Madagascar - Second Health Project - Supplemental Credit

Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB885 Project Name SUPPLEMENTAL CREDIT FOR SECOND HEALTH PROJECT Region AFRICA Sector Health (100%) Project ID P088729 Borrower(s) REPUBLIC OF MADAGASCAR Implementing Agency Ministry of Health Republic of Madagascar Madagascar Environment Category [ ] A [X ] B [] C [ ] FI Safeguard Classification [ ] S 1 [X ] S 2 [ ] S 3 [ ] S F Date PID Prepared April 26, 2004 Date of Appraisal Authorization April 26, 2004 Date of Board Approval May 18, 2004 1. Country and Sector Background Country context. After experiencing rapid economic growth in recent years, Madagascar plunged into deep political crisis at the beginning of 2002. The crisis ended 6 months later, but the social and economic impact was significant, with poverty rising to previous levels. The new Government presented a recovery program to the donor community in July 2002, and IDA supported this through a US$50 million emergency credit and a substantial portfolio restructuring. After emerging from this crisis, the new Government introduced an ambitious reform program. Sectoral background . Since 2001, infant mortality has improved, but is still 88/1,000; maternal mortality is high (with a rate of 488/100,000) due essentially to declining rates of skilled health care at birth and to poor accessibility and quality of referral obstetric services; and the use of modern contraceptive methods is stagnant at around 12%. Child mortality (136/1000) remains among the highest in Sub-Saharan Africa, and only 36% of children are fully vaccinated. As elsewhere in Africa, the major causes of under-five mortality are malaria, acute respiratory infections and diarrhea. Lack of access to potable water (75% of the population), widespread poor feeding practices, and the resulting repeated bouts of diarrhea explain the large proportion of children under five suffering from chronic malnutrition. Madagascar has one of the highest rates of classic Sexually Transmitted Infections in the world, and HIV/AIDS recently reached the generalized epidemic stage (1.1% in pregnant women). Health services are provided at approximately 2,500 health facilities nationwide (public sector and Non-Governmental Organizations (NGO)). Approximately 60% of the population is estimated to live within a five-kilometer radius of a public facility. An emerging but limited private health sector operates essentially in urban and suburban centers. Quality of services is below standard and the supply of basic medicines and supplies has been poor. Page 2 2. Objectives The Project Development Objectives (PDO) of the proposed supplemental credit are consistent with the PDO of the parent project: to contribute to the improvement of the health status of the population through more accessible and better quality health services. No changes in project design or in beneficiaries from the original project are expected. A Demographic and Health Survey currently underway will provide more specific results and a baseline for the rest of the remaining period of project implementation. Specific indicators include increased accessibility to health facilities from 65% to 85%, increased outpatient health facility utilization rates from 0.2 contacts per year to 0.6 contacts per year, increased district hospital utilization rates from 50% to 80%, increased contraceptive prevalence rates from 9.7% to 17%, increased child immunization rates from 40% to 75%, reduced hospital fatality rate in malnourished children hospitalized for nutrition rehabilitation from 20% to 10% (all by 2006), and finally to maintain the HIV prevalence rate in pregnant women below 0.25 per 100. 3. Rationale for Bank Involvement Overall project performance has been satisfactory during implementation. A mid-term review was carried out in December 2003 and discussed with the GOM and all of the health sector partners in January 2004. The review concluded that the project was well-managed and on track to meet its development objectives, but that actual project expenditures