pol io Eradication

Avian Influenza Control and Human Pandemic Preparedness and Response Project

Community-based Poverty Reduction

PROJECTS

Cr. 36530

Cr. 401 1

Cr. 35560

Cr. 37510, 3751 1 Cr. 41600

Cr. 34470

financed projec Development Objective (DO)

M S

MU

s

S

S

only) Implementation Progress (IP)

M S

M S

S

s

S

Ro l l Back Malaria Partnership o Halve burden o f malaria b y 2010

DFID, Global Fund

. Development o f national strategy for ITN, M&E, support for coordination and communication between agencies, and between agencies and commercial stakeholders

23

PDO

Annex 3: Results Framework and Monitoring

NIGERIA: Malaria Control Booster Project

Project Outcome Indicators

Results Framework

(i) Increase access to, and utilization o f a Malaria Plus Package o f Interventions (ii) Strengthen Federal and States ability to

The M&E framework, which has been developed o n the basis o f extensive consultation with the NMCP and the relevant RBM partners in Nigeria, will focus on developing information systems to measure output indicators that track activities carried out by the project, the quality o f services, and their outcomes (ie., access to, and utilization o f MPP, and maternal and chi ld protective behaviors). I t will also develop a management cycle for using information recurrently for management decision-making. Implementation o f the M&E system will be a team effort requiring the commitment o f the federal and State MOHs, the private sector, and the PIFs, where contracting such entities i s required. The project i s divided into two main components, the f i rst one aims to strengthen the capacity o f the Federal Government through a contract with a M&E Agent, and the second one aims to strengthen the State level health system that involves public and private sectors, and includes service contracts with PIFs o n an as-needed basis.

Increase access to, and utilization o f the Malaria Plus Package o f Interventions b y year 2010: o Percentage o f children < 5 years wi th fever treated with an effective

antimalarial wi th in 24 hours Erom onset o f symptoms o Percent o f infants aged 0-6 months who were fed breast milk only in the

last 24 hours

At thefederal level, a contracted M&E Agent will assist the M&E Unit o f the NMCP to strengthen i t s capacity to aggregate, analyze, and report to decision makers in an accessible, rapidly usable form; additional information will be collected by the disease surveillance and anti-malaria drug efficacy trials carried out by the NMCP. At the State level, the PIFs will strengthen the M&E o f the State health system that will emphasize the use o f data for monitoring and evaluating implementation strategies and process indicators.

Intermediate Outcome Indica tors

Intermediate Outcomes &

outputs

Use of Intermediate Outcome & Output

Monitoring

o Percentage children < 5 years who slept under an ITN the night preceding the survey

o Percentage o f pregnant women who received two or more doses o f IPT

manage and oversee delivery o f malaria plus interventions

Use of Project Outcome Information

Monitoring progress in meeting National Malaria Strategic Plan integrated to an expanded package, and revising strategy to better meet MPP objectives

o Percentage o f pregnant women who slept under an ITN the night preceding the survey

o Percentage o f States regularly using M&E data to manage malaria and or M C H Programs

Component I: Strengthen the capacity of the Federal Government to provide malaria control leadership and coordination over the medium and long-term.

(a) Strengthening procurement and logistics of commodities for accelerated implementation of the malaria

24

Output: Improve the availability and continuous provision o f drugs for effective case management and treatment of malaria among project target population

Output: Distribution of preventive and treatment supplies (ITN, LLIN, SP) to target sites (public and private)

Outcome: M&E systems in place, producing outcome and quality indicators, and decisions are project mangers are making decisions based on results

Output: M&E system developed as a dynamic management tool

Outcome: Sustainable MPP Control i s achieved through capacity building and active participation o f implementing agencies and stakeholders

Number o f pediatric doses of ACT distributed to LGA distribution sites per 10,000 children under 5 years of age by state, and health facility (public and private)

Number of distribution sites for pediatric ACT per 10,000 population, and percentage of distribution sites with no pediatric ACT stock-outs in last 3 months prior to the HFA

Number o f ITNILLIN and doses of SP distributed to LGA distribution sites per 10,000 population by service type (public and private) Number of ITN/LLIN distributed to children 4year of age during immunization sessions (IPD) Number of distribution sites for SP and ITNILLIN per 10,000 population by State and type o f health facility (public and private); and percentage of these distribution sites for SP and ITNILLIN with no stock-outs in the last 3 months (ITN/LLIN will be stocked differently to the SP)

Data validation system in place for M&E data collection and utilization Population based surveys and HFAs carried out. NMCP with the assistance of the M&E Agent, triangulate the information from population based studies and HFA for national level policy making M&E data used at least annually to modify and improve annual work plans for the National Malaria Control Program Annual reports of project attainments are produced and submitted to donor and collaborating agencies Number o f trainings on M&E carried out by the NMCP A National M&E Framework and operational plan developed and endorsed by the Federal MOH The M&E Operational Plan i s carried out

I the ros

Annual Results for Health forum i s convened to share achievements, lessons learned, identifying barriers for expanding access and utilization o f services and identifying best practices Percentage of State and LGA Malaria Boards convening regularly for efficient coordination, as an expression of the national level commitment

Indicator of availability of supplies and its continuity Assess number of cases observed and treated by type of health facility, health workers and target population

availability of supplies and unintempted distribution Assessment of the storage and distribution system, identify bottle-necks

Indicator o f

Systematic and uninterrupted collection o f outcome data for improving access, utilization and quality o f services’ delivery

Assess the implementation of the M&E system at the national level with the assistance of the M&E Agent Ensure the development and utilization o f standard protocols and job aids by the State level health system (public and private)

Share results and lessons learned by implementing partners Disseminate new approaches and technologies

25

Output: Technical leadership and human resource capacity at all levels of the health system are strengthened and fostered by the NMCP

Outcome: MPP activities (ITN, LLIN, IPT, IRS, ORS, EBF and Immunizations) have expanded and protective behaviors embraced by the population

Output: MPP preventive activities have been expanded to the State level by public and private implementing partners

Outcome: Case management and effective treatment of malaria among children below 5 years are improved

Number o f effective communication strategies developed and implemented Percentage of management problems raised by PIFs effectively addressed by coordinating unit(s)

Percentage o f households with at least one ITN/LLIN Percentage o f pregnant women who slept under an ITN/LLIN the night preceding the survey (LQAS) (See PDO) Percentage of children <5 years of age who slept under an ITN/LLIN the night preceding the survey. (See PDO) Percent of children aged 0-23 months with cough and fastldiffcult breathing in the last two weeks who were taken to a health facility or received antibiotics from an alternative source Percent o f children aged 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids (RHF) Percent of infants aged 0-6 months that were fed breast milk only in the last 24 hours (See PDO) Percentage o f children <1 who are vaccinated with the DTP3 and measles vaccine Percent of women with children 4 year of age who received an ITN/LLIN during last pregnancy Percentage of pregnant women who received two or more doses o f IPT.

(See PDO) Percent of women with children <1 year of age who received ANC care

Number o f ITNILLIN distributed by distribution points (public and private) Number o f ORS packages distributed by type of health services (public and

Number of pregnant women who received ITN/LLIN by type of service

during last pregnancy

private)

provider (public and private)

Percentage of health facilities who treated children <5 with febrile disease with an effective antimalarial using the IMCI protocol by type of health service (public and private)

1 Assess participation of all implementing partners and how are collaborating towards common goals

1 Indicator to show access, coverage and utilization of preventive services

To assess performance of service delivery partners, to identify barriers and propose solutions to meet project objectives

To assess whether public and private implementing partners are including MPP into their regular programs

Early warning of effectiveness o f scaling up treatment approach, from IECBCC, to service providers capacity, to drug procurement and distribution Reviewing

management performance, identifying blockages and undertaking remedial actions to meet the objectives

26

Output: Quality o f services maintained at treatment sites

n Outcome: Prevention activities (MPP) have expanded and risk reduction behaviors embraced by the population

Outputs: Social communication and B B C activities carried out

Outcome: M&E system in place and functioning

Output: M&E system developed as a dynamic management tool

other resources for

Output: Technical leadership and human resource capacity at a l l levels o f the health system are strengthened

Number o f health workers (private and public) trained to treat w i th ACTS and priority I M C I by state, health facility and type o f health worker Number o f patent medicine vendors/ TBAdvil lage health workers trained per 10,000 population as per a specific training curriculum to be determined

Percentage o f children who received ITNILLIN during IPD campaigns Percentage o f children with fast or difficult breathing or chest in-drawing who were treated for pneumonia Percentage o f mothers and caretakers who know the dangers signs for malaria, pneumonia and diarrhea signs and symptoms and when to seek

Number o f radio broadcast at the State and LGA levels (public sector, PIFs and other implementing partner) Number o f community organizations functioning and supporting the States.

nc State level M&E system in place lead by the SMOH and in close collaboration and coordination with implementing partners and PIFs, if necessary M&E data used at least annually to analyze and use the information to modify and to improve annual work plans for the SMOH, the State and LGA implementing partners Percentage o f State and LGAs implementing partners using M&E data to manage their MPP Project and to report results to SMOH A State M&E Framework and operational plan developed and endorsed by the State M O H

Assess the implementation o f the clinical delivery mode and performance

Maximize resource utilization among implementing partners and integration o f services

Assess channels o f communication and mass media strategies, and coverage o f messages on the target population

Recurrent collection o f information for decision making to manage the program based on quality data

Assess management activities implementation

Number o f community projects funded for malaria control under other sources o f funding

I

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31

Background

A draft M&E conceptual framework was prepared by the NMCP during March 2006 and was revised in June 2006. The major revision consisted o f organizing the project in two components; Component 1: Strengthen the capacity o f the Federal Government to provide malaria control leadership and coordination over the medium and long-term; and Component 2: Strengthen the health system to improve delivery o f the Malaria Plus interventions in the target states.

Contracting an M&E Agent at the federal level has also been agreed to by the NMCP. The N M C P i s currently preparing a TOR for the service contract.

The participation o f PIF in strengthening the State and LGA M&E systems, o n an as-needed basis, has been agreed to by the NMCP. Also, the N M C P has agreed to include al l other implementing partners at the State and LGA levels. The S M O H in each state contracting out the M&E function to a PIF, working with the NMCP, will prepare the TOR for the service contracts.

Currently, ITN and antimalaria drugs storage and distribution to the States, LGA and service providers are in a state o f flux. The N M C P has agreed to strengthen the system and hire an external consultant, who will assist in strengthening the system and the capacity to operationalize it at a l l levels, assist the program to monitor the supplies on a quarterly basis based o n forecast and establishing the minimum and maximum quantities required at the service delivery level.

Currently, there are n o regular supervision visi ts by the State MOH to the LGA, nor f rom the LGA to health facilities, and also n o systematic data collection and analysis. I M C I and Reproductive Health have included malaria in their management protocols, but their health facil i ty registration forms do not include information about malaria cases.

Health facilities in general, do have logbooks for recording malaria cases, but are not used systematically for analysis o f the cases, nor for reporting on the number o f cases seeing by the health facility.

The N M C P in collaboration with the GF have developed reporting forms for ITN and A C T distribution that are sti l l on a trial basis.

Monitoring and evaluation o f outcomedresults

72. Outcome indicators will be collected on an annual basis using a rapid population base survey, starting with baseline information at the initiation o f the project. The baseline survey, using the LQAS methodology, i s currently underway in the seven participating states as wel l as in two control states. The results o f this survey are expected to be ready in early December, 2006 and will be used to measure progress in project implementation and support local and national level decision-making over the l ifetime o f the project through the proposed annual follow-up surveys. As a direct consequence o f the baseline survey, capacities have been built up in the participating and the control states to undertake the annual surveys using the LQAS methodology. Outcome indicators will be collected at the State and LGA levels with the assistance o f the PIF, as required; also, public and private sectors will participate in data collection and analysis at feedback o f the information to local communities and stakeholders. The role o f the FMOH and the M&E Agent will be to oversee the overall design and sample selection; monitor and ensure the quality o f the data collected and entered into a software package; and to carry out an overall analysis, triangulating information f rom population-based data, health facility and other methodologies that may apply. The same process will be utilized for HFA that will include assessment o f the quality o f

32

the services provided (possibly through exit interviews or direct observation o f services delivered) and o f the logistics and distribution systems.

Output indicators will be mainly the SMOH’s responsibility with the assistance o f PIFs and local implementing partners. It i s expected that the State level partners develop an expanded M&E team whose main function will be to collate information f rom the different sources and partners, so the S M O H could assess the overall implementation o f the project for the state. The NMCP and M&E Agent’s main responsibilities wil l be to oversee the overall implementation o f the State level health systems, the quality o f the information, and collate information f rom a l l states to produce the overall project information. The frequency o f data collection at service delivery points i s daily with monthly summaries that will be sent to the next level for data collation and analysis. LGAs and S M O H wil l collate and report o n a monthly and quarterly basis. Mos t o f the outcome indicators will be used for tracking project progress to the FMOH and the Wor ld Bank.

The graphic below depicted the methodologies and data collection tools currently developed and implemented, and those that will be developed during the l i fe o f the project.

MALARIA CONTROL BOOSTER PROJECT LIFE LINE

j 2005 j 2006 j 2007 j 2008 i 2009

Su6velllance diseake surveillance/and antimalani drug efficacy trials I I’

IHS 0 3 I -

I / - Househojd-based s w f e d LQAS I I / I I I 111

Health fpcility assessmdnt LQAS

Special jstudi esioperatiqns research m j m j II

- j - j DHS08

I

II

2010 ~ 2011

Health Management Information System (HMIS)

At the LGA level, health services need to adapt or to create new logbooks to include information about MPP interventions. The current system i s not providing any regular information. In addition, the forms need to be revised (or to be developped if do not exist) to integrate childhood and maternal program interventions to include ACT, ITN and IPT service delivery. In addition, the S M O H with the assistance o f the PIF will have to harmonize one system for the private sector, including information f l ow and levels o f analysis and decision making.

The H M I S at service delivery points will also serve for supervision purposes. For instance, every supervision visit will include the review o f the logbooks, emphasizing target groups to see how services were provided, how the diagnosis was carried out, and the treatment according to the diagnosis. The

33

supervision team could also carry out a random home visits or to those families that would require fo l low UP.

The LGA M&E focal person needs to collate the information that come f rom health services into one summary form for the LGA, including the private sector; and the M&E focal person at the State level needs to collate the information f rom a l l LGA. The S M O H will be assisted by the PIF to monitor these efforts at the LGA level through HFA, wil l develop a training curricula and training p lan for health workers at a l l levels, and involving the private sector. Whi le the Project will aid the Federal MOH to develop the forms needed for the HMIS, i t will not be directly engaged in implementing this system.

The current maternal health card needs to be revised to include ITN and IPT. The project will support the creation o f logbooks as a means to enhance supervision o f health facilities by the States with support, where required from the PIF. I t will also support the redesign o f the maternal health cards.

The role of PIF, where their services are required, wi l l be to strengthen the HMIS for supervision of health facilities 'performance. The M&E Unit wi l l develop a supervision strategy geared to in-service support, data analysis, and feed-back.

Logistic Management Information System (LMIS)

The L M I S will be strengthened at the Federal and State levels. A logistic support specialist will be hired to oversee the overall L M I S from port o f entry to service delivery points. I t i s expected that f rom port o f entry, commodities will go straight to the States. The logistic support specialist's main responsibilities will also be to assist the N M C P to standardize requisition and reporting forms by levels; and if needed, oversee the development o f a software package. These forms will track the transmission o f commodities f rom the port o f entry in Nigeria through to the lowest level distribution site. Finally, the logistic support specialist will assist to monitor the stock situation in the country o n a quarterly basis and assist the in forecasting the requirements o n an annual basis.

At the State level, the logistic management information system (LMIS) will be supported by the S M O H with assistance, as required, f rom the PIFs. The Federal level will oversee and ensure that al l States, along with the PIFs, are standardized and have compatible systems. The SMOH, with assistance f rom the PIF, are expected to develop innovative mechanisms to distribute project commodities through public and private partners, including PMV and community organizations. Since ACT and ITN have individual characteristics, the L M I S will vary accordingly.

(a) Artemisin-Combination Antimalarials (ACT)

Procurement and distribution of ACTS will be as follows with al l transactions being recorded in the L M I S :

A C T procurement will be done by the Federal Procurement Office. Thereafter, the States, assisted by PIFs as necessary, will take delivery o f ACT and deliver them to the States and LGA distribution sites. The States will also distribute ACT to their sub-contracted partner institutions at the LGA level; and local partner organizations o f the S M O H will distribute A C T to service delivery points they support (i.e,, health clinics, health centers, NGO clinics, dispensaries, PMV, etc.). Each organization i s responsible to report o n the commodities it receives and delivers elsewhere.

1

34

Each transaction will be recorded. Any organization distributing ACT after taking possession will inform the supplying organization o f these transactions. That is, service delivery points will in form local partner organizations at LGA or State levels as appropriate. The States, assisted as required by the PIF, will in form the project Procurement Consultant at the federal level and the M&E Agent.

Public sector health facilities should report A C T utilization through their o w n mechanism: service delivery points + LGA focal person + State level focal person 3 Federal level. The States will be supported to strengthen the current system, but they cannot use it for Project management as it i s not providing regular or reliable information. However, as it becomes established, the Project L M I S can persist and can be used by the S M O H at project end. This particular component i s more properly l inked to the H M I S which i s reported elsewhere in this section.

Procurement o f ITN/LLIN will be through the project Federal Procurement Office. The States, and their contracted PIFs, can obtain LLIN through international suppliers as determined by the Bank’s procurement procedures. The States with assistance f rom the contracted PIFs wil l be required to track the distribution o f ITN from the point they take delivery. F rom there on, the L M I S will fo l low the system as described for ACT.

(c) Reliability Assessments of LMIS and LQAS Data

The Logistics’ consultant will assist the N M C P to take a sample o f L M I S data twice a year f rom the States and assess the accuracy o f the information.

Population-Based Studies - LQAS

L o t Quality Assurance Sampling (LQAS) will be used by State, LGA and PIFs to assess the status of key outcome indicators in their catchments’ areas. LQAS i s a sampling method adapted f rom industrial quality control methods. I t s key feature i s that, by using a small sample clients in the population, a local manager can judge whether a pre-determined coverage target has been reached. This rapid assessment method will complement existing epidemiological surveillance work by the NMCP by judging whether the behavioral targets in the population are being used for P T 2 , ITN use and ownership, treatment o f febrile children and the like. The benefit o f this approach i s that the same information which local managers collect and use to assess their programs locally can be aggregated to calculate coverage proportions at the State and federal levels.

The collection activities will include:

.

. . Sampling o f a sample o f the Project’s catchments areas (LGA) using the Large Country -- L o t Quality Assurance Sampling (LC-LQAS) methodology. Information by State with Federal aggregation for reporting purposes. Analysis o f the results by the State M&E Expanded Team (SMOH, LGA health team, PIF, and the private sector), geared to decision making and planning for improving the Project’s interventions.

The frequency o f these data will be annually, according to the NMCP needs. For more information, refer to the LQAS Detailed Implementation Plan. The only deviation f rom this plan will be for the Baseline Survey, which i s currently being undertaken and i s expected to be completed by December 2006.

Regarding the scale at which LQAS has been used in the past; in a recent global review done by WHO and the WB, LQAS has been carried out in population catchments’ areas ranging in size f rom 900 t o

35

1.2 b i l l ion people (Zhao, et a1 1999). In Uganda it was used in 30 districts comprised o f approximately 6 supervision areas each. This means that approximately 30 x 6 = 180 teams were trained to carry out the LQAS in Uganda to assess the H IV /A IDS program.

Health Facility Assessments (HFA)

Sampling methods will also be used to select a set o f facilities in the project site to determine whether their treatment and service provision i s consistent with that o f the FMOH. Public and private implementing partners will also be included in this assessment. HFA will be carried out annual to identify the technical weakness in the quality o f programs and to plan continuing education programs and supervision to improve the s k i l l s o f the health staff. The objective o f this M&E component i s to establish an efficient evidence-based approach to assess supply-side factors that can influence both demand and behavior change, and then to ameliorate problems when detected. The LQAS method has been adapted for sampling Health Facilities and PVM.

Operations Research and Special Studies

The project will reserve funding to support either the D H S or M I C S should one be carried out in Nigeria during the l i fe o f the project. The funds will be directed toward over sampling in the project area as a means to cross validate the reliabil i ty o f the project’s M&E system. The M&E system will attempt to develop as many user friendly approaches as possible. T o facilitate data entry many components o f the M&E system wil l test on an experimental basis PDA and/or optical readers for entry o f LMIS, LQAS and HFA data. An M&E Task Force o f the N M C P will be charged with vetting additional Operations Research studies. Pooling Methods may be an ideal way to test for ACT drug resistance. The idea behind pooling i s that when looking for a drug resistance individual by testing samples such as blood - rather than test each individual separately, one can form a pool o f b lood samples and then test the pool with a single test. With a perfect test, if the pool tests negative, then one can conclude that everyone in the pool wil l test negative if tested individually, and thus one will achieve in one test what will ordinarily take a number o f tests (however many are in the pool). If, o n the other hand, the pool tests positive, that means that at least one individual in the pool i s resistant. Then one can reduce the size o f the pool, ha l f it, say, and reconstitute it, and retest. The advantages o f pooling i s that in a l o w prevalence situation, with many fewer tests than required by individual testing, one can achieve higher accuracy (lower false positives and lower false negatives) than with individual testing. Together with Biostatisticians at the Harvard School o f Public Health who have developed this approach, Pooling Methods will be appraised to assess ACT drug resistance in the project area. Given that bloods have already been drawn to test for malaria parasites, the incremental costs o f testing, if pooling i s used, should be cost effective.

National Population-Based Survey - DHS

The national population surveys, such as D H S and M I C S or Malaria Indicator Survey, can be potentially used by the project to measure a l l cause mortality in children under 5 years o f age. In Nigeria, the latest D H S was carried out in 2003 and the next one would not be due until 2008 at the earliest, but there i s n o certainty o f i t s occurrence, or which survey methodology wil l be chosen. Nevertheless, if D H S or a similar study i s carried out around the end o f the project, project managers will discuss the possibility o f sub sampling the project states to examine changes in the under fives mortality rate.

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Arrangements for Results Monitoring

This section discusses the institutional and data collection arrangements for integrating monitoring and evaluation at the outcomeh-esults level into project management.

Institutional issues

Monitor ing and evaluation i s viewed as fundamental to the management o f the Project. An M&E Operational Plan for both components will explicitly describe how the M&E will be carried out and will include an agenda, the responsible units, the existence o f reporting forms, and an M&E budget. These two documents will be used to manage the project’s M&E and ensure that i t supports the National MPP Strategy Plan. Baseline outcome and output indicators wil l be used by management to review the priorities o f the NMCP. Additional priorities or modifications wil l be made based o n the M&E data obtain through the Operational Plan.

M&E output data will form the basis o f a year-1 review and then semi-annual work-plan reviews thereafter. The purpose o f these meetings i s to appraise the status o f activities using these data, and make tactical and strategic changes as needed.

Where S M O H capacities for effective M&E need to be strengthened, the PIF will p lay an important role in developing, maintaining, and institutionalizing a decentralized M&E system at the States and LGA. Their contracts or sub-contracts will specify the roles and responsibilities to implement the M&E subsystems (Le., LMIS, HFA, LQAS). The PIF wil l also be responsible for assuring the use o f M&E data for program decision-making and the strengthening o f the M&E public system through technology transfer and mentoring. Where such capacities exist at State level, these responsibility wil l l ie with the SMOH.

Outcome indicators collected annually using LQAS will form the basis for project review meetings. The purpose o f these meetings will be to determine changes to program tactics and strategies to improve access, coverage, and use o f protective behavior. In order to ensure State participating in the M&E, they will participate in the annual review meetings to interpret results, underlying problems and recommend tactical changes for the coming year.

At the federal level, the project will have an M&E Agent with the main role o f strengthening the M&E Unit to oversee that the project objectives are o n track, that the services are reaching the target groups, and that the M&E data reported by the StatesRIF are reliable.

Each State and LGA will have M&E and malaria focal persons, who will be assisted, as necessary by the PIF. Their responsibilities will be to coordinate M&E and capacity-building activities and to involve the private-for-profit and non-profit sectors. They will also streamline key program indicators f rom local stakeholders, analyze data, and recommend tactical changes to programs. They wil l also forward information to more centralized levels o f the system.

Each PIF, when contracted, will be asked to present semi-annual progress reports. These reports will contain consolidated information f rom their local contracts (NGOs, CBO, FBO, PMV, etc.), analyzed, and presented to the State authorities, to the PIU, and ultimately to the Wor ld Bank. Where PIFs are not contracted, the S M O H will take o n this responsibility.

In the case o f LQAS, public sector M&E focal persons and the States with assistance f rom the PIF will analyze the data based o n key outcome indicators disaggregated to the State level. In order to maximize

37

learning by doing, stakeholders will organize a State and LGA M&E Expanded Teams, which will include public and private partners and the PIF. The M&E expanded teams will analyze and interpret State-level data, and feed-back results to LGA. The main purpose o f the M&E Expanded Teams will be to develop learning networks to share results and to cany-out jo in t problem solving.

Engaging local communities

Local communities will be engaged as necessary to aid health professionals to interpret M&E data and solve problems. Nominal group methods will be used to solicit the advice and input o f communities as part o f this diagnostic work. The M&E expanded teams may choose to use rapid and qualitative assessment methods to expand or complement the information collected by the above described methods.

Technical assistance for M&E

1

1

1

The reliabil i ty o f data streams will be assessed by the M&E focal persons with support f rom the M&E Agent. The vector resistance surveillance will be supported by international stakeholders; e.g. CDC. This work i s not supported directly by the Project. The D H S will be managed by an external contractor specialized in carrying out these surveys. The Project may provide modest investment into the D H S and request the D H S to over-sample and disaggregate the data by the project states. Capacity building will focus on: . o Finalizing the national M&E framework and operational p lan o L M I S o HFA o LQAS o Improving case logbooks at health facilities as a medium for supervision.

Capacity

The current M&E capacity in Nigeria i s limited, particularly at the State and LGA levels. I t i s very l ike ly that substantial amounts o f capacity building will need to take place, which will be undertaken by the PIF, as required. Competency-based approaches will be promoted so that a l l training i s associated with systems developing, data collection, analysis and decision-making, and quality o f care. The PIF wil l have

education. This strategy has the implication that the PIFs wil l include capacity-building costs within their budgets.

, a mentoring role in order to build the local M&E capacity that i s based on hands-on rather than didactic

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A First-Year Agenda for M&E

Activities and Tasks Start-and- 1 End Responsible(s) I Costs in US$ 1

persons Tra in State and LGA malaria officer and M&E focal persons in data collection, analysis and decision making

Support Development Malaria H M I S Forms and their Field Testing

c.

6.

a.

b. c.

F ie ld test the HMIS forms in 3 LGA in three different states Assess the f ield testing exercise Develop scaling up strategy for a l l LGA in the 7 selected States

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A n n e x 4: Deta i led Project Description


Project objectives

The Project Development Objectives (PDO) are: (i) to ensure that the targetpopulation wi l l have improved access to, and utilization of well-defined package of Malaria Plus (MPP) interventions; and (ii) strengthen Federal and States ability to manage and oversee delivery of malaria plus interventions. These interventions consist o f key maternal and chi ld health interventions that can potentially double the impact on morbidity and mortality, with only a marginal cost increase as compared to the malaria-specific interventions alone, as outlined in the Economic and Financial Analysis (Annex 9). As a result, the program wil l leverage the shared modes o f delivery o f the MPP interventions and generate synergies between them, thereby maximizing the impact o n maternal and chi ld health indicators.

The matrix at the end o f this annex describes a l l interventions that are included in the MPP and supported by the program. All interventions are classified according to the mechanism by which they are delivered and thus according to the inputs and strategies needed for their delivery. The delivery modes are categorized into: (i) Family/ community based care: (ii) Population oriented services; and (iii) Clinical based individual care.

Family/ community based care: These interventions, which include some preventive measures and the management o f maternal and childhood illnesses, can be delivered by the households or the communities themselves under some guidance by health professionals. Insecticide treated bed nets (ITN) for pregnant women and children under five, condom use, breastfeeding, and oral re-hydration therapy (ORT) are some examples o f interventions that are fami ly or community based.

Population oriented services: These services are delivered to a l l the population, regardless o f whether or not they are currently sick. They are usually delivered through periodic outreach or scheduled clinical services. This delivery mode includes the fol lowing preventive care interventions: immunizations, antenatal care, family planning, etc.

Clinical based individual care: These activities include a l l type o f individual curative care interventions that need to be delivered o n a health facility and by a trained health care professional. They are offered in a continuous manner so that they can respond to unpredictable situations: a sudden illness, a delivery, etc.

The project i s consistent with the goals o f Nigeria’s Strategic Plan for RBM, which gives pr ior i ty to pregnant women and children under five and targets those with the worst prognoses when infected by malaria. In Nigeria, three out o f ten children and two out o f ten pregnant women die f rom malaria related complications. Malaria infection also contributes to the high numbers o f adverse pregnancy outcomes, which makes this group particularly vulnerable. I t thus makes both technical and economic sense to target pregnant women and children under five with tailored interventions through the project.

The following key indicators will be used during project implementation to measure the extent to which coverage o f key interventions and impact are achieved:

Percentage o f children < 5 years with fever treated with an effective antimalarial within 24 hours f rom onset o f symptoms Percent o f infants aged 0-6 months who were fed breast milk only in the last 24 hours Percentage children < 5 years who slept under an ITN the night preceding the survey

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Capital UYO

Percentage o f pregnant women who received two or more doses o f IPT Percentage o f pregnant women who slept under an ITN the night preceding the survey Percentage o f States regularly using M&E data to manage malaria and or M C H Programs

LGAs Km est. pop. 31 7 081 3 722 605

Target population and geographical coverage:

Kano

The project will target seven o f the states allowing for a significant scale-up (boost) effect in each state. The selection o f these states was the result o f a consultative process in which due consideration was given to one or more o f the fo l lowing criteria:

44 20 131 8 978 865 Sub Total 20 145 696 TOTAL 33 115 704

Mortal i ty rate among under-fives exceed 260/1000. Access to effective primary health care services i s poor to non existent (based on access within 5 lulometers). Access to secondary facilities i s very poor or non existent (based o n required travel time exceeding ha l f a day). The States have demonstrated commitment to implement (i) large scale campaigns to cut child- mortality and/or (ii) a comprehensive malaria booster program. Documented Plasmodium Falciparum resistance to chloroquine and SP (the f i rst l ine treatments in use) exceeds 85 percent. An implementable State-Level RBM Strategic Plan for malaria control (based o n federal guidelines and internationally recommended best practices) exists. N o other significant donor a id for malaria control i s currently available.

On this basis, the selected states are: Northern states: Kano, Jigawa, Gombe, Bauchi Southern states: A k w a Ibom, Rivers, and Anambra.

Southern States

Northern States

: Source: Boundaries

State Akwa I b o m Anambra Rivers

Bauchi Gombe Jigawa tKano

ippropriations

Table 1: Data on selected states

I No. o f I Area Sq. I2006

Awka Port-Harcourt

Bauchi Gombe Dutse

4 320 963 4 926 440

21 23 I

64 605 4 422 336 2 301 044

23 154 4 443 452

:ommission, Nigeria.

The identified set o f Malaria Plus interventions will be implemented in a l l recipient states. Promotion o f LLIN use will be the primary method o f vector control as outlined in the National strategy. Indoor residual spraying will be used in selected areas and in eligible households (Criteria o f eligibil i ty are spelled out in the 2006-2010 strategic plan). All pregnant women will have 2 doses o f IPT with SP free and at n o cost. Rapid diagnostic test k i t s (RDTs) will be used on a pi lot basis for malaria diagnosis before large deployment. RDTs are not recommended for children under five. Children under five will receive free Artemether-Lumefantrine (AL) through public sector and faith-based health facilities.

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Project Components

The fol lowing principles will guide the course o f project execution:

Capitalize on existing structures and delivery modes in an integrated manner with national programs and development partners for extensive scaling-up o f the RBM interventions (or Malaria Plus package) to achieve the desired coverage in the target population. Build on the capacity of all sectors to promote competition, innovation and public-private partnership. To achieve the program objectives, NGOs and other private sector entities will be contracted to support program implementation and strengthen program management capacity at Federal, State and Local levels. Focus on most vulnerable segments of the target population. Locally appropriate pro-poor targeting methods will be developed though subsidy schemes and other means. Adopt a “learning by doing” approach during implementation. This approach will be facilitated by the enhanced capacity o f the monitoring system that the program wil l advance.

The project has two main components and i s further divided into nine subcomponents:

Component 1: Strengthen the capacity of the Federal Government to provide malaria control leadership and coordination over the medium and long-term.

(a) Strengthening procurement and logistics o f commodities for accelerated implementation o f the

(b) Improving National Monitor ing and Evaluation for evidence-based management; (c) Coordinating program activities at the national level and across programs.

malaria plus interventions;

Component 2: Strengthen the health system to improve delivery of the Malaria Plus interventions in the target states.

(a) (b) (c) (d) (e) (f)

Increasing access to, and utilization o f preventive measures; Expanding access to, and utilization o f effective diagnostic and treatment services; Strengthening community mobilization and Communication for Behavior Change; Improving state-specific M&E for evidence-based management; Strengthening partnerships for resource mobilization and implementation; Enhancing capacity o f the states for oversight and project coordination.

I I

Component 1: Strengthen the capacity of the Federal Government to provide malaria control leadership and coordination over the medium and long-term. (US$86.5 million).

The Federal Government i s committed to delivering the Abuja targets on Malaria Control. However, i t requires additional support to develop necessary policy, to coordinate efforts o f donor agencies and funding streams, to engage in a meaningful way with the private sector including NGOs, to carry out central procurement for key commodities, to monitor and evaluate program performance, and to plan and commission operational research. T o support the ability o f FMOH staff to undertake these essential roles, the project will deploy technical assistance targeted to the NMCP. T h i s component will support:

(a) Strengthening procurement and logistics of commodities for accelerated implementation of the malaria plus interventions

Malaria control i s a commodity-intensive endeavor, and an important aspect in project coordination and implementation will be procurement and supply-chain management at a l l levels. The project will support

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strengthening the procurement systems that ensures continuous supply o f central procurement of key commodities. The project will finance procurement o f LLINs (2 per household in the target population), A C T for Children <5 years (Artemether-Lumefrantine -a), IPT (Sulphadoxine-pyrimethamine (SP)) for pregnant women, insecticide and spray pumps for R S where applicable, IM Artemether for advanced malaria, spray pumps and insecticide for the indoor residual spraying. The project wil l finance a l imited number o f RDTs for pi lot studies only. According to Government Strategy, RDTs will not be used for children < 5 and will be used on a pi lot basis for other groups. In addition, given the possible bottlenecks involved in procuring malaria commodities and distributing them to the states and LGAs (See Component 2 below), the Project will finance technical assistance to the NMCP in procurement and logistics management o f malaria commodities.

The cost of malaria commodities wi l l be part of the Federal component and wi l l not be passed on to the states through on-lending. I t will use and reinforce existing capacity o f the FMOH to carry out procurement. A full-time procurement officer has been placed at the federal level for the duration o f the project t o assist the N M C P in procurement. The procurement specialist will thus be entrusted with the critical task o f carrying out procurement in accordance with the IDA Credit and with the Wor ld Bank guidelines. He/She wil l work under the guidance and supervision o f the procurement specialist workmg under the HSDP I1 unit o f the FMOH.

In addition, a well-organized logistical supply chain f rom the central purchasing team at the FMOH to the States will be ensured under the project. For that, the project will finance a technical assistant in logistics management who wil l report directly t o the NMCP Director. The consultant will work in close collaboration with the procurement staff, S M O H and the PIFs, where contracted, to ensure the logistical supply chain o f project commodities f rom the central purchasing team at Federal level (at the point o f port clearance) to state level storage facilities. The NMCP will be accountable for effective co-ordination with the States to monitor utilization o f commodities. I t wil l provide the States and the PIFs standardized templates for recording stock usage and making quarterly supply requests. The provision o f adequate training to the Project Procurement Officer at N M C P will also be required in order for the NMCP to take over the procurement function at the end o f the project.

(b) Improving National Monitoring and Evaluation for evidence-based management

The M&E Unit o f the N M C P i s new and in need o f strengthening. Data received through the recurrent health information system are incomplete and exhibit substantial reporting delays and gaps. Medical records in health facilities are also incomplete and unreliable. The RBM i s an outcome-driven program and thus the FMOH will need systematic and regular M&E aggregate data f rom the States to assess the status o f the overall process, introduce program and pol icy changes as needed.

This component will assist the M&E Unit o f the NMCP to further develop an M&E system for the malaria program. It will provide the fol lowing types o f information for project management and outcome evaluation: (i) regular assessments o f inputs and processes related to the malaria program, including the tracking o f A C T and LLIN distribution; (ii) annual reporting o f service delivery quality and performance; (iii) changes in key outcome indicators as measured against baseline status and control areas; (iv) operations research and special studies to develop new knowledge to improve the malaria program and the M&E system; and (v) dissemination o f results to support evidence-based decision-making processes.

The project will finance a service contract between the FMOH and an M&E Agent that will have the fol lowing functions: (i) Assist the N M C P to carry out Population-Based studies on a biannual basis using LQAS. The Agent will also assist the N M C P to examine the association between population based indicators and output indicators collected by the state public and private sectors; (ii) Assist the N M C P to

43

carry out Health Facil ity Assessments (HFAs) o n a biannual basis; and (iii) Assist the NMCP to develop and implement a project Management Information System that will include inputs f rom both public and private sectors. Whi le each o f these M&E system elements will work at the State and LGA levels, the F M O H will have the role o f aggregating and using data for coordination o f the overall process to improve proj ect performance.

The project will also support the NMCP in undertaking further scoping o f organizations in the public sector, higher education institutions, and private sector which can design and implement operational research relevant to the control o f malaria. The project will promote capacity in identified institutions by meeting essential infrastructure and training needs. I t will support NMCP in the commissioning process.

(c) Coordinating program activities at the national level and across programs

This component will enhance coordination and oversight o f a l l administrative and technical aspects o f the project, including standardization o f implementation capacity and intervention delivery at state and local levels, and sharing experiences across states. The Director o f the N M C P will serve as the Project Coordinator and the Assistant NMCP Director will be the Coordinator o f the Federal Component.

The project will allocate resources to the N M C P to ensure: (i) adequate coordination o f project activities; (ii) timely identification and resolution o f issues affecting or potentially affecting implementation; (iii) adequate administrative support t o the NMCP, SMOH, and implementing partners; (iv) adequate provision o f project inputs in a timely and cost-effective manner; (v) appropriate management o f project resources in accordance with Bank requirements for procurement and financial management; and (vi) effective monitoring and progress reporting.

The project will support close collaboration among relevant programs and departments within the FMOH, in order to ensure appropriate quality control and national accountability in the implementation o f the Malaria Plus interventions, and maximize the impact o f the project o n maternal and chi ld health. For the implementation o f IPT, promotion o f LLINs and use o f pre-packed drugs, the Reproductive Health and I M C I programs are already collaborating with the RBM to enable the latter to use their established structures for implementation. The project also supports the establishment o f a formal national consultative mechanism which engages FMOH, the private sector and key donors and their LLIN project initiatives with the specific objective o f aligning interests and activities in a purposeful and coherent manner.

The Project Coordinator will be responsible for organizing an annual event, a “Results for Health” Forum which assembles a l l Malaria Plus stakeholders, at the federal as wel l as state levels. In addition to disseminating h o w l e d g e and attracting media attention for the program the forum will encourage competition among the States, and other implementing partners for the best strategies, coverage, and impact.

Finally the project will support Nigeria’s efforts to harness a l l available resources for malaria control and to use them as effectively as possible. Harmonization o f efforts o f donors and funding agencies around agreed national policies and plans for malaria control will help avoid wasted effort and accelerate progress towards national coverage o f effective actions. This approach will produce more effective jo in t programming and budgeting in support o f a commonly agreed National Malaria Control Plan. By project completion, i t i s anticipated that it will lead to additional leverage o f development assistance and pooling o f budgets by other donors and funding agencies.

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Component 2: Strengthen the health system to improve delivery o f the Malaria Plus interventions in the target states. (US$71.5 million)

Under this component the project will help build the capacity o f the SMOHs and the LGAs in the target states in planning, implementation, coordination and supervision o f activities aimed at expanding the Malaria Plus Interventions Package (MPP) (see appendix 1 to this annex). The tasks o f capacity strengthening will be undertaken by the FMOH and the FU3M partners, and where needed, contracted management entities, referred to as Project Implementation Facilitators (PIFs), the selection o f which wil l be subject to international competitive bidding. Each state will s ign an individual service contract with the highest evaluated contractor and the contract with the PIF will be financed through the project.

The primary purpose o f the FMOH, RBM partners and, where such capacities are weak, the PIFs, i s to assist the state’s health system to develop and disseminate state-wide plans to deliver the MPP, allocate resources, and monitor the effectiveness o f implementation. T o strengthen the state ownership, technical and managerial capacity, when contracted, the PIF shall work in a supportive and collaborative manner with the SMOH. T o the extent possible, the implementation wil l build o n existing structures and capacity to achieve sustainable results, but the support functions wil l be provided by the PIF o n an as-needed basis to achieve the intended rapid expansion o f MPP.

The project design principle i s to ensure large-scale access, coverage, and utilization o f the Malaria Plus interventions in the participating states. The extent to which any one state i s able to maximize delivery o f each malaria control tool and strategy will vary at any one time between states, and over time, within states. T h e variation i s based on the local health authority support and commitment, the level o f effective functioning infrastructure o f the three main health delivery systems, and the level o f community mobil ization that can be achieved.

When contracted to assist the States, the PIF will have autonomy to design their delivery approach to the extent that i t i s consistent with the National Malaria Control Strategy and five-year plan and responsive to their specified TOR. As part o f their proposals, potential PIFs shall present their situational analyses and based on that, propose approaches to improve project implementation and coordination between al l partners to ensure results and efficient use o f available resources.

(a) Increasing access to, and utilization o f preventive measures

The selected states will receive comprehensive support in scaling-up the preventive measures identified in the Malaria Plus Package. Activities to achieve this objective include: (i) Rapid scale-up o f coverage and uti l ization o f LLIN through a variety o f delivery mechanisms, i.e., through campaigns, health facilities and social marketing (including building o n the successful p i lot ing o f voucher systems). L L I N S financed through this project will be free to children -3 and pregnant women. Furthermore, States, with assistance f rom PIFs, as required, will support local authorities and will coordinate with the Social Marketing Agent to put in place mechanisms that will ensure financial accessibility o f the poor and vulnerable population to LLINs; (ii) Increase utilization by pregnant women o f Ante-Natal Care (ANC) and free IPT; (iii) Identify eligible areas for I R S and implement I R S accordingly; (iv) Mobi l ize communities and families to reinforce utilization o f prevention tools; and (v) Enhance social accountability between the States, LGA, and the communities. Activities to achieve this objective include the following:

(I) Rapid scaling-up of coverage and utilization of LLIN through a variety of delivery mechanisms. The preventive strategy builds o n achieving large-scale coverage and utilization o f LLIN in al l targeted communities where ever: (i) the use o f LLIN i s acceptable by the communities involved; and (ii) the S M O H considers their use feasible, i.e., logistical, security, cultural, and/or behavioral factors will not

45

hamper achieving effective LLIN coverage, retention, and usage. This involves provision o f L L I N s through campaigns, health facilities as wel l as the private sector with exploration o f pro-poor delivery routes through public sector, NGOs and community and faith based organizations. Synergies with existing systems and delivery mechanisms wil l be explored and, where appropriate, exploited and strengthened.

(2) Increasing utilization by pregnant women of Ante-Natal Care (ANC) and IPT. The project will further increase the relatively high attendance o f pregnant women at public sector antenatal care (ANC) clinics and use this channel to provide free IPT. Any cultural barriers to IPT uptake wil l be identified and addressed through the development o f appropriate BCC approaches. The project will also support the training o f A N C staff in IPT through the existing national cascade system and will provide commodity support to the national program.

(3) Mobilization of communities and families to reinforce utilization ofprevention tools. The project will ensure a comprehensive program o f malaria awareness education at community level in al l supported States primarily capitalizing o n existing community based structures to promote sustainability. Focus will be on household understanding o f the requirements, benefits and limits o f the preventive tools offered as part o f the Malaria Plus package. The States, assisted as necessary by the FMOH, RBM partners and the PIFs, will equally promote early recognition o f fever and early correct treatment-seeking behavior amongst the same communities to ensure chi ld malaria cases that will occur are detected and treated early.

(4) Enhancing social accountability between the LGA and the communities. Project aims to increase community awareness by assembling a critical mass o f informed consumers o f health services f rom the communities who are able to demand for effective treatment and prevention interventions part o f the MPP. The States should also strengthen the channel o f communication between LGA authorities and communities for periodic feedback to monitor client satisfaction.

(5) Increasing demand and supply through strategic collaboration with firms, including the manufacturers and distributors of LLINs and other Malaria Plus commodities. Sustainability i s a key issue for the project and emphasis will be placed o n the development o f cost effective domestic manufacturing o f LLIN.

(b) Expanding access to, and utilization of effective diagnostic and treatment services

The selected states and LGAs will receive comprehensive support in the scaling-up o f effective diagnostic and treatment services as part o f the Malaria Plus Package. Specific activities include: (i) identify and assess the health conditions o f populations living in rural or remote areas with l o w access to MPP, and propose strategies to reach them; (ii) increase access to diagnostic services, i.e., enhance clinical diagnostic sk i l l s through the strengthening o f IMCI/RBM strategy, expand microscopy, and introduce RDTs o n a pi lot basis; (iii) increase access to ACT (Artemether-Lumefantrine) for uncomplicated malaria in the target population; (iv) strengthen referral o f severe cases for appropriate case management; (v) ensure that the state and LGA public and private health system has the tools and competencies to assure the delivery o f quality MPP; (vi) strengthen in-service training and supervision geared to develop or improve sk i l l s in priority technical areas; and (vii) improve home-based management o f malaria and other maternal and chi ld interventions identified in the Malaria Plus package. The States will also have to work with various partners to ensure proper disposal o f biomedical waste. Depending on the results o f the implementation capacity assessment, PIFs will be contracted to assist the states in one or more o f the above activities.

46

Technical capacity for case management and services wil l be established through the existing functioning public, private (including the P M V network), and faith-based facilities and, where needed and achievable, through community healthlextension workers. Innovative ways to bringing services to rural communities in remote areas will be explored. I t i s expected that the scale-up in delivery o f treatment services will be phased in each state according to the absorption capacity o f the three delivery systems in each area and that where facility based implementation strategy i s not feasible, the preventive strategy will gain more emphasis.

Technical coaching wil l be provided to improve health personnel’s diagnostic abil ity to recognize malaria symptoms based o n IMCI guidelines and to change over f rom the use o f mono therapies to ACT for uncomplicated malaria; IM artemisinin for pre-referral treatment o f suspected severe cases, and either IM artemisinin plus A C T or full course IV quinine for case management o f severe malaria. Delivery o f diagnostic and treatment materials for children under-five will be free o f charge, and the S M O H will be responsible for ensuring the required support to the three systems to incorporate this service in line with the National Malaria Control Strategy.

The development o f a referraycounter-referral system linking facil i ty and community-based services, including private providers will also be supported under the project. Community-based delivery systems using e.g., traditional birth attendants or community volunteers will be trained, equipped and linked to the nearest local health facil i ty for referral.

The National Malaria Strategy has adopted guidelines for home-based care as a response to the finding that over 60 percent o f malaria cases in the communities do not seek treatment at one o f the three recognized health systems. The project will encourage the state partners, to assess, design, and integrate community case management systems through community-level health workers and other means to increase the proportion o f true cases that are correctly managed and survive. As part o f the home-based care strategy, the states will work through pharmaceutical retailers, such as PMV, and build o n the role model mother system t o make A C T available directly to households. This would enable the provision o f ACT at community-level through selected mothers to whom fellow mothers can bring their children for malaria treatment 24 hours a day. The MPP identifies also other key interventions part o f the community IMCI that are expected to be delivered and sustained thought role model mother network or other community driven structures. All community delivery systems wil l be monitored carefully and experience shared with other states and countries.

(c) Strengthening community mobilization and Communication for Behavior Change

The Project recognizes the need for community mobilization and the involvement o f the political, traditional and religious leadership in project activities for achieving rapid improvements in malaria control. Furthermore, the ownership of, and involvement and participation in, project activities by the community has significant implications for the financing, scaling-p and sustainability o f Malaria Plus interventions. Awareness education will promote community understanding o f the requirements, benefits and limits o f any effective preventive and curative tool part o f the MPP. States will promote early recognition and correct treatment-seeking behavior for childhood diseases amongst communities.

The project interventions will be supported by intensive community mobilization campaigns, including social marketing o f malaria-related commodities, which are expected to promote positive behavior change at a l l levels. Community education will also be repeated after prevention campaigns and, where possible, the States will ensure the incorporation o f targeted malaria education into existing community education mechanisms including health extension workers, school curriculums, local radio/television, and other media.

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(d) Improving state-specific M&E for evidence-based management

This component will provide technical assistance and capacity-building activities to strengthen the M&E technical and training skills o f the applicable SMOH, LGA and other implementing partners. The objective i s to introduce the decentralized M&E system as results based management tool to assess the status o f the overall process and introduce program changes as needed. Collection o f several types o f information and tools are needed for management purpose that will be supported by the project: (i) process indicators (inputs, activities, and outputs); (ii) results indicators (primarily outcomes); (iii) Logistic Management Information System (LMIS) data; (iv) Health Management Information System (HMIS) data; and (v) L o t Quality Assurance Sampling systems (LQAS).

More specifically the States will be supported, either directly or through the service contracts, to: (i) develop an information system to measure output and outcome indicators. Outcome indicators will be collected on a biannual basis and output indicators will be collected and reported on a routine basis; (ii) develop a management cycle for using information recurrently for managerial decision-making . Implementation o f the M&E system wil l be a team effort requiring the cooperation o f the State, LGA and implementation partners; (iii) establish a project logistic management information system (LMIS) in close collaboration with the Federal level procurement team to serve as a standardized system followed by a l l states and public and private implementation partners; and (iv) collaborate with local authorities, community leaders and health personnel to analyze and interpret information on the epidemiological situation o f the state and to adjust health activities accordingly. The State health system will also be required to assess the performance and effects o f the immunization plus days and other community mobilization activities.

(e) Strengthening partnerships for resource mobilization and implementation

There will be opportunities for economies o f effort and impact on the wider health sector environment if the project can develop effective linkages with other initiatives in the health sector and beyond. NMCP i s a priority health program but it works within the context o f the overall health delivery system. It wil l have to make strenuous efforts to establish links with other projects and programs within the sector, across ministries, and with the private and business sector. The project will support S M O H and LGA to capitalize on shared delivery modes o f other national programs and campaigns targeting pregnant women and children under five. Hence, where opportunities exist, the delivery o f the MPP may be l inked with other mass population campaigns, such as measles vaccination campaigns and EPI catch-up day campaigns, which selectively target the same vulnerable groups.

The three existing health delivery systems will be leveraged in the implementation o f the project: (i) public health service; (ii) faith-based health delivery system; and (iii) the private sector, including Patent Medical Vendors. The technical, operational, and management capacity o f the public and faith- based health services will be reinforced to introduce, rapidly scale up, and monitor a comprehensive package o f Malaria Plus interventions including ANC-related services.

The private health care sector i s a major component o f the health care delivery system in Nigeria. About one third o f utilization o f formal medical services i s accounted by the private sector. In addition, there i s significant use o f non-formal private services, particularly patent medicine vendors - with surveys finding utilization to be 50 percent (o f those treated) in cases o f ch i ld illness. None o f these retailers are allowed to prescribe drugs but in practice many do. T h i s combined with litt le knowledge and training, especially among patent medicine vendors and drug hawkers, has resulted in irrational prescription o f drugs. The project aims to support the development o f a vibrant private sector, particularly the Patent Medical Vendors that i s able to work in partnership with the public sector in the delivery o f public health goods. I t

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will also develop an efficient referral system between the sectors and set up a system for monitoring and reporting o n their activities. In addition to direct project benefits, this will contribute to a greater understanding o f h o w markets work in Nigeria and h o w incentives can be developed to encourage the private providers to support public services more generally.

The S M O H and its implementing partners wil l seek to harness a l l available resources for malaria control at State level and to use them as effectively as possible. Harmonization o f efforts o f donors and funding agencies around agreed national policies and plans for malaria control will help to avoid wasted effort and accelerate progress towards national coverage o f effective actions.

The States will be encouraged to work with the communities and equip them with contacts and information o n potential sources through which additional funding could be available for malaria control. Such an opportunity exits e.g., through the Wor ld Bank financed Community Social Development Project, which i s currently effective and accepting applications f rom communities.

(0 Enhancing capacity of the states for oversight and project coordination.

Capacity for effective implementation at state and local levels i s variable. Fol lowing an init ial assessment o f capacity and functions in the identified states, the project will provide tailored support according to identified needs. Within the guidelines o f their contract and the project’s framework, the contracted PIFs will be given significant autonomy to fulfill their contracts in partnership with their respective SMOH, delivery systems, and communities. They will be required to ensure that strong malaria technical assessment, planning, training, implementation, monitoring and evaluation sk i l l s and lasting capacity are built. Furthermore, they will progressively encourage their counterparts to take full responsibility for these functions as their capacity increases. This will ensure maximum coordination within the states and between S M O H and the NMCP, strengthen quality control and build state and local level accountability. I t i s anticipated that this package o f support will assist States and LGAs to meet their public health obligations in relation to malaria and will also provide the necessary oversight o f the resources being deployed by FGN and development partners.

P

0 I

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Annex 5: Project Costs NIGERIA: Malar ia Control Booster Project

The project costs indicated below are indicative. The final breakdowns will be determined on the basis o f the discussion and agreements reached on the detailed Annual Implementation Plans to be developed by the FMOH and the participating States.

Component

1. Federal level: Strengthen the capacity of the Federal Government to provide malaria control leadership and coordination over the medium and long-term. This component will support: a) Procurement and logistic o f commoditiesS b) Social Marketing o f LLIN (To be determined c) Monitor ing and Evaluation and Operational research d) Program coordination 2. State level: Strengthen the health system to improve delivery of the Malaria Plus interventions in the target states. This component wil l support the states, including any service contracts between the SMOHs and the PIFs in the fol lowing states:

A h a Ibom

Anambra

Rivers

Bauchi

Gombe

Jigawa

Kano

Physical and price contingencies

TOTAL PROJECT C O S T

Total US$ Mil l ion

86.5

75.5 3 .O 3 .O 5 .O

71.5

8.5

9.5

10.5

9.75

6.0

9.75

17.5

22.0

180.0

'LLIN :-7,258,237 LLIN (2 per household) will be distributed over the five-year period to achieve 80 percent coverage o f households. IPT: The total target population for intermittent preventive therapy for the 7 states i s 1,655,785 pregnant women (5 percent o f 331 15704) receiving at minimum o f 2 IPT during the course of the 20d and 31d trimesters. The coverage will increase over five years to reach 50 percent o f pregnant women in northern states and 70 percent in southem states. Case management of malaria ACT and artemether are budgeted for under-five year's children only. 60 and 40 percent o f malaria cases are expected to be treated with ACT respectively in southern and Northern states by the end of the project.

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Annex 6: Implementation Arrangements NIGERIA: Malaria Control Booster Project

1. Partnership Strategy

The project will be implemented through, and maximize the use of, the three existing health care providers: the public health delivery system, faith-based health organizations, and the private sector, including the Patent Medical Vendors (PMV), as wel l as the affected communities themselves. This will allow the National program to expand in reach but by the same token, promote competition, innovation and public-private partnership. Furthermore, the expansion o f the Malaria Plus service package (MPP) in the target States will build o n strong cross-cutting partnerships between programs, sectors and Donor initiatives and fully capitalize o n existing delivery capacity at a l l levels.

At the Federal level this implies that FMOH will ensure collaboration o f relevant programs, departments and Ministries to reinforce implementation. All existing channels to reach the target groups (pregnant women and children less than five years o f age), wil l be explored and if found feasible and cost-effective, they will be utilized. The delivery o f the MPP interventions, financed by the Project will combine key maternal and chi ld interventions o f shared delivery modes by building o n the clinical synergy to maximize i t s impact o n morbidity and mortality.

Efficient management o f the National Program requires smooth information f low between the FMOH, SMOH, LGA and the communities, and use o f this information for decision-making at a l l levels. Furthermore, as the services will be delivered uti l izing a l l existing health care providers, i t i s important to establish a standardized monitoring system to assess progress at a l l levels. The project will contract a Monitor ing and Evaluation Agent to assist the N M C P o n systems development, i t s implementation and training. Finally, the project will support the establishment o f a national consultative mechanism which engages FMOH, the private sector and key donors with the specific objective o f aligning interests and activities in a purposeful and coherent manner.

2. Implementation Strategy

The project design principle i s to increase access to, and utilization o f malaria control, case management and other MPP interventions in the participating states. The extent to which any one state i s able to maximize delivery o f each malaria control tool and strategy will vary at any one time between states, and over time within states, based o n the local health authority support and commitment, the level o f effective functioning infrastructure o f the three main health delivery systems, and the level o f community mobilization that can be achieved. Each participating state will count o n the technical and managerial support o f a Project Implementation Facilitator in the areas where i t s capacities need to be strengthened. Below i s an outline o f the implementation strategy:

Establishing Basic Case Manapement and Prevention Services through MultiDle Health Care Providers

The existing public health system and faith-based health care organizations in the target states wil l receive significant support to ensure effective technical capacity building in a l l new malaria plus diagnosis and treatment protocols at State, LGA and Ward levels. The project will provide support to the States including for the contracting o f Project Implementation Facilitators (PIFs) in areas where the States capacities need to be strengthened, using service contracts between the selected States and PIFs. Exist ing and supplementary supply chains for the three health care providers wil l be supported and supervised to ensure effective supply management and distribution f r o m Federal supply points to the State and f r o m there onto the LGA and Ward health care providers.

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e

e

e

e

e

e

e

e

e

e

The FMOH, RBM partners and the PIFs, when contracted for this purpose, w i l l provide technical coaching and monitoring support so that al l health care providers are trained in the new protocols and supplied with essential materials. Support wil l aim to ensure good quality prescription practices, nursing practice, materials management, and essential reporting practices. Where feasible, in LGA and wards with poor access to health facilities, community-based delivery systems w i l l be strengthened using health education, traditional birth attendants, health extension, and community volunteer structures. The state and LGA health teams, wi th the assistance o f the PIFs, on an as-needed basis, and private partners w i l l provide training, equipment, and basic monitoring and supervision. Scale up in delivery o f malaria case management services w i l l be phased in each state according to the absorption capacity o f the three delivery systems in each area. In each o f the target states, malaria prevention w i l l be scaled up through routine delivery services o f each heath system and specific community schemes. Public health facilities and faith-based health service providers will be supported to include provision o f intermittent preventive therapy and LLIN into their existing ante-natal clinic services. All pregnant women attending ANC w i l l receive a family-size LLIN, free o f charge, on her f i r s t A N C visit. Private health care suppliers w i l l be engaged to provide LLIN through their existing state and LGA-level retail outlets, at heavily subsidized cost. Direct campaigns to educate communities and to distribute LLIN directly to al l households, wi th pregnanthreast-feeding women andor young children (under 5 years) as the priority targets, w i l l be implemented (a) where existing health care services and private retail outlets are insufficient to achieve effective access for all, or (b) are too slow to achieve high-coverage rates in the time frame required. Where feasible, LGA-wide free LLIN distribution campaigns w i l l be implemented opportunistically wi th other suitable health campaigns, l i ke the Immunization Plus Days, in order to increase coverage rates in areas where LLIN coverage may be difficult to achieve by other means. IRS i s not foreseen as a major prevention tool, but i t w i l l be pragmatically deployed on some communities according to the NMCP criteria for selecting target communities. In cases where LLIN i s not be feasible, the project w i l l pi lot other insecticide-treated materials, (long-lasting wall linings, long lasting treated curtains, etc.), as these new tools become available.

To reinforce current capacity at a l l levels, contracts will be awarded to specialized agencies to assist Government during implementation. The various types o f service contracts at Federal and State levels are described below.

Federal Level:

(a) Monitoring and Evaluation Agent. The ma in purpose o f the M&EA will b e to assist the NMCP in developing informat ion systems to measure output indicators that t rack activities carried out by the project, the qual i ty o f services, and their outcomes (Le., access to, and ut i l izat ion o f MPP, and maternal and ch i l d protective behaviors). It will also assist the NMCP t o develop a management cycle for using informat ion recurrently fo r management decision-making.

(b) Social Marketing Agent. The m a i n purpose o f a Social Marke t ing Agency (SMA) i s to engage the pub l ic health system, the pr ivate sector, P M V s and NGOFBO to improve their knowledge o f k e y issues in malaria treatment and compliance with the NMCP guidelines. The S M A must work in close col laboration with SMOH and, where such entities have been contracted, with the State level PIFs. For LLIN distribution, the SMA will assist the SMOH and PIFs to develop comprehensive L L I N s ’ distr ibution strategies by combin ing publ ic and private sector efforts at the State, LGA and W a r d levels. Achieving complementarities between the two sectors will be the k e y for success. Price subsidies must reinforce or complement the private sector rather than compete with it. When LLINs are available to everyone, subsidies may inhibit commercial sales, thus, appropriate mechanisms, such as a voucher system and effect ive targeting must b e developed.

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(c) Procurement Specialists: The main purpose o f the procurement specialist i s to strengthen the Federal procurement system for commodities and drugs. A technical specialist, who will be responsible for assisting the Federal government and the States in the evaluation o f bids and proposals-and particularly in the evaluation o f the PIF bids-may be added, depending on need.

(d) Logistics Support Specialist. The main purpose o f the logistics specialist i s to strengthen the Federal capacity to undertake and advise the States o n drug logistics including the distribution o f drugs and commodities to state level public and private health care providers.

State Level:

(e) Project Implementation Facilitator. The primary purpose o f the PIF will be to assist the state’s health system, o n an as-needed basis, to develop state-wide plans for delivering decentralized Malaria Plus Package, identify and allocate resources, and monitor the effectiveness o f its implementation. When contracted, the PIFs shall work in a supportive and collaborative role, in order to strengthen the State and LGA ownership, technical and managerial capacity, and sustainability. The SMOH, supported as necessary by the PIF, will also have a key role in training and supervision.

The Project will be implemented over a period o f f ive years f rom January 2007 to December 201 1. Given the decentralized nature o f the Project, the implementation arrangements have been designed to offer a balance between effective overall supervision and monitoring o f activities at the Project level, as wel l as reinforcing the management and institutional responsibilities o f individual states.

At the State Level, the SMOH o f each participating state will be responsible for implementing project activities at state and local levels. The S M O H will be supported in i ts technical and operational functions, as needed, by the PIF. In each o f the participating states, a State MOH Focal Unit will be in charge o f implementing project activities at the state and local levels. It also serves as the liaison between state and federal levels. In addition, the Project Financial Management Unit (PFMU) o f the Off ice o f the State Accountant-General wil l be tasked to provide the required Financial Management services to the State MOH Focal Unit responsible for implementing project activities at the state and local levels.

At the Local level, LGA health authorities will have implementation oversight at LGA and Ward levels and will coordinate project activities at this level, reporting back to their respective SMOH.

3. Institutional Arrangements at the Federal Level

Project Steering Committee (PSC). The Project will be overseen by a PSC chaired by the Federal Minister o f Health (or h isher representative). The PSC will consist o f a balanced representation f rom the FMOH, FMOF, states and LGAs, other development partners, faith-based organizations active in delivery o f health services at the primary level, and the private sector. The PSC wil l be responsible for ensuring timely implementation o f the project by the N M C P and various contracting agents. I t will convene quarterly to: (i) review progress reports prepared by the NMCP and states N M C P Focal Person and clear the forwarding o f these reports to IDA with comments; (ii) review and approve annual work programs and budgets; (iii) ensure that agreed performance targets and timelines for activities under the different components are met; and (iv) proactively address critical issues that could hinder Project implementation.

At the Federal Level, the NMCP, within the FMOH, will be responsible for the overall coordination o f project activities, specifically with other Ministries, other FMOH departments and SMOH, and federal representatives o f the faith-based and private sector health care providers. The NMCP Director will act as the project coordinator. In addition to overall coordination, the N M C P will be responsible for: (i) overall technical management; (ii) procurement o f malaria commodities; (iii) overall accountability for the

54

financial management o f the credit at the Federal level. Specifically, i t will be responsible for preparing activity budgets, monthly S A reconciliation statement, quarterly SOE Withdrawal Schedule, quarterly Inter im Financial Reports (IFRs) that are acceptable to the Government and IDA. I t will also forward the reports and statements to the Federal Ministries o f Health and Finance and IDA; and (iv) monitoring, evaluation and reporting o n progress. The Assistant NMCP Director will coordinate activities for the Federal component o f the project.

With respect to procurement and financial management, the N M C P has obtained the transfer o f a procurement staff and a FM officer f rom other parts o f the Ministry to focus solely o n this project. They wil l report to the Director o f the NMCP but will work in close collaboration with the P l U o f the HSDP I1 Project based under the FMOH Directorate o f Planning, Research and Statistics. T h i s arrangement wil l permit the new staff t o be mentored by the experienced staff o f the HSDP I1 and strengthen at the same time the capacity o f the NMCP. In addition, a procurement consultant has been recruited and a logistics specialist wil l be added to the roster to assist and advise the NMCP. Furthermore, a Technical Assistant specialized in procurement and logistics management may be recruited, on an as-needed basis, to assist with the evaluation o f bids and proposals, including o f the state level PIFs. The Bank team assessed these arrangements and found them adequate. These arrangements will be reviewed periodically by IDA as part o f regular project supervision.

A financial management assessment o f the HSDP I1 FM Unit had been undertaken and the existing financial management arrangements are acceptable to IDA. The financial management arrangements will be reviewed periodically as part o f regular project supervision missions. A procurement assessment was finalized during appraisal.

In addition, the NMCP will be strengthened through two service contracts financed under the Project:

(a) M&E Agent; to assist the M&E Unit o f the NMCP to aggregate, analyze, and report results to

(b) Social Marketing Firm; to support supply and demand side strategies for mass-awareness raising decision makers in a rapidly usable form.

and behavior change at National level.

I

PH Directorate

Planning, Research 1 & Statistics I Directorate I

HSDP II-PIU Coordlnator

Prncure Flnan

Other t-ea th _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Pro&rams

State A c c o ~ n t a n t General P - c j r c t M a na g em en t Financial Unit

Project C3ord naior

M8E Contracior

Logistic Maiagement TA

Froject M e n a j e m e n t Prozuremeit OffiEer Finarc el 3 f f cer

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4. Institutional Arrangements at the States level

All State MOH (SMOH) have an appointed Focal Unit for M P P that i s responsible for implementing project activities at the state and local levels. As needed, and based on a capacity assessment undertaken by the FMOH, Project Implementation Facilitators (PIFs) will be hired o n a competitive basis to provide support to the States, LGAs and communities in their provision o f the MPP services. When contracted, the PIF wil l build the technical capacity o f S M O H malaria control counterparts to ensure full partnership engagement in the planning and implementation o f a l l interventions and enhance quality o f monitoring and evaluation functions at this level. On an as-needed basis, the PIF will also work with the S M O H to reinforce the technical, operational, and management capacity o f the public health services to introduce, rapidly scale up, and monitor the Malaria Plus interventions.

Contracts between the S M O H and the PIF will be performance-based, prompting a l l concerned to focus o n results and leaving the PIF the flexibil i ty t o design an approach that i s best adapted to achieve results. Their implementation strategy should be based o n an extensive situational analysis o f the local circumstances and the strategy will be assessed and ranked during the bid evaluation process as a central selection criterion for the PIF. I t i s anticipated that PIF will, as necessary, sub-contract multiple partner agencies o n varying lengths o f contract as needed to achieve their specific contract targets. A key task o f the PIF and i ts sub contractor will be to build lasting technical and operation capacity amongst State, LGA, Ward and community levels.

Planning and implementation should be carried out with full involvement o f the community leaders to ensure maximum community responsibility, acceptance, correct use, and adherence to the intervention tools made available through the project. The S M O H will also be encouraged to assess, design, and pi lot community based delivery models to improve access to effective treatment for communities with poor access to health facilities and to improve access in areas where health facilities are not open through the night. Hence, the S M O H wil l be responsible for adequate monitoring o f such pilots and for sharing the lessons learnt with al l program partners locally and through the NMCP.

As procurement o f malaria commodities i s done by the Federal level, procurement responsibilities o f the S M O H are l imited to l imited procurement, supported as necessary by the PIF. Staff o f the S M O H will participate in the procurement process at the national and state levels as part o f capacity building and institutional strengthening.

The State MOH Focal Unit for MPP and his team, supported by the Project Financial Management Unit (PFMU), will have overall accountability for the financial management o f the credit at the participating State level. Specifically, i t will be responsible for: (i) preparing activity budgets, monthly S A reconciliation statement, quarterly SOE, Withdrawal Schedule, quarterly Inter im Financial Reports (IFRs), and annual financial statements; and (ii) ensuring that the project financial management arrangements are acceptable to the Government and IDA. I t will also forward the reports and statements to the State Ministries o f Health and Finance and IDA. As workload necessitates, additional professionally qualified Project Accountants and Internal Auditors will be recruited for the duration o f the project. A financial management assessment o f the respective PFMUs had been undertaken and the existing financial management arrangements are acceptable to IDA. The financial management arrangements will be reviewed periodically as part o f regular project supervision missions.

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5. Implementation and Monitoring of Project Activities

The project i s expected to be fully implemented within f ive years. Besides the standard early activities such as project launch, the first activities o f the project wil l include drafting o f an operations manual, init iating the procurement o f commodities, and selecting PIFs, the M&E Agent, the Logistics Specialist and the Social Marketing Firm.

The operations manual has been discussed, and an in i t ia l draft prepared by NMCP was refined during negotiations. I t will include: (i) description o f the relationship between the various actors involved in implementation; (ii) detailed description o f procurement and financial management procedures to be respected by each actor; and (iii) description o f specific arrangements for key activities. T o ensure transparency, copies o f the manual will be widely disseminated to a l l project partners.

Target states have confirmed their participation in the project pr ior t o appraisal. PIFs will be evaluated mostly on technical merit based o n their assessment o f the priority needs in each state and a fixed per capita budget. Potential M&E Agent will be evaluated o n technical merit and financial proposals.

An important task o f the NMCP i s to lead the Results for Health Forum which will be organized once or twice a year to review project progress. The forums will provide opportunities to rethink strategies as needed and facilitate the coordination o f the various public institutions and donors involved in the project. Also the independent performance monitoring o f the PIFs carried out by the M&E Agent wil l be disclosed and discussed during the forums

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‘he FGN has made a significant effort t o advance reform o f the PFM system since 2003. The CPS, l e d by IDA, supports the efforts to improve governance through improved transparency and accountability. This has translated in various projects, including the ERGP and the SCBGP at the Federal and State levels respectively, focusing o n improv ing accountability, good governance, transparency and fighting fraud and corruption. Reforms in budgeting, FM systems, procurement and auditing are being supported.

Annex 7: Financial Management and Disbursement Arrangements NIGERIA: Malaria Control Booster Project

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Financial Management Arrangements

Introduction

The financial management assessment was done in line with the Financial Management Practice Manual (November 2005) o f the FM Board. The objective o f the assessment i s to determine whether the implementing entities have acceptable financial management arrangements, which wil l ensure: (i) that funds are used only for the intended purposes in an efficient and economical way; (ii) the preparation o f accurate, reliable and timely periodic financial reports; and (iii) safeguarding o f the entities’ assets.

Country Issues

A review o f implementation o f CFAA (2000) recommendations in January 2005, further supported by a recent PEMFAR, observed that the Federal Government o f Nigeria (FGN) has made a significant effort to advance reform o f the PFM system since 2003. Major achievements so far have been: (i) the adoption o f an oil-based fiscal ru le that has greatly improved the quality o f macroeconomic management; (ii) launching o f significant steps toward increased transparency o f the budget process; (iii) more efficient cash management; (iv) procurement reforms; (v) updating the legal framework for PFM; (vi) reallocation o f budget resources in support o f MDG-related government functions; (vii) strengthening monitoring and evaluation (M&E); and (viii) introducing a more strategic longer-term focus in budget management. This has clearly helped to reduce waste o f public resources, particularly o n the capital budget and payroll sides. The impact o f these early measures i s also evident in significantly improved fiscal and broader macroeconomic outcomes. There i s nevertheless s t i l l a long way to go and PFM initiatives and reforms are articulated in the Government’s PRSP - NEEDS, which are supported under the Country Partnership Strategy (jointly developed by IDA and DFID) specifically through 3 Bank assisted projects - EMCAP, SCBGP and the ERGP.

Risk Assessment and Mitigation

Inherent R i s k s 1 ICountry 1 H 1 Country H

Leve l

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htity Level

3 roject Level P

I Control R i s k s

3udgeting

4ccounting

hternal 2ontrol

'unds F l o w

'inancia1 Xeporting

S

L

M

M

L

M

e overseen FMOH and Focal Units for M P P in participating SMOH. These units operate under an agreed Nigerian strategy, action p lan and monitoring arrangements. An Agent wil l b e appointed to strengthen and support implementation capacity and progress wil l be regularly monitored. FM capacity i s provided through existing and strengthened FM units.

i t both the Federal and participating State levels, xisting FM unit with professionally qualif ied iccountants and Internal Auditors wil l be deployed 5 undertake the FM responsibilities during Project mplementation. A staff wil l b e designated for the JMCP. Addit ional staff wil l b e added as required.

FM Uni ts wil l assist N M C P and Focal Units for M P P to prepare annual cash budgets for the work program.

FM Uni ts are staffed by professionally qualif ied accountants who are competit ively recruited f r o m the public and private sectors. The project wil l directly benefit f r o m these existing and well- established FM Units, which provide support across projects. A computerized FM system, supported by a Financial Procedures Manual, wil l be deployed at a l l levels o f project implementation.

Internal control is strengthened by using trained staff, proper FM procedure manuals, processes and systems and also by deployment o f internal audit services t o test the effectiveness o f the control system. Again, the existing FM Uni ts wil l support the project o n these aspects. Project funding wil l be f r o m the IDA Credit, to be None disbursed through a Designated Account, which wi l l be managed by the FM Unit o f HSDP 11.

h o n e

h o n e

h o n e

The respective FM Uni ts will use a computerized accounting system. Monthly, quarterly and annual reports wil l b e prepared to a l low monitoring o f Project implementation. The reports will be submitted to the N M C P and Focal Units for MPP, and Federal and State MOF and Health and IDA.

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internal control system at the Federal and State levels. An external auditor will be engaged at each level to carry out an independent audit o f the project financial statements.

internal auditors who are trained in Bank procedures and have a good appreciation o f the use o f computers; (b) a robust internal control system, which allows for segregation o f functions; and (c) sound financial procedures and systems in which

o f the respective FM Units has been

i t ia l M-Moderate L -Low

Strengths

The use o f existing project FM un i ts at Federal level (HSDP 11) and the State level (PFMUs in the State Accountants-general offices) are significant FM strengths in the project. These FM Units are trained in Bank fiduciary requirements, staffed with professionally qualified staff and equipped with FM systems and FPMs.

Weaknesses and Action Plan

The plan below indicates the actions to be taken for the project to further strengthen i t s financial management system:

1 Assign staff in the FM Units to the project and agree the Memorandum o f Financial Management Services to the NMCP and Focal Units for MPP (Done for NMCP, in progress for States).

2 Agreement o f Interim Financial Report (IFR) Negotiation IDA and formats (Done at Negotiations). Government

3 Retain short-term consultant to: (a) advise on the November 30, 2006 Government/NMCP set-up o f the computerized FMS; (b) prepare the FPM; and (c) train staff in the operation o f the system.

auditor and commence process o f appointment (in

November 30,2006 PFMUs and NMCP

4 Agreement o f terms o f reference for external November 30,2006 PFMUs and NMCP _. I progress; letters sent to-States).

5 I Open Designated Dollar Account, Current Draw- I November 30,2006 I PFMUs and NMCP down and Project Accounts in Naira. FMOF, SMOH and IDA advised o f authorized bank signatories (in progress; letters sent to States).

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Implementing Entity

At the Federal level, it has been agreed between the N M C P and the FMOH Directorate Planning, Research and Statistics, that the FM Unit o f the HSDP I1 Project will be tasked to provide the required FM services to the N M C P for this project. A designated project accountant, who will be a professionally qualified accountant, will work under the technical guidance, support and quality control o f the Head o f Finance o f the HSDP I1 project, using i t s existing systems and procedures as a basis for the design and implementation o f an accounting and financial management system for this project. The staff will be accountable to the NMCP Coordinator for the financial management o f the project, with the Head o f Finance HSDP I1 taking responsibility t o oversee the technical quality o f service delivery by such staff. This arrangement wil l strengthen the capacity o f the NMCP and permit quick implementation o f a financial management system for the project under experienced guidance and quality control. The NMCP, supported by the designated FM Unit, will have overall accountability for the financial management o f the credit at the Federal level. Specifically, i t will be responsible for: (i) preparing activity budgets, monthly S A reconciliation statement, quarterly SOE Withdrawal Schedule, quarterly Inter im Financial Reports (IFRs), and annual financial statements; and (ii) ensuring that the project financial management arrangements are acceptable to the Government and IDA. I t wil l also forward the reports and statements to the Federal Ministries o f Health and Finance and IDA. As workload necessitates, additional professionally qualified Project Accountants and Internal Auditors will be recruited for the duration o f the project. A financial management assessment o f the HSDP I1 FM Unit had been undertaken in 2002 when the project commenced. All audit reports are up to date and have been reviewed by the Bank. Based o n these, as wel l as the recent FM supervision carried out in M a y 2006, the existing financial management arrangements are acceptable to IDA. The financial management arrangements will be reviewed periodically as part o f regular project supervision missions.

At the participating State level, i t has been agreed that the Project Financial Management Unit (PFMU) o f the Off ice o f the State Accountant-General will be tasked to provide the required FM services to the State MOH Focal Unit for MPP, responsible for implementing project activities at the state and local levels. The State MOH Focal Unit for MPP, supported by the PFMU, wil l have overall accountability for the financial management o f the credit at the participating State level. Specifically, it will be responsible for (i) preparing activity budgets, monthly S A reconciliation statement, quarterly SOE Withdrawal Schedule, quarterly Inter im Financial Reports (IFRs), and annual financial statements; and (ii) ensuring that the project financial management arrangements are acceptable to the Government and IDA. I t will also forward the reports and statements to the State Ministries o f Health and Finance and IDA. As workload necessitates, additional professionally qualified Project Accountants and Internal Auditors will be recruited for the duration o f the project. A financial management assessment o f the respective PFMUs had been undertaken and the existing financial management arrangements are acceptable to IDA. At the community level, in order to ensure transparency in project activities and implementation, the community representatives will be actively involved in reviewing implementation progress vis-a-vis the financial commitments. The financial management arrangements will be reviewed periodically as part o f regular project supervision missions.

Planning and Budgeting

Cash budget preparation will be detailed in the FPM. At a minimum an annual cash budget for the l i f e o f the project at each level o f implementation will be prepared, by the responsible FM Unit respectively in consultation with the N M C P and State Focal Units for MPP. The annual cash budget will be broken down quarterly and monthly, in support o f project activities as reflected in the approved work plan and

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procurement plan. All annual cash budgets o f the State Focal Units for M P P will be sent to the NMCP at least two months before the beginning o f the project fiscal year.

Internal Control and Internal Auditing

Internal control comprises the whole systems o f control, financial or otherwise, established by the NMCP and State Focal Units for MPP in order to: (i) carry out the project activities in an orderly and efficient manner; (ii) ensure adherence to policies and procedures; (iii) safeguard the assets o f the project; and (iv) secure as far as possible the completeness and accuracy o f the financial and other records.

The key elements to ensure a sound internal control system will include: Segregation o f duties Physical control o f assets Authorization and approval Clear channels o f command Arithmetic and accounting accuracy

Supervision Integrity and performance o f staff at a l l levels

In addition to these internal control measures, there will be involvement o f the community in the review o f projects activities, as wel l as the implementation. This will promote transparency in project implementation.

Project activities will also be periodically reviewed by the Internal Audit Unit (MU) o f the respective Federal and State FM Units. The Heads o f Internal Audit in the FM Units will report t o the Project Managers and the Steering Committee, and at minimum will (i) carry out periodic reviews o f project activities, records, accounts and systems; (ii) ensure effectiveness o f financial and accounting policies and procedures, as wel l as compliance with internal control mechanisms; (iii) review SOEs; (iv) physically verify purchases and assets; and (v) carry out other functions as stated in the their approved charter. The internal auditors in each o f the units are accountants. They prepare monthly reports to management. They have undergone training in Bank procedures o n Financial Management and Disbursements, as wel l as training o n risk-based auditing.

Accounting

Project accounts will be maintained o n a cash basis, augmented with appropriate records and procedures to track commitments and to safeguard assets. Accounting records will be maintained in dual currencies (i.e., Naira and S).

The Chart o f Accounts will facilitate the preparation o f relevant monthly, quarterly and annual financial statements, including information o n the following:

Total project expenditures Total financial contribution f rom each financier Total expenditure o n each project component/activity Analysis o f that total expenditure into goods, works and consultants’ services for the Project; and Operating costs.

Annual financial statements will be prepared in accordance with relevant International Public Sector Accounting Standards (IPSAS).

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All accounting and control procedures will be documented in the FPM and regularly updated by the respective Project Accountant.

Financial Reporting

Interim Financial Reports (monthly and quarterly) and Annual Financial Statements to be submitted by the respective FM Units are outlined below. Quarterly and annual reports are to be submitted respectively to: (i) the NMCP, FMOH and FMOF; (ii) the State Focal Units for MPP, S M O H and SMOF; and (iii) IDA - for the purpose o f monitoring project implementation.

Monthly Reports:

Bank Reconciliation Statement for each bank account Statement o f cash position for project funds fi-om a l l sources Statement o f expenditure classified by project components, disbursement categories, and variance analysis with budgets; and Statement o f Sources and Uses o f funds (by Credit Category/ Act iv i ty showing IDA, Counterpart and other funds separately).

Quarterly Reports:

Financial Reports, which include a statement showing for the period and cumulatively (project l i fe or year to date) inflows by sources and outflows by main expenditure classifications; opening and closing cash balances o f the project; and supporting schedules comparing actual and budgeted expenditures. The reports will also include cash forecast for the fo l lowing two quarters as wel l as analysis o f disbursements against contracts. Physical Progress Reports, which include narrative information and output indicators (agreed during project preparation), linking financial information with physical progress and highlighting issues that require attention. Procurement Reports, which provide information on the procurement o f goods, works, and consultants and on compliance with agreed procurement methods. The reports will compare procurement performance against the plan agreed at negotiations or subsequently updated, and highlight key procurement issues such as staffing and building borrower capacity. SOE withdrawal schedule, listing individual withdrawal applications relating to disbursements by the SOE method, by reference number, date and amount; and Special account statement reconciliation, showing deposits and replenishments received, payments supported by withdrawal applications, interest earned on the account and the balance at the end o f the reporting period.

Indicative formats for the reports are available in a Bank guideline called “Financial Monitor ing Reports: Guidelines to Borrowers”.

Annual Financial Statements:

A Statement o f Sources and Uses o f funds (by Credit Categoryhy Act iv i ty showing IDA, Counterpart Funds and Other Funds separately). A Statement o f Cash Position for project funds from a l l sources. Statements reconciling the balances o n the various bank accounts (including IDA Special Account) to the bank balances shown on the Statement o f Sources and Uses o f funds.

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Notes to the.Financia1 Statements.

SOE Withdrawal Schedule listing individual withdrawal applications relating to disbursements by the SOE Method, by reference number, date and amount.

Audit in g

The IDA Financing Agreement will require the submission o f audited Annual Financial Statements for the project at each level o f project implementation, within six months after year-end.

Relevantly qualified, experienced and independent external auditors will be appointed for the project at Federal level. At the State level, the external auditors appointed to the respective PFMUs will audit the project activities based o n TORS acceptable to IDA.

Besides expressing an opinion o n the Annual Financial Statements in compliance with International Standards o n Auditing (ISAs), the auditors will be required to include a separate opinion paragraph o n the accuracy and propriety o f expenditures made under the SOE procedures and the extent to which these can be relied upon as a basis for loan disbursements. Regarding the Special Account, the auditor will also be expected to form an opinion on the degree o f compliance with IDA procedures and the balance at the year-end.

In addition to the audit report, the external auditors will be expected to prepare a Management Letter giving observations and comments, and providing recommendations for improvements in accounting records, systems, controls and compliance with financial covenants in the IDA agreement.

FM Supervision Plan

The f irst FM review will be carried out after 6 months o f project implementation. A consultant will be engaged to carry out this detailed review which will cover a l l aspects o f FM, internal control systems, reviewing the overall fiduciary control environment and tracing transactions f rom the bidding process to disbursements as wel l as SOE review. Thereafter, given that the FM risk rating for the project i s moderate, subsequent reviews will be as follows: review o f quarterly FMRs; review o f audited Annual Financial Statements and management letter as wel l as timely fo l low up o f issues arising; annual SOE review which will be jo in t ly done with the post audit review by the procurement unit; participation in project supervision missions as appropriate; and updating the financial management rating in the Implementation Status report (ISR). The FM staff at the Country Off ice will play a key role in monitoring the timely implementation o f the action plan.

Fund Flows and Disbursement Arrangements

Bank and IDA Accounts

IDA will disburse the credit through U S $ Designated Accounts (DAs), opened and operated respectively by the N M C P and State Focal Units for M P P with support o f their FM Units.

Specific funding, banking and accounting arrangements are as follows:

1 A US$ DA to which the in i t ia l deposit and replenishments f rom IDA funds will be lodged. A current US$ Interest Account in a bank acceptable to IDA to which interest o n the DA will be credited.

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. A current draw down account in Naira to which draw-downs f rom the DA will be credited once or twice per month in respect o f incurred eligible expenditures, maintaining balances o n this account as close to zero as possible after payments.

All bank accounts will be reconciled with bank statements o n a monthly basis. A copy o f each bank reconciliation statement together with a copy o f the relevant bank statement will be reviewed monthly by the Project Accountant who wil l expeditiously investigate identified differences. Detailed banking arrangements, including control procedures over al l bank transactions (e.g., check signatories, transfers, etc.), wil l be documented in the Financial Procedures Manual (FPM).

Additionally, N M C P and each participating State Focal Units for MPP will have an IDA Ledger Loan Account (Washington) in U S Dollars/Naira/SDR to keep track o f withdrawals f rom IDA credit. The account will show (i) deposits made by IDA, (ii) direct payments by IDA, and (iii) opening and closing balances.

Funds Flow Diagram

SourceofFunds I IDA I L I

1 Bank Accounts .

Current (Draw down) account in Naira

Bank Accounts

Disbursement Methods

By effectiveness, the Project will use the Transaction-based Disbursement Procedures (as described in the Wor ld Bank Disbursement Handbook), i.e., direct payment, reimbursement, and special commitments. When project implementation begins, the quarterly Inter im Financial Reports (IFRs) produced by the Project will be reviewed. Where the reports are adequate and produced o n a timely basis, and the borrower requests conversion to report-based disbursements, a review will be undertaken by the Task Team Leader (TTL) to determine if the Project i s eligible for report-based disbursement. The adoption o f report-based disbursements by the Project will enable it to move away from time-consuming voucher-by- voucher (transaction-based) disbursement methods to quarterly disbursements to the Project’s Special Account based o n IFRs. Detailed disbursement procedures will be documented in the FPM.

Minimum Value of Applications

The Minimum Value o f Applications for reimbursement, direct payment and special commitment i s 20 percent o f outstanding advance to Designated Account.

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6.76 1.44

Reporting on Use of Credit Proceeds

100% Amount payable pursuant to Section 2.07 o f the General Conditions

The supporting documentation for reporting eligible expenditures paid f rom the Designated Account should be a summary report o f the Statement o f Expenditures and records evidencing eligible expenditures for payments against contracts valued US$200,000 for goods, US$lOO,OOO for consulting f i r m s and US$50,000 for individual consultants and a l i s t o f payments against contracts that are subject to the Bank’s prior review. The supporting documentation for requests for direct payment should be records evidencing eligible expenditures (copies o f receipt, supplier’s invoices, etc). All supporting documentation for SOEs will be retained at by the FM Units and must be made available for review by periodic Wor ld Bank review missions, internal and external auditors.

Designated Account

The Designated Accounts will be managed by the NMCP and State Focal Units for MPP, under delegation o f the FMOF and State MOF respectively. The currency for Designated Accounts will be Uni ted States Dollar. The allocation ceilings o f the Designated Accounts will be as indicated o n the Disbursement Letter (DL).

Counterpart Funding

No counterpart funds from the Federal or State Governments are anticipated.

Monthly Replenishment Applications

The DAs will be replenished through the submission o f Withdrawal Applications o n a monthly basis by the FM Units and will include reconciled bank statements and other documents as may be required until such time as the Borrower may choose to convert to report-based disbursement.

Disbursements by category

The table below sets out the expenditure categories and percentages to be financed out o f the Credit proceeds

Table 1- Disbursement Categories

Category

(1) Goods, works, consultant services; workshops, training and audit for the Project (2) Operating Cost (3) R e h d o f Project Prenaration Advance

TOTAL AMOUNT

Amount o f the Financing Allocated (expressed in

Percentage o f Expenditures to be Financed

121.70 I

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Annex 8: Procurement Arrangements


A. General

Country Environment

Before 2000, public procurement in Nigeria was in fact unregulated and non-transparent, and represented a huge cost to the Treasury because o f widespread fraud and corruptive practices. Since FY2001, Nigeria has been implementing slowly a procurement reform program based o n the recommendations o f the 2000 CPAR. A review o f the implementation o f the 2000 CPAR recommendations, as reflected in the recent PEMFAR, shows that implementation o f the procurement reform program has brought about improvements in obtaining value for money in public sector expenditures and in introducing some level o f transparency into the procurement process. M a n y CPAR recommendations have been implemented or are being carried out. In this regard, the CPAR o f 2000 has been a positive catalyst, because i t supported the agenda o f financial sanitation o f the current Government. The FGN took the fol lowing several key actions to advance the procurement reform.

The Federal Ministry o f Finance (FMF) circulated Guidelines for Due Process Certification o f Contracts, contained in Circular No.Fl5775 o f June 27,2001, on “New Policy Guidelines for Procurement and Award o f Contracts in Government Ministries and Parastatals.” The guidelines included a number o f critical measures such as: (i) the abolition o f Federal and Departmental Tender Boards and their replacement with Ministerial Tender Boards; (ii) the requirement for the preparation o f quarterly procurement plans; (iii) the application o f open competitive tendering procedures and the making o f contract splitting to circumvent this principle a serious offence; (iv) the nationwide advertising o f public contracts above 10 m i l l i on Naira; (v) the creation o f clearly defined and transparent tender and proposal evaluation criteria; (vi) the requirement to submit tender and performance securities, public tender openings, and award contracts to the lowest evaluated bidder; and (vii) the publication o f tender awards in the national press, and the carrying out o f procurement audits and inspections.

The Government created the Budget Monitoring and Price Intelligence Unit (BMPIU) in the same year as a Due Process Unit located within the Presidency, to ensure that this Circular was carried out. The BMPIU provides “due process certificates for award o f contract” after review o f the procurement documents prepared by the MDAs. The BMPIU also carries out due process reviews for the certification o f contract payments. Market prices are reviewed for adequate guidance (“the right cost o f the contract”); i f proposed contracts are too costly compared with this price analysis, the BMPIU may not certify the proposed award o f the contract and may request that the price be adjusted to the market level. The recent PEMFAR report indicated that contract prices were reduced substantially and, in 2004, reportedly saved the Treasury substantial amount. Six years after the 2000 CPAR, collaboration between procurement and financial management has been strengthened considerably. A Cash Management Team chaired by the Minister o f Finance, o f which the BMPIU i s a member, ensures that payments are made only when certified by the BMPIU.

A Procurement Bill has been prepared by Government and currently being debated at the National Assembly for enactment. The Bill adheres to the principles o f the UNCITRAL model law, and outlines the principles o f open competition, transparent procurement procedures, clear evaluation criteria, award o f contract to the lowest evaluated tender, and contract signature. The legislative framework i s applicable to a l l procurement categories (suppliers, contractors, consultants) and must be applied for al l public funds regardless o f value. The Bill has provisions for exceptions to competitive tendering, which are the

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exception rather than the rule. In anticipation o f the enactment o f the Bill in 2006, Government i s also preparing Regulations, Standard Bidding Documents and Manuals for the Procurement o f Goods, Works and Consulting Services, which describes the minimum contents o f the tender and proposal documents as wel l as the essential elements are in line with internationally acceptable procurement standards. The Procurement Bill presents o f a complaints and appeals mechanism.

Procurement Risk at the Country level: However, the contract administration in the public sector s t i l l suffers f rom inefficiency and delays in contract payments, while delays in the Nigerian Customs further exacerbate the problem. For project in Nigeria, in general, the key issues and r isks concerning procurement during implementation o f projects include: (i) a lack o f appropriate regulation (bidding documents, Standard Evaluation formats, etc.); (ii) a lack o f National Procurement Manual; (iii) lack o f adequate record keeping; (iv) lack o f effective procurement planning; and (v) inadequate contract management systems and techniques that are common in the public sector.

Currently, the Government Procurement reform program i s being supported by an IDA Credit -ERGP with a substantial component focusing on procurement reforms and an IDF Grant, to assist Government address the weak procurement capacity in the public sector and to build appropriate partnership with the private sector. On the other hand, Government i s also in the process of reforming the Custom practices to modernize and make it more effective.

Though there has been improvement in obtaining value for money in public sector expenditures and increased level o f transparency into the procurement process, and substantial steps are being taken by Government to reform i t s procurement policy and practices to make them more efficient, effective and transparent, but until the Procurement Bill i s passed to l aw and the current procurement reform program and implementation i s institutionalized, the procurement risk in the country i s high.

Procurement risk at the Sector and Project level: The Health sector has had a long history o f implementing various Bank-financed projects, and it i s currently implementing the Second Health System Development Project. During the implementation o f these projects, substantial weaknesses have been identified. They include insufficient procurement capacity at both federal and state levels, lack o f effective and efficient storage and faulty distribution systems. This can be attributed in part to the size o f the country and to the centralization o f procurement activities. Post-procurement reviews for previous projects have also identified inadequate procurement planning and contract management skills, due to the lack o f capacity, inadequate storage facilities, and filing system.

T o mitigate above identified weak capacity, under the proposed project, NMCP will hire a Procurement Consultant, and a Logistic Consultant to strengthen i t s capacity. In addition to the support that wil l be received from the Procurement and Logistic consultants, supply o f majority o f the commodities especially A C T and LLIN under the project will be contracted by the NMCP using a framework contracts. These - fixed price- framework contracts will have a period o f 18 months and will require phased deliveries directly to the respective States by the suppliers. This will reduce the number o f intermediate points, thereby reducing the risk o f pilferage, waste and delivery lead time. Appropriate bidding documents for such framework contracts are being prepared and will be discussed further during negotiations. An organized private sector deliveryAogistic organizations referred to as PIF above, with proven experience in this area, will be hired on an as-needed basis by each participating state for the distribution o f a l l commodities f rom the State level to the facilities and communities. The FMOH with the assistance o f consultants and the RBM partners will carry out a comprehensive assessment o f the storage facilities at the state and LGA level. Depending o n the result o f this assessment, the S M O H (assisted, where necessary by the PIFs) wil l make a decision as follows: (i) use the existing facilities (as they are); (ii) rehabilitate existing facilities; and (iii) arrange for use o f private spaces as an interim measure while capacity at both the State and LGA i s being enhanced. The S M O H may also require acquisition o f some

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ancillary equipment to complete the rehabilitation. In a l l cases, the Bank procurement procedures shall be used by the SMOHs for procurement o f goods, works and contracting o f services.

A proper filing system i s being developed as part o f the PPF activities. Also the PPF has funded the services o f a Procurement Consultant and will fund a Logistic Consultant, and a Technical Specialist (with experience in similar projects), t o assist with effective management o f the proposed centralized procurement. They will also participate as independent experts in al l evaluation committees at federal and at state levels. The TORS for these consultants have been developed and EO1 i s expected to be issued before negotiations.

B. Implementation Arrangements

Federal level

The NMCP, within the Federal MOH, will be responsible for the overall coordination o f project activities, specifically with other Government Ministries, other Federal MOH departments and SMOH, and federal representatives o f the faith-based and private sector health delivery systems. The project procurement function will be centralized at the federal level for major procurements to ensure maximum coordination, quality control, and national accountability. S M O H will be represented by their Procurement Officer who will participate in a jo in t procurement board at the federal level. The procurement board will meet in Abuja, as needed, to agree and approve centralized project procurements that the states will benefit from. This i s to ensure that the participating states are fully aware o f what, quantities and quality o f the products being procured centrally. The contracting arrangement enumerated (see A para 9 above) i s acceptable to the states because the commodities will be procured and delivered to the states at n o cost to the state. The Ministry o f Finance will be responsible for ensuring removal o f taxes and tariffs on a l l project-related materials purchased and, io int lv with the FMOH. for facilitating rapid customs clearance o f a l l international bidding.

Since the project will finance large quantities o f commodities, A Logistic Management Information System (LMIS) will be created to track a l l project commodities, such as LLITNs and ACTs f rom their point o f entry into Nigeria through to the decentralized distribution points in the states and LGAs (public health facilities, FBO and private sector). The L M I S will use a standardized form that record the transmission o f the quantity o f LLITNs and A C T at each point where an organization takes delivery or delivers these commodities. The L M I S will track the distribution o f the ACT and LLITNs down to the lowest level service delivery point. Each State with the assistance o f the PIF where necessary will be responsible for tracking i ts own allotments but will be required to use one reporting system and forward this information to the federal level, assisted by a logistic support specialist and an M&E Agent. The L M I S will show the spatial distribution o f LLITNs and ACTs in the project area, and provide the project management to determine commodities’ stock-on-hand, consumption and losses, and adjustments. The system wil l use a set o f standardized forms and records to track the commodities’ storage and distribution. These records will provide information on stock-keeping, transaction and consumption records and will enhance easy implementation o f the framework contract. As an extension o f the L M I S a procurement monitoring and complaints database shall be established. This database should include a l l documents supporting each bid including unit prices quoted and prices at which contracts are awarded, quantities and dates o f supplies, rejection o f supplies, date bill received, value and date o f payment, complaints received, responses sent, and actions taken. This database should be updated o n a monthly basis.

Each SMOH, with the assistance o f the PIF, will be responsible for using the L M I S data to monitor the stock levels and forecasts for the state and LGA. The L M I S will show the spatial distribution o f LLITNs and ACTs in the project area, and provide the project management to determine whether any area i s deprived o f needed commodities. The M&E Agent will biannually sample the L M I S data and ver i fy the

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chain o f transactions f rom the port down to the lowest level service delivery point t o authenticate the information.

State and LGA levels

The S M O H o f each participating state will be responsible for implementing project activities at state and local levels. The S M O H procurement function will be supported, as necessary, in their technical and operational functions by the PIF, which would also maximize the coordination o f the activities between the federal, state, and local levels. In each o f the participating state, the S M O H teams will oversee the implementation o f PIF activities, when such entities are recruited. Each SMOH, with the assistance o f the PIF, will be responsible for using the L M I S data to monitor the stock levels and forecasts for the state and LGA. The L M I S wil l show the spatial distribution o f LLITNs and ACTS in the project area, and in form project management whether any area i s deprived o f needed commodities. The M&E Agent will biannually sample the L M I S data and verify the chain o f transactions f rom the port down to the lowest level service delivery point to authenticate the information. This information will feed in into the preparation o f the project periodically updated procurement plan.

Payment to suppliers should be made within 30 working days o f receiving the bill with supporting documents f rom the suppliers or communicating deficiency in the bill within 15 working days.

C. Guidelines

Procurement for the proposed project will be carried out in accordance with the W o r l d Bank's "Guidelines: Procurement Under IBRD Loans and IDA Credits" dated M a y 2004; and "Guidelines: Selection and Employment o f Consultants by Wor ld Bank Borrowers" dated M a y 2004, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the Loadcredi t , the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, pr ior review requirements, and time frame was agreed between the Borrower and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.

The procurement procedures and SBDs to be used for each procurement method, as we l l as model contracts for goods procured were presented in the Malaria Control Booster Project Implementation Manual, which includes an accompanying Procurement Manual, that was discussed and agreed at Negotiations.

Procurement of Goods. Major goods procurement under this project will take place at the federal level and it would include: anti-malaria drugs, LLITNs, insecticides for spraying, spraying equipment, computer ware, office equipment and supplies for project implementation units, and vehicles to visit project sites. Major i ty o f the procurement function will be carried out by the States with support, as necessary, f rom the PIFs. I t would include purchase o f other drugs for treatment o f related symptoms, minor rehabilitation works, ancilliary equipment etc. Procurement will be done using the Bank's SBD for a l l ICB, LIB and NCB as there are n o National SBDs that are satisfactory to IDA. Drugs and LLITNs may be purchased directly f rom WHO pre-selected suppliers. Procurement for readily available off-the- shelf goods that cannot be grouped or standard specification commodities for individual contracts o f less than US$50,000 equivalent, may be procured under Shotming Procedures as detailed in paragraph 3.5 o f the "Guidelines: Procurement under IBRD Loans and IDA Credits" May, 2004 and June 9,2000 Memorandum "Guidance on Shopping" issued by IDA.

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Procurement of non-consulting Services. Non-consulting services may include spraying services, but larger contracts are envisaged. These services expected to be procured by the States with the assistance o f the PIF, where necessary, may fol low NCB procedures or Shopping depending o n the amount in question. Smaller contracts may be concluded following prudent shopping procedures as detailed in paragraph 3.5 of the "Guidelines: Procurement under IBRD Loans and IDA Credits" May, 2004 and June 9,2000 Memorandum "Guidance on Shopping" issued by IDA will be followed.

Selection of Consultants. Consultancy services which includes, technical assistance, selection o f the Project Implementation Facilitators, the Monitoring and Evaluation Agent and the Social Marketing Agent, quantification, distribution and logistic operations, baseline studies for quantitative monitoring, external audit etc, will be selected using Request for Expressions o f Interest, short-lists and Bank SRFP, where required by the Bank's Guidelines. Short l i s t s o f consultants for services estimated to cost less than $200,000 equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paras. 2.7-2.8 o f the Consultants Guidelines. Research Institutes, public training institutions and NGOs may be hired to carry out specific researches, training, distribution and monitoring services in accordance with paragraph 1.1 1 (b - d) and 3.16 o f the Consultant Guidelines. The services o f the PIF shall be contracted using QCBS in accordance with para 2 o f the Consultants Guidelines.

Operating Costs financed by the project will be procured using the implementing agency's administrative procedures which were found acceptable to the Bank.

Standard Bidding Documents: The procurement procedures and SBDs to be used for each procurement method, as wel l as model contracts for goods procured, are presented in the Malaria Control Booster Project Implementation Manual that has been developed. The PIM includes a chapter o n Procurement Manual that has been adopted from the Generic procurement Manual for Bank assisted projects in Nigeria.

D. Assessment of the agency's capacity to implement procurement

An assessment o f the capacity o f the Implementing Agency to implement procurement actions for the project has being carried out using the Procurement and Supply Management T o o l h t template. The outcome o f the assessment has been discussed and factored into the design o f the procurement arrangements. The assessment has reviewed the organizational structure for implementing the project, the supply chain management, the interaction between the project's s t a f f responsible for procurement and the Ministry's relevant central unit for administration and finance and the roles o f each o f the actors that will be involved in the procurement function.

The assessment o f NMCP department shows that the unit does not have adequate experience in the supply chain management required for the same magnitude o f commodity that will be procured by the project. Therefore, the department will be assisted by an experienced Procurement Officer and a Logistics Officer, as wel l as a Technical Specialist that shall be recruited using a competitive process. Whi le the procurement consultant has been recruited, the other two consultants will be recruited immediately after negotiations with funds f rom the PPF. The TORS for the Logistic consultant will include among others the followings: (i) based o n strategic and annual work plans, facilitate forecasting and quantification process; (ii) with input from technical specialists o f both the Federal and State M o H s build technical specifications needed for procurement; (iii) advise on packaging, labeling and determine logistics requirements for drugs, equipment and supplies; (iv) review and suggest enhancement o f in-country logistics warehousing and distribution management system and capacities; (v) advise on equipment and drugs quality issues working in conjunction with the drug regulatory authority and the Pharmacy Units o f the Federal and State M o H ; (vi) advise on realistic lead time requirements for the supply chain so that this

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Action

Procurement Plan for the f i rs t 18 months prepared and agreed with the Bank

section o f the Project Implementation Manual (PIM) including adoption o f the Generic Procurement manual for Bank financed Projects in Nigeria

Preparation o f Procurement

i s incorporated in the procurement plans; (vii) identify capacity gaps, develop training plan, carry out training or recommend appropriate training to build the MoH 's capacity in logistics and supply chain management; and (viii) advise or develop monitoring and evaluation systems for supply chain management.

Responsibility

NMCP

NMCP

However, some o f the key issues and r isks concerning procurement for implementation o f projects in the sector have been identified. These risks shall be finalized after the completion o f the ongoing assessment using the P S M Toolk i t template questionnaires. The corrective measures are reflected in the table below.

Ref. No.

1

2

7

8

Set up adequate f i l l ing system

Computerize record system

Organized Contract Management NMCPIBank trainin for ro'ect staff Develop procurement and distribution tracking system --t

Due Date

Draft prepared during appraisal

By Negotiations

By Negotiations

31/01/2007

31/01/2007

31/01/2007

1511 212006

0/03/2007

Remarks

To be finalized during negotiations

Reviewed and agreed to by the Bank prior to negotiations

Documents adopted prior to negotiations

As part o f the contract, the FMOH wi l l be required to carry out a comprehensive assessment o f the storage facilities at the state and LGA level To ensure easy retrieval o f informatioddata To ensure easy retrieval o f informatioddata To improve project staff cont. mgt. sk i l l s To monitor effectiveness and efficiency o f both procurement and distribution o f centrally procured items

Despite a l l o f above progress made by Government o n procurement reforms, the use o f existing units in the sector with procurement capacity, and the mitigation measures being put in place at the project level, the overall project risk for procurement i s Substantial.

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E. Procurement Plan

A procurement plan for the f i rst 18 months o f project implementation based o n the report o f a survey - Population based Mobi l i ty data (expected number o f Malaria episode per year) - has been completed. The p lan that will provide the basis for the procurement methods was discussed at appraisal. This plan was agreed between the Bank and the Project Team at negotiations and will be made available at both the Federal and the participating State Ministry o f Health. I t wil l also be available in the project’s database and in the Bank’s external website. The Procurement Plan will be updated in agreement with the Project Team annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.

F. Publication of Results and Debriefing.

On-line (DG Market, UN Development Business, andor Client Connection) publication o f contract awards will be required for a l l ICB, NCB, Direct Contracting and the Selection o f Consultants for contracts exceeding a value o f U S D 200,000. In addition, where prequalification has taken place, the l i s t o f pre-qualified bidders wil l be published. With regard to ICB, and large-value consulting contracts, the Borrower will be required to assure posting o f bidding documents on the web site o f the implementing agency and publication o f contract awards as soon as IDA has issued its ‘no objection’ notice to the recommended award. With regard to Direct Contracting and NCB, publication o f contract awards could be in aggregate form o n a quarterly basis and in local news papers. All consultants competing for an assignment involv ing the submission o f separate technical and financial proposals, irrespective o f i t s estimated contract value, should be informed o f the result o f the technical evaluation (number o f points that each firm received), before the opening o f the financial proposals. The P M U should be made available to any member o f the public promptly upon request al l shortlists o f consultants and it will be required to offer debriefings to unsuccessful bidders and consultants should the individual f i r m s request such a debriefing. The P M U will post annual progress and Mid-Term Review reports o f the program o n the implementing agency’s website.

G. Frequency of Procurement Supervision

In addition to the prior review supervision to be carried out fi-om Bank offices, the capacity assessment o f the Implementing Agency has recommended two supervision missions annually to visit the field to carry out post review o f procurement actions at the federal level and the state level, including the PIFs, as necessary. Likewise, a Procurement Technical Audit shall be conducted o n yearly basis.

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1

Ref. No.

1

2

3

4

H. Details o f the Procurement Arrangements Involving International Competition

2 3 4 5 6 I 8 9 10

Contract Estimated Procurement P-Q Domestic Review Expected Expected Comments (Description) cost Method Preference by Bid- Contract

(yeslno) Bank Opening Award (Prior Date Date I Post)

Procurement o f 14,000,000. LIB POS-q NO Prior 01/11/06 21/04/07 LLrnS Procurement o f ACT 6,080,000 DC POS-q NO Prior 05/01/07 21/04/07 There i s only

one internationally approved supplier

Procurement of SP 250,000 NCB Pos-q No prior 10/03/07 30/05/07 for Intermittent Preventive Treatment Procurement of 1,200,000 ICB Pos-q Yes Prior 15/01/07 30/04/07 Indoor Residual Spray

1. Goods, Works, and Non Consulting Services

(a) List o f contract packages to be procured following ICB and direct contracting:

(b) ICB contracts estimated to cost above U S $250,000 per contract and all direct contracting wil l be subject to prior review by the Bank. Except for one contract, procurement package for the f i rst 18 months will be prior reviewed. This i s because o f the large size o f the packages, limited or sole manufacturer and also to ensure compliance with Bank’s procurement procedures.

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6

2. Consulting Services

(a) L i s t o f consulting assignments with short-list o f international f i rms.

7 8 1 ) 2 3 I I

Not Applicable

Ref. Description of Assignment Estimated No. cost (%)

1 Recruitment of Procurement 40,000 Specialist

2 Recruitment o f Logistic 40,000

3 Recruitment of Technical 60,000 Specialist

Specialist

completed. 07/12/06

I I

4 I Base Line Survey I 300,000 I 340,000 I Monitoring and Evaluation

Not Applicable

Facilitators

02/01/07

4 I 5

12/09/06 18/12/06

Prior

Prior

Prior

13/02/07 27/04/07

7 j E i J r

Prior

18/03/07

1 510 1 107

10/09/07

15/05/07

Expected Proposals

Submission Date

Not Applicable

Expected Contract Award

Date

30/10/06

Comments

Recrui tment has been

75

Annex 9: Economic and Financial Analysis


Project rationale

There i s a strong economic and public health rationale for investing in malaria control intervention in Nigeria and for involvement o f the public sector in the fight against that scourge.

First, malaria i s a major public health problem in Nigeria. The disease i s highly endemic throughout the country and constitutes one o f the leading causes o f morbidity and mortality, especially among children under the age o f f ive and pregnant women. Malaria prevalence rate i s estimated at 919 per 100 000 and accounts for 40 percent o f the burden o f disease reported at outpatient department (Abebe et al, 2003.) I t represents about 30 percent o f estimated ch i ld deaths or about 300 000 children each year (World Bank, 2005). It i s also associated with 11 percent o f maternal deaths.

Transmission of malaria i s stable and perennial in al l parts o f the country. In the northern part o f Nigeria, transmission i s intense during the short wet season and lower during the long dry season. In the southern part o f the country, transmission i s intense, stable and uni form throughout the year. More than 80 percent o f the cases o f malaria are caused by Plasmodium Falciparum, the most deadly form o f the parasite responsible for the disease. The remaining cases are due to Plasmodium malariae, Plasmodium ovale, or a combination (Leighton et al, 1993). The increasing resistance o f Plasmodium Falciparum malaria to conventional antimalarial drugs such as chloroquine and sulfadoxine-pyrimethamine has been reported in several areas o f the country and can be as high as 65 percent in the case o f chloroquine and 25 percent in the case o f the association sulfadoxine-pyrimethamine (Onwujekwe et al, 2004.)

Second, the economic and social burden o f malaria in Nigeria i s substantial. The economic impact o f the disease has been extensively studied in several countries across the wor ld including Nigeria and it i s clear that the disease affects long-term economic growth and development. At the macroeconomic level, Sachs and Malaney (2002) estimated that, over the period 1980 - 1995, Nigeria suffered an accumulated loss f rom the economic growth penalty o f malaria endemicity o f about US$ 17 billion, which represents a per capita loss o f US$156 or 18 percent o f actual 1995 income. In addition to the traditional direct and indirect costs used in previous attempts to estimate malaria economic burden, Sachs and Malaney identified other pathways through which malaria affects economic development. Malaria has long-term demographic consequences. I t affects the acquisition o f human and physical capital, as we l l as movement o f people. I t also has a negative impact o n trade and foreign direct investment.

There i s no comprehensive data on public health sector expenditure o n malaria in Nigeria. However, given the epidemiological profi le o f the disease and the high proportion o f suspected malaria cases received in outpatient and inpatient services, i t can be expected that a significant proportion o f the Government health budget goes to treatment o f malaria cases at health facility level.

At the household level, the consequences o f malaria include considerable direct (prevention, medical consultations, hospitalizations, laboratory tests, medications, transport, etc.) and indirect (productivity losses and income forgone due to morbidity and mortality) costs that affect most vulnerable and poor groups. In a study conducted in 1993 in Nigeria among Ibadan and Oyo State communities, Leighton and Foster estimated that school-aged children could miss up to 12 schooldays per year due to malaria or up to 6 percent o f a typical school year o f 186 days. The same study estimated that malaria prevention and treatment could absorb up to 13 percent o f household annual disposable income. Such a cost burden can be considered catastrophic for the economy o f a poor household, meaning that i t i s l ikely to force

76

household members to cut their consumption o f other minimum needs, trigger productive assets sales or high levels o f debt, and lead to impoverishment (Russell, 2004).

Third, the market failure and the poverty dimension associated with malaria control provide support for extensive public intervention (Hanson, 2004). The patent system confers a monopoly status to pharmaceutical f i r m s over a defined period for a specific product in order to al low them to recoup the costs o f research and development. Although this can be justified, the immediate consequence i s that the prices o f new and often most effective drugs are not determined by the market mechanism and, thus can be excessive for poor countries. This i s particularly true o f the ACT, which cost at least US$1 per adult treated, roughly 10 times more than current monotherapy (Mutabingwa, 2005). The Government o f Nigeria has recently adopted an ACT as the first l ine treatment in response to the increasing resistance o f the parasite to usual antimalarial drugs and it i s obvious that subsidy can not be avoided i f these drugs are to be used at large scale by the population, particularly the poorest.

Furthermore, many malaria control interventions have public goods characteristics or externalities. Therefore, the private market will not produce enough o f these interventions relative to their social benefits (Hanson, 2004). For example, the benefits conferred by a mass uti l ization o f I R S or LLIN at the community level in terms o f reduced vector capacity o f the mosquito population are non-excludable (those who do not use the intervention will also benefit) and non-rival (the benefits o f the interventions to a household are not reduced by enjoyment o f those benefit by another household.) Hence, public intervention i s necessary to ensure adequate uptake o f the above mentioned interventions.

Another source o f market failure i s the asymmetry o f information between patients and providers or the ignorance o f both o f them about the most appropriate and effective treatment (Hanson, 2004). The level o f knowledge o f the population about malaria control interventions i s very l o w in Nigeria and does not generate sufficient demand for these interventions. The benefits o f ITN are not widely known in many communities in the country. A study conducted in three rural communities in 2003 in Enugu State found that at least 98 percent o f the people interviewed had never heard o f ITN (Onwujekwe, 2003.) Similarly, a study conducted in 2003 in Ibadan found that only 56 percent o f the health workers visited knew the correct dosage o f chloroquine (Fawole et al, 2004.)

Finally, as discussed above, the cost burden o f malaria i s very high for poor household. Although n o difference has been identified between poor and r i ch household in terms o f malaria incidence in Nigeria (Uzochukwu and Onwujekwe, 2004) and elsewhere in the world, it i s clear that the costs o f technologies available to prevent or treat malaria can represent an insurmountable barrier for poor households. For example, the LLIN and ACT are known to be highly cost-effective but they are not affordable for a significant proportion o f Nigerian households. This gives justification for a public intervention to ensure equal access to malaria control interventions for everybody irrespective o f income and other socio- demographic characteristics.

Costs and potential impacts of scaling up malaria control interventions

Policy makers need information o n the costs and effectiveness o f interventions. The existing knowledge base on cost-effectiveness is, however, sparse, and i s l imited to a few studies that are hard to compare, generalize, or relate to operational situations. T h i s section examines the potential cost and impact related to the project. Specifically, this section seeks to answer the fo l lowing questions: (i) how much extra money i s needed to increase malaria interventions coverage f rom the current level to the achievable targets in 2010; and (ii) what results, in terms o f reduction in chi ld and maternal mortality, can be

77

achieved by spending the extra money? Using the Marginal Budgeting for Bottlenecks (MBB6) tool, this section presents the estimated cost o f increasing the coverage o f high impact malaria interventions in Nigeria along with the impact o f these interventions on maternal and chi ld mortality. B o x 1 provides the different steps required to apply the MBB tool.

Box 1: Steps for applying the M00 tool

Stepl: Analvsis o f the health svstem Establish the epidemiological profile o f the country Understand the organization and the functioning o f the health system (norms, policies, strategies) Identify the health care interventions already in place in the country

Step2: Identification o f high impact interventions Selection o f effective interventions to improve maternal and child health i s based on the Lancet series o n child7 and neonatal8 survival, the Cochrane review o f maternal health interventions, and the British Medical Journal

Step3: Identification and analysis o f bottlenecks Organize the interventions selected according to their delivery mode Obtain data from reliable sources on the availability, accessibility, utilization, continuity and quality o f the services related to each intervention Identify and analyze the weak links in the chain o f detenninants for an effective coverage

Step 4: Formulation o f a strategy Define a health package intervention Set up realistic coverage objectives for each intervention in the package

Step 5: Cost and impact analvsis Determine the impact and the cost o f reducing the bottlenecks identified

This costing exercise should normally begin with the analysis o f the health system but, we will go through only the last four steps required to apply the MBB. The analysis o f the health system has been conducted extensively in several documents produced by the Government o f Nigeria and the Wor ld Bank (World Bank, 2005). For a br ie f description o f the country and the health sector issues, refer to section A1 o f this document.

Identification of high impact interventions

There are relatively few interventions available to fight malaria and the control strategies vary with local malaria endemicity (Table 1). The various means focus either o n prevention or o n treatment o f malaria cases. Preventive interventions are based on vector control (LLIN, IRS, etc.) or o n preemptive treatment o f presumed malaria cases (IPT). For treatment o f malaria, several drugs exist and a few are relatively inexpensive. However, resistance to most drugs i s growing rapidly. Recently, combination treatments with and without artemisinin derivatives have been tested and found not only to be effective but also to slow the growth o f resistance (White, 1999).

Given the endemicity o f malaria in the Nigeria and the reported increasing resistance o f the parasite to conventional anti-malarial drug in the country, the Government o f Nigeria, with the support o f WHO and other technical partners, has adopted an A C T (Artemether-Lumefantrine) as the first-line treatment. The

The MBB i s a tool developed by teams from the World Bank, UNICEF and WHO to help plan, cost, and budget 6

incremental allocations to the health sector ’ Lancet, 2003, Child Survival: 361, 362. Lancet, 2005, Neonatal Survival. Published online, March 3, 2005.

78

association pyrimethamine - sulfadoxine has been reserved for intermittent preventive treatment o f pregnant women. Moreover, the country has adopted the use o f long lasting ITN as main strategy to prevent the disease.

Table 1 : Priority malaria control strategies, by epidemiological setting

Epidemiological setting Control Strategy

Stable endemic malaria Prevention Examples: large parts of East, Central and West Africa (Nigeria), Papua New Guinea, Solomon Islands and people living with HIV/AIDS Vanuatu - IRS, where appropriate

- ITN for children under 5 years of age, pregnant women and

- IPT in pregnancy

- Early and effective case management including presumptive treatment for suspected cases and home management where appropriate

Treatment

Unstable malaria Prevention Examples: parts of Southern Africa, Transcaucasia, Central - IRS Asia and the Americas; highland and desert fringe areas, some urban areas, plantations, irrigation schemes - Environmental management

- Larviciding

- ITN Treatment - Early and effective case management in suspected cases - Diagnostics to confirm cases, if possible before treatment

- For travelers going to malarious areas, chemoprophylaxis and personal protective measures against mosquitoes

- Earlv and effective case manaaement in SusDected cases

Free o f malaria Prevention Examples: parts of Southern and North Africa, Ethiopian and Eritrean highlands and Transcaucasia

Treatment

- Diagnostics to confirm cases, possible before treatment Source: WHO, 2005, World Malaria Report

In this costing exercise, we evaluated several scenarios. First, we estimated the cost and impact o f malaria-specific interventions when they are implemented alone or in combination with other malaria- specific interventions (ACT, IPT, LLIN, A C T + LLIN, IPT + LLIN). Then, we assessed the cost and impact o f combination o f malaria-specific interventions with other effective health interventions that can be delivered through the same mode and are already present in the country (cf. B o x 2 for definition o f the service delivery mode). W e have chosen interventions that are simple to deliver and could benefit f rom lifting the constraints that hamper delivery o f malaria-specific interventions. When interventions are implemented together, the MBB estimates the impact in a residual way to avoid double counting or saving the same l i fe twice. Likewise, the cost estimation allows for interactions between interventions. Table 2 summarizes the interventions evaluated, categorized according to their delivery mode, the level o f care, and the period o f implementation in the l i fe cycle.

Table 2: Malaria-specific interventions and other interventions evaluated

1. Family/community based care 1.1 Environmental care

Insecticide Treated Mosquito Nets’ Use of safe drinking water Hand washing by mothers

1.2 Family neonatal care Early breastfeeding (4 hr)

1.3 Infant and child feeding

1.4 Community based illness management Breastfeeding for children 0-6 months

Oral Rehydration Therapy

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Artemisinin-based combination therapy (ACT)’

Antenatal care Intermittent presumptive treatment (IPT)’ Tetanus immunization Prevention and treatment of iron deficiency anemia in pregnancy LLlN for pregnant women through ANC’

2. Population oriented services, through periodic outreach or scheduled clinic sessions 2. I Preventive pregnancy care

2.2 Preventive infant & child care Routine measles DPT3 Hepatitis vaccine Vitamin A - P LLlN for under five through EPI*

3. Clinical individual oriented care (needs to be continuously available) 3.1 Clinical primary level maternal 8 neonatal care

3.2 Clinical primary level child and adult care Delivery by skilled attendant

Antibiotic for pneumonia and dysentery at PHC level Artemisinin-based combination therapy (ACT)’

* Malaria-specific intervention

Identification and analysis of bottlenecks

T o identify delivery constraints, an analysis was made o f bottlenecks that hinder increases in the coverage o f the selected interventions. For this analysis, a l l the interventions were classified according to the mechanism by which they are delivered and thus according to the inputs and strategies needed for their delivery (See B o x 2). Identification o f bottlenecks i s based on an analysis o f indicators measuring the availability o f essential drugs and supplies, access to health services and health workers, in i t ia l utilization o f service, continuity in utilization (adequate coverage) and quality o f the service. These indicators measure a “chain” o f determinants for effective coverage. The bottlenecks identified constitute the “weakest links’’ in the chain. Subsequent analysis o f the main underlying causes and potential strategies to overcome the bottlenecks allows the identification o f “frontiers”, which are the effective coverage levels o f intervention packages that are achievable after removing any o f these bottlenecks.

Box 2: Classification of health care interventions according to their delivery mode.

i. Family/ community based care: These interventions, which include some preventive measures and the management o f maternal and childhood illnesses, can be delivered by the households or the communities themselves under some guidance by health professionals. Insecticide treated bed nets (LLIN) for pregnant women and children under five, condom use, breastfeeding, and oral re-hydration therapy (ORT) are some examples o f interventions that are family or community based.

ii. Population oriented services: These services are delivered to al l the population, regardless o f whether or not they are currently sick. They are usually delivered through periodic outreach or scheduled clinical services. Th is delivery mode includes the following preventive care interventions: immunizations, antenatal care, family planning, etc.

iii. Clinical based individual care: These activities include al l type o f individual curative care interventions that need to be delivered on a health facility and by a trained health care professional. They are offered in a continuous manner so that they can respond to unpredictable situations: a sudden illness, a delivery, etc.

Source: Soucat et al. 2005

In order to allow for potential differences between northern states and southern states, we conducted separate analysis for each group. T w o (Kano and Jigawa) o f the four states targeted by the project in the north are located in the Nor th West region o f the country and the other two are in the Nor th East region (Bauchi and Gombe). Because o f data constraints, we limited our analysis to the Nor th West region and

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use this as model for the northern states o f the country. Since more than t w o third o f the targeted population in the north i s located in the Nor th West region, the situation in that region can be assumed to reflect to a great extent the systemic bottlenecks that will be faced by group I states during implementation phase. Based o n the same arguments, we chose the South region as model for the southern states.

Figure 1 shows the bottlenecks identified in each service delivery mode for each group o f states. The assumption behind i s that interventions that share the same delivery mode are very l ikely to face the same constraints to their implementation. Hence, the bottlenecks identified for EPI reflect the issues any malaria control intervention i s l ikely to face if it i s to be coupled with EPI or, more generally, delivered through outreach or scheduled clinical services (e.g. IPT through A N C or LLIN through EPI). Likewise, the analysis o f LLIN delivery constraints gives an idea o f the possible barriers a service can face if it i s delivered at the family and community level, and the analysis o f AFU delivery constraints mirrors the potential obstacles to the provision o f curative service at the health facil i ty level (e.g. case management with ACT at clinical level). W e relied as much as possible o n regional data to estimate the level o f the indicators used. When regional data were not available, we used national level data or information provided by regional or federal health authorities. The analysis o f the bottlenecks was f i rst conducted during a workshop organized jo in t ly by UNICEF, the Wor ld Bank and the FMOH, in Abuja in February 2006. A state level application o f the MBB tool was then conducted the fol lowing week in Gombe State to adapt the findings to the specific situation o f two states, Gombe and Nasarawa. Table 3, which i s an excerpt f rom the findings o f the Abuja and Gombe workshops, summarizes the major bottlenecks for each service delivery mode related to the above mentioned interventions, along with the underlying causes o f the bottlenecks and the potential operational strategies to overcome the bottlenecks in question.

In the case o f utilization o f LLIN by pregnant women, the health system faces bottlenecks at almost a l l levels, except for geographical accessibility o f the nets. The graphs exhibit the same profi le in both regions, suggesting that both regions face bottleneck at the same level, though the underlying causes might be different in their nature and intensity. Availabil ity o f the net i s generally l o w (60 percentg) in both regions, ownership o f net by households i s extremely l o w (barely more than 10 percent in Nor th West and in South South and does not reflect the level o f availability and accessibility), utilization o f any type o f net by pregnant women i s even lower (less than 4 percent in both cases) and utilization o f treated net during pregnancy i s almost non existent (hovering at 1 percent). Based o n this analysis, the major bottlenecks for an effective use o f LLIN by pregnant women and children under the age o f five l ie between availability and uti l ization (proxied by ownership o f net) and between utilization and quality (most nets are not treated when they are used).

Regarding immunization, which i s used here to understand the potential constraints that can face delivery o f IPT or distribution o f LLIN through EPI, the availability o f vaccine i s l o w at the facility level (40 percent) but accessibility to immunization sessions i s satisfactory in both regions (75 percent and 80 percent, respectively in Nor th West and in South South). The EPI graph shows a big drop from accessibility to utilization o f immunization in North West but a very small drop in South South, suggesting that on one hand population in South have much more contact with the intervention than their counterpart in Nor th and o n the other hand there i s n o bottleneck at this level in South but the Nor th faces a major bottleneck at uti l ization o f immunization. Both regions then show some constraints in continuity of immunization and completion o f the immunization series by children before their f i r s t birthday. The major bottleneck in South South l i e at the continuity o f the series o f immunization by children but this i s unlikely to affect distribution o f LLIN since only one contact i s sufficient t o provide a net.

National level data 9

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90% -

80% -

70% -

60% -

50% -

40% -

30% -

Concerning treatment o f ARI at the facility level, used here to proxy case management with ACT at clinical level, the system faces bottlenecks at a l l level in both regions. The l o w level o f essential drugs availability i s the f irst major constraint, followed by the l o w level o f utilization o f the service and compliance with the treatment. Management o f cases o f malaria at health facil i ty or distribution o f LLIN in a facility-based approach wil l face these bottlenecks.

90% -

80% -

70% -

80% -

50% .

40% .

30% .

20% ~

1 0 % .

Figure 1: Effective coverage bottlenecks for LLIN, ANC, and IRA in North West and South South regions of Nigeria

80% -

70%.

80% -

SO% -

40% -

30% -

20% -

10% -

IT N

- .*-. South -*-North

Districts with Villages Families with Using net in Usirg treated iTN stock distributlng bed net pregnancy net in

ITN's pregnancy

IRA

- .*-. South -*-North

PHC stock Access to DPTI Fully Fully vaccines immunization immunized immunized by

12-23 months Rrst birthday

0% 4 PHC with nu out Women ARilfever ARiIfever ARiIfever of stocks for ED reported heanh treated ~UtStde treated by treated by past 3 months care access home professional professional +

WmpiyinQ

82

Table 3: Bottlenecks, underlying causes and potential strategies for scaling up malaria control interventions

Bottlenecks Underlying Causes Operational Strategies - - -

Family and community care (LLIN, Breastfeeding, Complementary feeding) Poor supply of and access to affordable LLIN and other household commodities commodities

Long distances, limited transport Cost of commodities;

Lack of legal framework for retail of Strengthen supply logistics and legal frameworks Implement community-based distribution

Strengthen existing community health extension workers, if appropriate deploy additional providers

Low demand for LLIN and low continuity in utilization

Lack of demand for neonatal and child care

Limited access to media (especially for poor women)

Few, irrelevant or inappropriate messages.

Cultural context such as traditional practices, fatalism governmental organizations

Partner with community opinion leaders and involve women’s groups

Develop specific messages and use culturally appropriate channels

Promote intrasectoral and intersectoral collaboration-e.g,, with family planning, education, nutrition-and involvement of non-

Develop social marketing-e.g., for LLIN, IRS; consider subsidization Research to understand practices and beliefs Develop specific messages and use culturally appropriate channels Ensure that all community health and nutrition promoters and opinion leaders are well informed

Poor quality of commodities utilized or practices

Inadequate information about healthy or unsafe behaviors for newborn and child care

Schedulable population oriented Services (LLIN through EPI and IPT through ANC)

IEC Improve client friendliness of services Empower women.

Low demand for immunization and Distance ANC

Negative experiences with health system

Engage and educate communities -Training and deploying more auxiliary health staff to schedulable population oriented services -Mapping of unreached and micro planning of schedulable population oriented services

Late use and poor compliance with ANC and EPI cost.

Lack of information, unpredictable contacts.

-Performance based incentives for defaulter tracing and tracking Strengthen Human Resources. Promote evidence-based guidelineslstandards Provide job-aids Strengthen in-service and pre-service training Provide supervision and incentives, not necessarily financial

Inadequate manpower, absenteeism. Competing programs (e.9. polio eradication). Lack of standards for care; existing global guidelines not known and/or adapted or promoted at national level; poor supervision.

Low quality of care, esp. antenatal care

Clinical Care at Primary and Referral Level (ACT) Erratic supply of essential commodities and diagnostics; Relevant

Poor management of supply chain Transport and cold chain failures

Develop essential commodity policies Strengthen skills of supply management team Consider use of appropriate innovative technologies

commodities not in guidelines

83

Low access due to lack and/or absenteeism of skilled personnel

Low utilization by the poor due to affordability barriers and lack of information

Delayed use of services and poor compliance with treatment

Poor quality of care in public and private sector

Inadequate numbers trained Low pay, disincentives to work in rural areas Absenteeism, “Brain drain” Inadequate human resource policies

Low incomes/resources Lack of social security systems Corrupt practices by public sector providers High cost of private sector care

Delays in recognition of illness, decision- making, and lack of transportation Social gap between health staff and poor families

Lack of standards for care, standards not known, low sense of urgency for emergencies Training often not skills-based; Low accountability and motivation of health staff

Training, recruiting, deploying of additional nurses, midwives and physicians with life saving skills for maternal, neonatal and child clinical care Consider performance-based payment Consider hardship allowances for rural postings if appropriate Implement incentives for starting private services in underserved areas Protect the poor from out of pocket expenses for health with a mix of approaches including: community funds and loans, subsidized care, conditional cash transfers, health insurance voucher based reimbursements for providers, ensure accountability of the health system Use a mix of strategies as appropriate including: Birth preparedness messages; Emergency transport schemes and maternity waiting homes; Harness telecom technology for timely response community loans

Purchasing arrangements for primary and referral clinical maternal, neonatal and child care based on performance contracts and introduction of patient report cards Adapt and promulgate clinical guidelines and accreditation systems Strengthen in-service and pre-service training Provide supervision, promote quality assurance;

Source: adapted from Knippenberg and al, 2005.

Formulation of a strategy

A detailed description o f the Project and i t s strategy can be found in Annex 4. Here we provide only additional information o n the assumptions o n which the cost and impact o f the health interventions evaluated are based. Overall, the analysis i s based o n the assumption that results will be obtained through addressing the above identified systemic bottlenecks to service delivery and strengthening the health system. In North West region, we assumed a 50 percent reduction in al l bottlenecks between 2006 and 2010 for the three service delivery modes. The set the bottleneck reduction at a more optimistic level (70 percent) in South South region since the potential for a rapid development o f the system i s higher. Table 4 shows the potential increase in the effective coverage o f malaria-specific interventions that could result f rom lifting the systemic bottlenecks faced by the health system to deliver the service at family and community level, through outreach or scheduled clinical sessions, and at clinical level.

Given the context o f Nigeria and the bottlenecks identified, i t i s very l ike ly that results will be achieved faster by focusing o n family service and o n outreach or scheduled clinical services. In fact, policy, staffing, and basic competency conditions seems to exist already to facilitate scaling up o f malaria control interventions through these channel (distribution o f LLIN for pregnant women and children, community- based malaria treatment, etc.).

X of househoids with net f 3.3% 54.1% % of pregnant sleeping under treated net 1 1% 22.4% % Under fives s l e e ~ ~ ~ ~ under treated net I 7% 22 4%

IPT ~ ~ ~ t r ~ a ~ h sehed~~ed % pregnant women h o received 2 doses of IPT 7 291~ 37 3% ctinical sewices

% Under fives sleeping under treated net f .7% 21.7% ~ n a n ~ women who received 2 doses of IPT I .2% 37.3%

I3.3% 5.a 59'0

South South: 70% reduction in all ~ o ~ t e n % ~ k s over 5 years

~ n ~ e ~ % n ~ i Q n ~ Coverage indicators Basetine 2040 LLlN ~ F a ~ ~ l ~ ~ ~ Q ~ ~ ~ n ~ t ~ ~ ?& of ~ o ~ s e ~ o l d s with net 30 5?& 68 0%

I 5% 45 3% 0 5?4 45 3% 2.3% 77 4%

% of ~ r e ~ ~ a n ~ sleeping under treated net X Under fives sleeping under treated net

IPT (Outreach )Or schedu'ed % pregnant w o ~ ~ n who received 2 doses of IPT clinical services ACT ~ c ~ i n i ~ ~ level) % of malaria cases treated with ACT (under fives) 1 0% 62.4%

Figure 2: E ~ e e ~ ~ ~ e coverage ~ o ~ ~ e n e c ~ s and frontiers for LLIN in North West and South South regions, ~ i ~ e r i a

I North WB5i

orwnawy ' Sources: authors, based on data from Na%3 2003 and ~~1~

85

Cost and impact

The effectiveness o f the interventions was expressed as a reduction in chi ld or maternal mortality. Data o n effectiveness come f rom the Lancet Series o n chi ld survival, the Lancet Series o n neonatal survival, the Cochrane Review and the British Medical Journal paper on maternal survival. The MBB model uses those data to assess the impact o f the proven effective interventions o n neonatal mortality rate, under-five mortality rate and maternal mortality rate when effective coverage i s increased. The difference between the n o intervention scenario and the intervention i s expressed as total number o f l i fe saved each year. Due to lack o f evidence, we did not estimate the impact o f IPT o n maternal mortality, thus underestimating the real impact and the real cost-effectiveness o f that intervention.

The cost estimated i s that o f the resources needed to reduce the identified bottlenecks and ultimately increase effective coverage. W e took into account the costs o f a l l inputs required to deliver the services, namely the cost o f commodities, training, human resources, distribution, incentives, etc. Unit costs were obtained, when possible, through the Ministry o f Health. Otherwise, we used generic values for West Afr ican countries.

Estimation o f impact and cost o f the intervention allows calculation o f the cost per l i fe saved. Furthermore, the MBB model allows estimation o f the additional cost per capita necessary to remove or reduce the identified bottlenecks. Table 5 and Table 6 summarize the simulations results, with the cost expressed as incremental dollar per capita per year. The results are based o n the expected increase in coverage for the interventions evaluated by 2010, as presented o n Table 4. It i s worth noticing at the outset that by international standard almost al l scenarios exhibits high cost-effectiveness ratio except delivery o f A C T at clinical level in South South region. This i s probably the result o f l o w uti l ization o f health care and the considerable resources needed to overcome the systemic bottlenecks. However, it i s clear that over the long term, when the system i s improved and utilization i s high, A C T will exhibit a high cost effectiveness ratio as suggested by other studies conducted in Afr ica (Morel and al, 2005). The result also suggests that utilization o f only A C T at clinical level i s not the best approach to fight malaria in the context o f the South South region o f Nigeria.

Looking at the interventions taken alone, the results suggest that increasing only the coverage for LLIN at family and community level appears, in both regions, to be the most cost-effective option, with a relatively high impact at a very l o w cost. In Nor th West region, i t i s expected to reduce all-cause chi ld mortality by 4.41 percent and maternal mortality by 0.76 percent at an extra cost o f US$0.06 per capita per year, thus costing as l o w as US$. 123 per l i f e saved. In South South region, i t i s predicted to decrease under-five mortality by 9 percent and maternal mortality by 1 percent at an extra U S $ 0.10 per capita per year and costing U S 1 5 4 per l i fe saved. Management o f malaria case with ACT at clinical level exhibits a higher impact than delivery o f LLIN at community level in both regions, but it also shows a higher cost and a lower cost-effective ratio because it requires more investment to improve the delivery system, especially to increase availability o f ACT at health facil i ty level and utilization o f the services. Delivery o f IPT through outreach or scheduled clinical services i s generally expected to shows the lowest impact but also the lowest cost, resulting in a cost-effective ratio higher than that o f ACT but a l o t lower than that o f LLIN.

Analysis o f combinations o f malaria-specific interventions suggests that increasing coverage for LLIN and case management with A C T at family and community level will y ie ld a greater impact in terms o f chi ld and maternal mortality reduction than increasing LLIN and IPT through outreach or scheduled clinical services. However, the latter will have a better cost-effectiveness ratio. The project delivery strategies a im to provide a combination o f malaria control interventions through a combination o f

86

delivery mode: ACT at community level and at clinical level, LLIN at community level, through outreach or scheduled clinical sessions, and at clinical level, and IPT through outreach or scheduled clinical sessions, and at clinical level (cf. Annex 6 for details). The model suggests a substantial impact of this approach o n chi ld and maternal mortality in both regions. In Nor th West, delivery o f a l l interventions through their chosen channel i s expected to reduce chi ld mortality by nearly 17 percent and maternal mortality by 1.57 percent at an extra cost o f US$3.82 per capita per year, exhibiting an impressive US$2,068 per l ive saved. In South South, we can expect over 22 percent decrease in under-five mortality and 1.68 percent reduction in maternal mortality at an additional cost o f US$4.5 1 per capita per year and costing US$2,752 per l i fe saved.

Considering the whole package o f services presented o n Table 2 (malaria-specific interventions along with non malaria-specific interventions), i t i s particularly interesting to notice that it shows a much higher impact o n chi ld and maternal mortality than the malaria-specific package (almost twice as much reduction in chi ld mortality in South South) but the cost difference between the too packages i s relatively marginal, resulting in a much higher cost-effectiveness ratio for the package containing non malaria-specific interventions. The simulations results suggest that we can expect a 23.65 percent reduction in all-cause ch i ld mortality and 3.45 percent reduction in maternal mortality in Nor th West with the whole package; this at an extra cost o f US$3.84 and costing US$1,464 per l i f e saved. Likewise, we can predict over 40 percent reduction in under-five mortality and 9.18 percent decrease in maternal mortality in South South at an additional cost o f US$5.19 per capita per year and saving a l i fe at an extra cost o f US$1,730.

Table 5: Cost and impact of each scenario in North West, assuming 50% reduction in bottlenecks

Interventions Impact Extra cost Extra cost per life saved U5MR MMR (US$ per capita) (US$)

ITN (Family/Community)

IPT (Outreach or scheduled clinical services)

ACT (clinical level)"

LLIN + ACT (Family/Community) IPT+LLIN (Outreach or scheduled clinical services) LLIN+IPT+ACT (Combining all modes)''

Family/Community package

Outreach or scheduled clinical services package

Clinical package

4.41%

0.19%

6.60%

9.68%

4.45%

16.71%

13.11%

6.19%

7.86%

0.76%

0.72%

0.76%*

1.21 %

1.57%

0.37%

0.28%

2.88%

0.06

0.05

1.84

1.90

0.14

3.82

1.79

0.27

1.78

123

3,245

3,981

1.772

290

2,068

1,240

393

2,022

All packages 23.65% 3.45% 3.84 1,464 ' Impact of LLIN only

W e assumed only 25 percent reduction in bottlenecks for ACT in North West Cf. annex 6 for details o n delivery strategies

I O

87

Table 6: Cost and impact of each scenario in South South, assuming 70% reduction in bottlenecks

Interventions

LLlN (Family/Community) 9.14% 1.06% 0.10 154

IPT (Outreach or scheduled clinical services) 0.60% .. 0.06 1,694

ACT (clinical level)12 10.81% 1.17% 2.89 5,003

ITN +ACT (Family/Community) 16.86% 1.06%' 2.73 2,231

Extra cost per life saved Impact Extra cost USMR MMR (US$ per capita) (US$)

12.99% 1.58% 0.29 309 IPT+LLIN (Outreach or scheduled clinical services) LLIN+IPT+ACT (Combining all modes)" 22.57% 1.68% 4.51 2,752

Family/Community package 17.53% 0.35% 1.79 1,414

Outreach or scheduled clinical services package 16.57% 0.39% 0.48 402

Clinical package 17.00% 8.93% 2.93 2,273

All packages 40.75% 9.16% 5.19 1,730 Impact of LLlN only

Figure 3: Projected costs and reduction in mortality associated with implementation of malaria control interventions in North West region, Nigeria

North West - Under-flve mortality reduction .II Maternal mortality reduction ---Extra cost (US$ per caplta per year)

0% IPT (Outreech) ITN IPT+ITN ITN + ACT ACT (clinical) ITN+IPT+ACT All paCkeOeB

(FamlCom) (Outreach) (Fam/Corn) (All modes)


4.5

4

3.5

1 .5[

1

0.5

0

l2 We assumed only 50% reduction in bottlenecks for ACT in South South

88

Figure 4: Projected costs and reduction in mortality associated with implementation of malaria control interventions in South South region, Nigeria

South South

4 5 % - Under-five mortality reduction I " 40%

35%

30%

2 5 %

1 5%

1 0%

6%

0 %

- Maternal mort8

5

4

3

! - 4

1

IPT (Outreach) ITN IPT+lTN I T N + ACT ACT (clinical) ITN+lPT+ACT All packages (FamlCom) (Outreach) (Fam/Com) (All modes)


Fiscal sustainability

The fiscal sustainability refers to the abil ity o f the Government o f Nigeria to finance in the future the project expenditure and sustain scaling up o f malaria control interventions. This issue involves the government capacity to create a fiscal space to finance the cost associated with implementation o f the project without any prejudice to the sustainability o f i t s financial position (Heller, 2006). T h i s i s particularly important in the context o f a country such as Nigeria where the internal resources remain l imi ted and very reliant o n the volatile o i l revenue. Since the project will be financed 100 percent by a Grant f rom IDA, the Government o f Nigeria must find alternative sources o f revenue to replace this funding and sustain malaria control interventions when the grant i s phased out.

Fiscal space can be created through various means. Indeed, additional resources cans be raised by Governments through borrowing, by receiving grants, through tax measure or by reinforcing tax administration, by reprioritizing expenditures or by improving efficiency in service delivery. In light o f the fo l lowing facts, the Government o f Nigeria appears to have room for increasing primary health care expenditure and sustaining o n i t s own malaria control intervention in medium and long term.

Table 7: Selected health accounts indicators, Nigeria, 2002

External resources for health (% of total expenditure on health) 6.1 19 4.7 1.2 3.5 25.6 74.4 90.4

Per capita health expenditure (current US$) Total health expenditure (% of GDP) Public health expenditure (% of GDP) Public health expenditure (% of Government total expenditure)

Private health expenditure (% of total health expenditure) Public health expenditure (% of total health expenditure)

Out-of-pocket health expenditure (% of private expenditure on health) Source: World Health Report, 2005

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According to the World Health Report 2005 (Table 7), total health expenditure accounted for approximately 4.7 percent o f GDP in Nigeria (US$19 per capita per year in 2002) and public health expenditure represented 1.2 percent o f GDP en 2002. T h e external resources contribution to the Government health expenditure was estimated to be around 6 percent in 2002. The private health expenditure in the same year represented 74.4 percent o f total health expenditure, largely coming from out-of-pocket expenditure (90 percent). These figures suggest that the health sector i s very dependent on patients for financing. Other estimates (World Bank, 2005) based on data from the Account General Office, the University o f Ibadan’s national health accounts study for 2002, and the living standard survey for 2004 suggests that health spending i s higher than WHO figures and could be as high as US$30 per capita per year. Nevertheless, health expenditure appears to be very inefficiently allocated and biased against primary health care.

Reprioritization o f expenditure by reducing unproductive expenditure can prove politically difficult to implement, especially intersectoral reallocation. The pattern o f health expenditure in Nigeria, significantly skewed toward hospitals (World Bank, 2005), suggests that intrasectoral reallocation i s possible and can free more resources for high-impact primary health care, especially malaria control interventions. Substantial resources could be made available through this means to sustain malaria control interventions, provided that the Government strong commitment to improving primary health care service continues. Improving efficiency in service delivery and institutional capacity building can also free resources for primary health care, but these options will take time.

Efforts to mobilize domestic revenues have translated into more resources available for the health sector, thanks to strong economic growth over the past few years and the Government commitment to improving primary health care (World Bank, 2005). Furthermore, a draft Health Bill submitted to Assembly in 2004 clearly designate a source o f financing for primary health care: National Primary Health Care Development Fund which i s to be financed in part by earmarked tax on alcohol and tobacco.

Nigeria can also rely on loans or international aid to sustain malaria control intervention but these options raise serious concern given the volatility o f aid and the potential burden o f debt service obligation on public resources. In connection with these options, we can notice that the recent US$18 bi l l ion debt-relief granted by the Paris Club o f creditor countries offers a window o f opportunity for some additional fiscal space in Nigeria to sustain the project objectives in the long term since it will generate some permanent and predictable stream o f resources.

References Abebe E, Mosanya ME, Amajoh C, Otsemobor 0, Ezedinachi ENU, Afolabi BM, Fatumbi B, et al.

(2004) “Nigeria ro l l back malaria consultative mission : essential actions to support the attainment o f the Abuja targets,” Malaria Consortium, London, United Kingdom

Fawole 01, Onadeko MO, Oyejide CO. (2004) “Knowledge o f malaria and management practices o f primary health care workers treating children with malaria in Ibadan, Nigeria,” International Quarterly of Community Health Education 22(1-2): 95-1 09

Hanson K. (2004) “Public and private roles in malaria control: the contribution o f economic analysis,” American Journal of Tropical Medicine and Hygiene 71 (Suppl2): 168-1 73

Heller PS (2006) “The prospects o f creating ‘fiscal space’ for the health sector,” Health Policy and Planning 21: 75 - 79

Jones G, Steketee R, Black R, Bhutta Z, Morris S, and the Bellagio Child Survival Study Group. (2003) The Lancet: Child Survival Series 362: 65-71

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Knippenberg R, Lawn JE, Darmstadt GL, Begkoyian G, Fogstad H, Walelign N, Paul VK. (2005) “Systematic scaling up o f neonatal care in countries,” The Lancet Neonatal Survival Series365: 1087- 98

Lawn JE, Cousens S, Zupan J. (2005) “4 mil l ion neonatal deaths: When? Where? Why?” The Lancet

Leighton C, Foster R. (1993) “Economic impact o f malaria in Kenya and Nigeria. Major applied research

Neonatal Survival Series 365: 891-900

paper No. 6,” HFS project, Abt Associates, Bethesda

Morel CM, Lauer JA, Evans DB (2005) “Achieving the millennium development goals for health: Cost- effectiveness analysis o f strategies to combat malaria in developing countries,” British Medical Journal doi:lO. I 136/bmj.38639.702384.AE

Mutabingwa EA, Barnes KI, Whitty CJM. (2005) “Antimalarial treatment with artemisinin combination therapy in Africa: desirable, achievable, but not easy,” British Medical Journal d0i:lO.I I36/bmj.331.7519.706

Onwujekwe 0, Hanson K, Fox-Rushby JA. (2003) “Who buys insecticide-treated net? Implication for increasing coverage in Nigeria,” Health Policy and Planning 18(3): 279-289

Onwujekwe 0, Uzochukwu B, Shu E, Ibeh C, Okonkwo P. (2004) “Is combination therapy for malaria based on user-fees worthwhile and equitable to consumers? Assessment o f costs and willingness to pay in southeast Nigeria,” Acta Tropica 91: 101-1 I 5

Rol l Back Malaria, World Health Organization, UNICEF. (2005) “World malaria report 2005,” Geneva: WHO 2005.

Russell S. (2004) “The economic burden o f i l lness for households in developing countries: a review o f studies focusing on malaria, tuberculosis, and human immunodeficiency virus / acquired immunodeficiency syndrome,” American Journal of Tropical Medicine and Hygiene 71 (Suppl2): 147-155

Sachs JD, Malaney P. (2002) “The economic and social burden o f malaria,” Nature 415: 680-685

Soucat A, Van Lerberghe W, Diop F, Nguyen S, Knippenberg R. “Marginal Budgeting for Bottlenecks: A new costing and resource allocation practice to buy health results: Using health sector’s budget expansion to progress towards the Millennium Development Goals in Sub-Saharan Africa” The World Bank Policy and Sector Analysis Support Team-Africa, Washington.

Uzochukwu BSC, Onwujekwe 0. (2004) “Socio-economic differences and health seeking behaviour for the diagnosis and treatment o f malaria: a case study o f four local government areas operating the Bamako initiative program in south-east Nigeria,” International Journal for Equity in Health 3:6 d0i:lO.I 186/1475-9276-3-6

World Bank (2005) “Nigeria: Health, Nutrition, and Population Country Status Report,” World Bank, Forthcoming

World Health Organization (2005) “World health report 2005: Make every mother and child count,” Geneva: WHO 2005

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Annex 10: Safeguard Policy Issues


Potential Long Term Impacts

This project falls into Environmental Category B because n o adverse long term impacts are anticipated. No long term adverse impacts were identified in the Integrated Vector Management Plan (IVMP) and the addendum to the harmonized medical waste management plan o f the Abidjan - Lagos Corridor project.

Project Location and salient Physical Characteristics Relevant to the safeguard Analysis

The project will target seven o f the thirty -six states allowing for a significant scale-up effect in each state. Selected states are: - Kano - Jigawa - Gombe - Bauchi - A k w a I b o m - Rivers - Anambra

Measures Taken by the Borrower to Address Safeguards Issues

An Integrated Vector Management Plan (IVMP) and an addendum (in the absence o f a national healthcare waste management plan) to the harmonized medical waste management plan o f the Abidjan-Lagos Corridor HIV/AIDS were prepared by the borrower. The IVMP and addendum has been disclosed in- country and the Bank’s In fo shop

The contents o f the IVMP include: (i) Vector management approaches; (ii) Pesticide use and management; (iii) Policy, legislative and regulatory framework; (iv) Institutional arrangements; and (v) Capacity building. The objectives o f the Integrated Vector Management Plan are: (i) to reduce or eliminate breeding sources o f malaria and other disease vector: (ii) to improve vector-borne disease prevention and control through appropriate strategies; (iii) to reduce human vector contact; (iv) to boost malaria control intervention using social, health and environmental indicators; and (v) to safeguard the environment f rom chemicals and management strategies adopted through sound management o f healthcare wastes generated or released in the process. The IVMP works within an integrated disease management framework, dealing with multiple vector-borne diseases within a given locality. In the selected states, the IVMP Initiative will be applied within the context o f the Health Sector Reform Program and the Initiative will move f rom the older vertical programs to broader systems: grafting specific aspects on to the existing health system.

In addition to describing the environmental and human health aspects, the IVMP helps select the options that are available in accordance with the l i f e history o f the traits o f vector and human activities. The Plan makes recommendations regarding capacity-building needs, training, and awareness building to ensure proper and effective implementation

As far as health care wastes are concerned, i t i s pertinent to note that the additional medical wastes expected to be generated are those related to the diagnosis and treatment o f malaria; but not exclusive to malaria: needles and syringes, gloves, and glass slides. Although i t i s highly unlikely for malaria to be

92

transmitted v ia unsafe handling o f medical waste, the material may be co-infected with HIV, viral hepatitis, etc, so needs to be handled with care.

The IVMP will be implemented by the National Malaria Control Program (NCMP). Already, an environmental health specialist has been identified and i s working with the program. During project implementation, he will be working with the environmental health specialists at the Federal, State and local levels, in collaboration with Federal and States’ ministries o f environment.

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Annex 11: Project Preparation and Supervision

NIGERIA: Malar ia Control Booster Project

Planned Actual PCN review 0 1/26/2006 09/16/2005 Initial P ID to PIC 0 1/26/2006 02/07/2006 Init ial ISDS to P IC 01/26/2006 02/07/2006 Appraisal 08/10/2006 8/1 0/2006 Negotiations 10/04/2006 10/27/2006 Board/RVP approval 12/12/2006 Planned date o f effectiveness 03/15/2007 Planned date o f mid-term review 0911 612009 Planned closing date 03/30/20 12

Key institutions responsible for preparation o f the project:

Federal Ministry o f Health (FMOH) Federal Ministry o f Finance (FMOF) States Ministry o f Health Ministry o f Finance

Bank staff and consultants who worked on the project included:

Name Title u n i t Ramesh Govindaraj Senior Health Specialist, Team Leader AFTH3 Eva Jarawan Lead Health Specialist AFTH3 Joseph Valadez Sr. M&E Specialist AFTHD Gert Van Der Linde Lead Financial Mgmt Specialist AFTFM Adenike Sherifat Oyeyiola Sr. Financial Mgmt Specialist AFTFM Bay0 Awosemusi Sr. Procurement Specialist AFTPC Luc Lapointe Procurement Consultant AFTPC Hisham Abdo Kahin Counsel LEGAF Chau-Ching Shen Senior Finance Officer LOAG2 Chukwudi H. Okafor Sr. Social Development Specialist AFTS3 Africa Eshogba Olojoba Sr. Environmental Specialist AFTS3 Maria-Eugenia Bonilla-Chacin Economist AFTH3 Suprotik Basu Public Health Specialist AFTHD Therese Tshimanga Language Team Assistant AFTH3 Marcel0 Castrillo Consultant Wi l l iam Vargas Consultant Mer i Helleranta Consultant Richard Al lan Consultant Mentor Initiative Marc Nene Consultant UNICEF Liliane Vert Consultant AFTH3

Bank funds expended to date on project preparation: 1. Bank resources: US$364,000 2. Trust funds: None 3. Total: US$364,000

1. Remaining costs to approval: US$15,000 2. Estimated annual supervision cost: US$150,000

Estimated Approval and Supervision costs:

94

Annex 12: Documents in the Project File NIGERIA: Malar ia Control Booster Project

F M O H Federal Ministry o f Health, Nigeria (2005) “Draft: Guidelines for Integrated Vector Management in Nigeria” Abuja.

FMOH Federal Ministry o f Health, Nigeria “Draft: National Malaria Control Program, A 5-year Strategic Plan: 2006-2010, A Road Map for Impact on Malaria in Nigeria” Abuja.

F M O H Federal Ministry o f Health, Nigeria (2005) “Draft: Plan o f Action for Integrated Vector Management in Nigeria, 2006-2009” Abuja.

FMOH Federal Ministry o f Health, Nigeria (2006) “Malaria Control in Nigeria, National Malaria Control Operational Plan, 2006-2008” Abuja.

FMOH Federal Ministry o f Health, Nigeria “National Malaria Control Program, Update on Integrated Vector Management in Nigeria” Abuja.

FMOH Federal Ministry o f Health, Nigeria (2005) “Policy Framework for the Development and Implementation o f Integrated Vector Management in Nigeria” Abuja.

World Bank (2005) “Nigeria: Health, Nutrition, and Population Country Status Report,” Report No. 34177-NG, Washington.

World Bank (2005) “Rolling back Malaria - The World Bank Global Strategy and Booster Program.” Human Development Network, Washington.

Annex 13: Statement of Loans and Credits


Project FY Purpose ID

Difference between expected and actual disbursements Original Amount in US$ Millions

IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev’d

PO71340 2007

P100122 2006

PO73686 2006

PO90104 2006

PO71391 2006

PO74447 2005

PO88150 2005

PO86716 2005

PO71817 2004

PO71075 2004

PO83082 2004

PO69892 2004

PO63622 2004

PO80295 2003

PO74963 2003

PO72018 2002

PO70291 2002

PO70290 2002

PO69901 2002

PO70293 2001

PO65301 2000

Lagos Metropolitan Dev

Avian Influenza Emergency

GEF Fadama 2

NG-Natl Energy Dev SIL (FY06)

NG-Natl Urb Water Sec Ref S I M 2 (FY06)

NG-State Governance & Cp Bldg TAL (FY05)

NG-Econ Reform & Govern S I L (FY05) NG-Min Res Sustain Mgmt (FY05)

NG-GEF LOC Empowerment & Env Mgmt (FY04)

NG-Urb Water Sec Reform 1 S IL (FY04) NG-MSME (FY04)

NG-Local Empowerment & Environmental Mgm

NG-Fadama SIL 2 (FY04)

NG-Polio Eradication (FY03)

NG-Lagos Urb Trans SIL (FY03)

NG-Transmission Dev S I L (FY02)

NG-HIV/AIDS Prog Dev (FY02)

NG-Health Sys Dev 2 (FY02)

NG-Com Based Urb Dev (FY02)

NG-Privatization Supt SIL (FYOl)

NG-Econ Mgmt CB (FYOO)

0.00

0.00 0.00

0.00 0.00

0.00

0.00

0.00 0.00

0.00

0.00 0.00

0.00

0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00

200.00

50.00

0.00 172.00

200.00

18.10

140.00

120.00

0.00

120.00

32.00

70.00

100.00

80.4

100.00

100.00

90.30

127.00

110.00

114.29

20.00

0.00

0.00 0.00 0.00 0.00

0.00

0.00

0.00 0.00

0.00

0.00 0.00

0.00

0.00 0.00 0.00

0.00 0.00

0.00 0.00

0.00

0.00 0.00

10.03

0.00 0.00

0.00

0.00

0.00 8.00

0.00

0.00 0.00

0.00

0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00

0.00 206.25

0.00 41.58

0.00 9.18

0.00 167.42

0.00 189.23

0.00 17.21

0.00 119.24

0.00 104.12

0.00 4.91

0.00 107.07

0.00 29.93

0.00 47.41

0.00 42.09

0.00 21.30

0.00 48.51

0.00 41.20

0.00 29.06

0.00 60.89

0.00 101.59

0.00 75.78

0.00 1.58

2

14.49

3.48

26.00

8.63

7.83

37.45

27.77

1.67

51.95

10.90

-3.01

-1.39

-28.99

16.01

26.14

14.99

36.08

69.29

58.02

1.64

0.00

0.00

0.00 0.00 0.00

0.00

0.00

0.00 -0.30

0.00

0.00 -7.57

0.00 16.25

-11.68

26.14

-3.42

33.60

14.38

58.62

0.00

Total: 0.00 1,964.09 0.00 18.03 0.00 1,465.55 380.95 126.02

96

NIGERIA STATEMENT OF IFC’s

Held and Disbursed Portfolio In Millions of U S Dollars

Held Disbursed

FY Approval Company Loan Equity Quasi Partic Loan Equity Quasi Partic 1999 AEF Global Fabri 0,32 0 0 0 0,32 0 0 0 1999 AEF Hercules 2000 AEF Oha Motors 2000 AEF SafetyCenter 1995 AEF Vinfesen 1994 Abuja In t l 2005 Accion Nigeria 2003 Adamac 2000 CAPE FUND 200 1 Delta Contractor 2000 Diamond Bank 2005 Diamond Bank 2006 Diamond Bank 2000 FSB 1992 FSDH 2000 GTB 2004 GTB 2005 GTB 2006 GTB

GTFP Access Bank 2006 GTFP Access Bank

GTFP Diamond Bnk GTFP GTB Nigeria GTFP IBTC Plc. GTFP Zenith

2000 IBTC 2006 I B T C 1981 Ikeja Hotel 1988 Ikeja Hotel 2002 MTNN 2002 NTEF 2005 OCC 2006 SOCKETWORKS 2004 UPDC Hotels Ltd.

1,3 0,84 0,4 1

0 1,75

0 25 0 0 0 0 0

5,25 0 6

20 20 30

33,58 0

30,28 20,4 1 5,03

32,18 20 0 0 0

70 20 75 0

10,62

0 0 0 0 0 0 0 0 0 0 1 0 0 0 0

1,89 0 0 0 0 15

6,17 0 0 0 15 0 0 2 0 0 30 0 0 20 0 0 3,75 0

0,86 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 30 0

0,06 0 0 0,Ol 0 0

15 0 0 0 0 0 0 0 0 0 2,5 0 0 0 0

1,3 0,84 0,4 1

0 1,75

0 11,56

0 0 0 0 0

5,25 0 6

20 20 0

3334 0

29,38 20,4 1 4,69

32,18 20 0 0 0

40 0

59,12 0

4,82

0 0 0 0 0 0 0 0 0 0 1 0 0 0 0

0,57 0 0 0 0 6,94

5,76 0 0 0 0,2 0 0 2 0 0 30 0 0 0 0 0 3,75 0

0,86 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0,06 0 0 0,Ol 0 0

14,56 0 0 0 0 0 0 0 0 0 1,88 0 0 0 0

Total Portfolio: 427,97 23,99 119,25 15 311,57 21,82 38,83 6,94

97

Annex 14: Country at a Glance

Nigeria : Malaria Control Booster Project

POVERTY and SOCIAL

2005 Population, mid-year (millions) GNI per capita (Atlas method, US$) GNI (Atlas method, US$ billions)

Average annual growth. 1999-05

Population (%) Labor force (%)

Most recent estimate (latest year available. 1999.05) Poverty (% of population below national poverty line) Urban population (% of total population) Life expectancy at birth (years) Infant mortality (per 1,000 live births) Child malnutrition (% of children under 5) Access to an improved water source (% ofpopulation) Literacy (% ofpopulation age 15+) Gross primaryenroilment (% of School-age population)

Male Female

KEY ECONOMIC RATIOS and LONG-TERM TRENDS

1985

GDP (US$ billions) Gross capital formationlGDP Exports Of goods and services/GDP Gross domestic savings/GDP Gross national SavingslGDP

Current account baiancelGDP Interest payments/GDP Total debVGDP Total debt service/exports Present value of debVGDP Present value of debthxports

28.4 9.0

16.1 12.6

-0.8 4.5

65.6 33.6

1985-95 1995.05 (average annual growth) GDP 4.5 4.1 GDP per capita 1.8 1.6 Exports Of gOOdS and services 4.3 2.7

Nigeria

131.5 560

73.7

2.3 2.3

48 44

101 29 48

99 107 91

1995

28.1 16.3 44.3 18.4 11.4

-3.2 3.1

121.3 15.3

2004

6.0 3.7 3.1

Sub- Saharan

Afrlca

74 1 745 552

2.3 2.3

37 46

100 29 58

93 99 87

2004

72.1 22.4 54.6 39.5 27.5

4.5 I .4

49.8 6.2

49.2 90.7

2005

6.9 4.7

-1.8

Low- Income

2,353 580

1,364

1.9 2.3

31 59 80 39 75 62

104 110 99

2005

99.0 20.9 53.1 38.8 29.9

12.6

2005-09

5.4 2.5 4.4

3evelopment diamond*

Life expectancy

T GNI Gross per primav capita enrollment

1 Access to improved water source

-Nigeria - Low-income grouo

Economlc ratlor.

Trade

Indebtedness

-Nigeria ~ Low-income group

STRUCTURE of the ECONOMY

(% of GDP) Agriculture Industry

Services

Household final consumption expenditure General goVt final consumption expenditure imports of gOOdS and services

Manufacturing

(average annual growth) Agriculture Industry

Services

Household final consumption expenditure General goVt Rnal consumption expenditure Gross capital formation Imports of goods and services

Manufacturing

1985 1995

37.3 31.6 29.2 48.7

8.7 5.4 33.5 21.7

73.8 70.5 13.5 11.1 12.4 42.2

1985-95 1995-05

3.6 4.7 3.4 2.8 3.9 4.5 6.9 4.8

-1.6 -10.5 4.6 21.5

14.7 12.7 -0.5 8.5

2004 2005

16.6 23.3 56.9 56.8

26.5 19.9

38.3 40.1 22.1 21.1 37.4 35.2

2004 2005

6.5 8.2 4.6 5.0 9.6 8.2 6.9 7.1

-0.9 -6.0 3.1 9.7

10.5 25.7 2.0 21.3

I V G C F - O - G D P 1

Growth of exports and Imports (%)

45 T I

Note: 2005 data are preliminary estimates. This table was produced from the Development Economics LDB database. * The diamonds show four key indicators in the country (in bold) compared with its income-group average. If data are missing, the diamond will

be incomplete.

98

Nigeria

PRICES and GOVERNMENT FINANCE

Domestic prices (% change) Consumer prices Implicit GDP deflator

Government finance (% of GDP, includes current grants) Current revenue Current budget balance Overail surplus/deficit

TRADE

(US$ millions) Total exports (fob)

Fuel Liquified natural gas Manufactures

Total imports (ci0 Food Fuel and energy Capital goods

Export price index (2000=100) Import price index f2000=100) Terms of trade (2000-100)

BALANCE of PAYMENTS

(US$ millions) Exports of goods and services Imports of goods and services Resource balance

Net income Net current transfers

Current account balance

Financing items (net) Changes in net reserves

Memo: Reserves including gold (US$ millions) Conversion rate (DEC, iocai/US$)

EXTERNAL DEBT and RESOURCE FLOWS

(US$ millions) Total debt outstanding and disbursed

IBRD IDA

Total debt service IBRD IDA

Composition of net resource flows Official grants Official creditors Private creditors Foreign direct investment (net inflows) Portfolio equity (net inflows)

World Bank program Commitments Disbursements Principal repayments Net flows Interest payments Net transfers

1985 1895

7.4 72.8 3.7 56.0

.. 22.6

.. 15.1

.. 9.9

1985 1995

12,566 11,734 12,203 11,449

70 8,989 9,059 1,527 1,060

78 118

99 64 72 119

137 53

1985 1995

13,032 11,869 10,070 11,278 2,962 591

-2,916 -2,221 .. 733

-214 -897

910 1,296 6 9 6 -399

1,892 1,709 2.5 70.4

1985 1995

18,643 34,093 1,357 3,221

35 268

4,425 1.833 123 657

2 3

4 33 -110 -37 -955 -448 486 1,079

0 0

172 0 271 276 42 393

229 -117 02 267

147 -384

2004

19.4 19.9

43.1 13.9 7.7

2004

37,272 33,386

3,034 107

21,184 2,763 8,928

135 130 104

2004

38,943 26,695 12,248

-1 1,749 2,751

3,251

6,236 -9,487

17,257 132.9

2004

35,890 1,027

967

2,412 265 30

149 -1,007

-145 1.875

0

252 156 235 -79 60

-1 39

~

2005

13.5 26.9

43.3 19.0 9.9

2005

52,739 46,141

5.898 87

27,588 3.589

193 135 143

2005

54,715 33,616 21,099

-12,050 3,399

12,447

-1,123 -1 1,324

28,632 131.3

2005

722 1,136

263 31

265 243 22 51

-29

Inflation (Oh)

150 T 40 30 20 10 0

00 01 02 03 04 05

-GDP deflator +CPI

I Export and Import levels (US9 mlll.)

60,000 T

40,000

20,000

0

I E Exports 0 Imports I

~ ~ ~

Note: This table was produced from the Development Economics LDB database. 9/15/06

Current account balance to GDP (%)

‘5 T I 10

5

0

5

-10

-15

Composition of 2004 debt (US$ mill.)

A - IBRD B . IDA D. Other multilateral F . Pr ime C. IMF G . Short-term

E - Bilateral

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10°E 15°E

5°E 10°E

10°N10°N

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NIGERIA

This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other informationshown on this map do not imply, on the part of The World BankGroup, any judgment on the legal status of any territory, or anyendorsement or acceptance of such boundaries.

0 50 100 150

0 50 100 150 Miles

200 Kilometers

IBRD 33458

SEPTEMBER 2004

N IGERIASELECTED CITIES AND TOWNS

STATE CAPITALS

NATIONAL CAPITAL

RIVERS

MAIN ROADS

RAILROADS

STATE BOUNDARIES

INTERNATIONAL BOUNDARIES