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TRANSCRIPT
Document of
The World Bank
FOR OFFICIAL USE ONLY Report No: 49394-AFR
PROJECT APPRAISAL DOCUMENT
ON PROPOSED CREDITS TO THE
REPUBLIC OF KENYA
IN THE AMOUNT OF SDR 15.5 MILLION
(US$23.5 MILLION EQUIVALENT)
UNITED REPUBLIC OF TANZANIA
IN THE AMOUNT OF SDR 10.0 MILLION
(US$15.05 MILLION EQUIVALENT)
REPUBLIC OF UGANDA
IN THE AMOUNT OF SDR 6.6 MILLION
(US$10.1 MILLION EQUIVALENT)
AND A GRANT TO THE
REPUBLIC OF RWANDA
IN THE AMOUNT OF SDR 9.9 MILLION
(US$15.01 MILLION EQUIVALENT)
FOR THE
EAST AFRICA PUBLIC HEALTH LABORATORY NETWORKING PROJECT
April 29, 2010
Human Development Department
Regional Integration Department
Africa Region
This document has a restricted distribution and may be used by recipients only in the
performance of their official duties. Its contents may not otherwise be disclosed without World
Bank authorization.
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CURRENCY EQUIVALENTS
(Exchange Rate Effective: March 31, 2010)
Currency Unit = Kenya Shilling (K.Shs)
Rwandan Franc (RWF)
Tanzania Shilling (T.Shs)
Uganda Shilling (U.Shs)
Kenya Shilling:
Rwanda Francs:
Tanzania Shilling:
Uganda Shilling:
77.3
573.5
1357.5
2085.0
= US$1
US$1.00 = SDR 1.51824
FISCAL YEAR
July 1 – June 30
ABBREVIATIONS AND ACRONYMS
ACCA Association of Chartered Certified Accountants
ADB African Development Bank
AFENET African Field Epidemiology Network
AIDS Acquired Immune Deficiency Syndrome
ART Antiretroviral Therapy
CAS Country Assistance Strategy
CD Case Detection
CDC Centers for Disease Control, United States
CPHL
CTRL
Central Public Health Laboratory
Central TB Reference Laboratory
DALY Disability Adjusted Life Years
DDFS Department of Diagnostic and Forensic Services
DCP Disease Control Priorities in Developing Countries
DHMIS District Health Management Information System
DDPC Department of Disease Prevention and Control
DOTS Directly Observed Treatment, Short Course
DPP Directorate of Policy and Planning
DPS Department of Preventive Services
DPs Development Partners
DRC Democratic Republic Of Congo
DRS
DSS
Drug Resistance Surveillance
Diagnostic Services Section
DST Drug Susceptibility Testing
EAC East African Community
EAIDSNet East African Integrated Disease Surveillance Network
ECOWAS Economic Community Of West African States
ECSA-HC East, Central, and Southern Africa Health Community
EPTB Extra-Pulmonary Tuberculosis
EQA External Quality Assurance
ESMF Environmental and Social Management Framework
ESMP Environmental and Social Management Plan
FBO Faith-Based Organization
FELTP Field Epidemiology and Laboratory Training Program
FIND Foundation For Innovative New Diagnostics
FM Financial Management
FMS Financial Management System
FY Fiscal Year
GDF Global Drug Facility
GDP Gross Domestic Product
GFTAM Global Fund To Fight AIDS, Tuberculosis And Malaria
GLI Global Laboratory Initiative
GoK Government of Kenya
GoR Government of Rwanda
GoT Government of Tanzania
GoU Government of Uganda
HBC High Burden Country
HD Human Development
HIV Human Immuno-Deficiency Virus
HMIS Health Management Information System
HNP Health Nutrition and Population
HRH Human Resources for Health
HSO Health Systems for Outcomes
IBRD International Bank for Reconstruction And Development
ICB
ICT
International Competitive Bidding
Information and Communication Technologies
IAD Internal Audit Department
IDA International Development Association
IDS Integrated Disease Surveillance
IDSR Integrated Disease Surveillance and Response
IEG Independent Evaluation Group
IFC International Finance Corporation
IFMIS Integrated Financial Management System
IFR Interim Financial Report
IHR International Health Regulations
IL Intermediate Labs
IMR Infant Mortality Rate
IPPF Indigenous Peoples Policy Framework
IRMPF Institutional Risk Management Policy Framework
ISAC
ISR
Intensified Support Action Country Initiative
Implementation Status Report
JAS Joint Assistance Strategy
K.Sh. Kenya Shilling
KEMRI Kenya Medical Research Institute
KNCV Dutch Tuberculosis Foundation
LAN Local Area Network
LIMS Lab Information Management System
LIS Lab Information System
LTIA Long-term Institutional Arrangements
M&E Monitoring and Evaluation
MAP Multi-Country HIV/AIDS Program
MCH Maternal and Child Health
MDG Millennium Development Goal
MDR Multidrug Resistance
MIC Middle Income Country
MoF Ministry of Finance
MoFPED Ministry of Finance, Planning and Economic Development
MoH Ministry of Health
MoHSW Ministry of Health and Social Welfare
MoPHS Ministry of Public Health and Sanitation
MoMS Ministry of Medical Services
MTEF Medium-Term Expenditure Framework
NCB National Competitive Bidding
NEPAD New Partnership for Africa's Development
NGO Non-Governmental Organization
NPHL
NRL
National Public Health Laboratory
National Reference Laboratory
NSC National Steering Committee
NTLP National Tuberculosis And Leprosy Program
PBF Performance-Based Financing
PCR Polymerase Chain Reaction
PDO Project Development Objective
PEAP Poverty Eradication Action Plan
PEFA Public Expenditure and Financial Accountability
PEPFAR US President's Emergency Plan For AIDS Relief
PLHIV People Living with HIV
PMU Project Management Unit
POC Point of Care
PPP Public-Private Partnership
PS Permanent Secretary
PNFP Private-not-for-profit providers
PTB Pulmonary Tuberculosis
QMS
RAP
Quality Management System
Regional Advisory Panel
RCIP Regional Communications Infrastructure Project
RIAS Regional Integration Assistance Strategy
RWF Rwandan Franc
SBDs Standard Bidding Documents
SIL Specific Investment Loan
SOE Statement Of Expenditure
SOP Standard Operating Procedure
SRL Supranational Regional Laboratory
SWAP Sector Wide Approach
SC Steering Committee
TA Technical Assistance
TB
TB-CAP
TRAC+
TS
Tuberculosis
Tuberculosis Control Assistance Program
Center for Treatment and Research on AIDS, Malaria, TB, and Other Epidemics
Treatment Success
T.Sh. Tanzania Shilling
UNAIDS Joint United Nations Programme on HIV And AIDS
UNICEF United Nations Children's Fund
UNION International Union Against Tuberculosis and Lung Disease
UNITAID International Drug Purchase Facility
USAID United States Agency for International Development
USG United States Government
UPSPEP Uganda Public Sector Performance Enhancement Project
WB World Bank
WHA World Health Assembly
WHO World Health Organization
XDR Extensive Drug Resistance
Vice President: Obiageli Katryn Ezekwesili
Country Directors: John McIntire (Tanzania, Uganda)
Johannes Zutt (Kenya, Rwanda)
Richard Scobey (Regional Integration, Acting)
Sector Manager: Eva Jarawan Task Team Leader: Miriam Schneidman
AFRICA
East Africa Public Health Laboratory Networking Project
CONTENTS
Page
I. STRATEGIC CONTEXT AND RATIONALE ............................................................. 5
A. Country and Sector Issues ............................................................................................... 5
B. Rationale for Bank Involvement ..................................................................................... 7
C. Higher Level Objectives to which the Project Contributes ............................................ 7
II. PROJECT DESCRIPTION ............................................................................................. 9
A. Lending Instrument ......................................................................................................... 9
B. Project Development Objective and Key Indicators ....................................................... 9
C. Project Components ...................................................................................................... 11
D. Lessons Learned and Reflected in the Project Design .................................................. 15
E. Alternatives Considered and Reasons for Rejection ..................................................... 16
III. IMPLEMENTATION .................................................................................................... 17
A. Partnership Arrangements ............................................................................................. 17
B. Institutional and Implementation Arrangements .......................................................... 17
C. Monitoring and Evaluation of Outcomes/Results ......................................................... 21
D. Sustainability................................................................................................................. 21
E. Critical Risks and Possible Controversial Aspects ....................................................... 22
F. Loan/Credit Conditions and Covenants ........................................................................ 25
IV. APPRAISAL SUMMARY ............................................................................................. 26
A. Economic and Financial Analyses ................................................................................ 26
B. Technical ....................................................................................................................... 27
C. Fiduciary ....................................................................................................................... 27
D. Social............................................................................................................................. 29
E. Environment .................................................................................................................. 30
F. Safeguard policies ......................................................................................................... 31
G. Policy Exceptions and Readiness.................................................................................. 31
ANNEXES
Annex 1: Country and Sector or Program Background ................................................................ 32 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies .......................... 46
Annex 3: Results Framework and Monitoring.............................................................................. 47 Annex 4: Detailed Project Description ......................................................................................... 73 Annex 5: Project Costs.................................................................................................................. 93 Annex 6: Implementation Arrangements ...................................................................................... 98 Annex 7: Financial Management and Disbursement Arrangements .......................................... 109
Annex 8: Procurement Arrangements ......................................................................................... 133 Annex 9: Economic and Financial Analysis ............................................................................... 156 Annex 10: Safeguard Policy Issues............................................................................................. 163 Annex 11: Project Preparation and Supervision ......................................................................... 165
Annex 12: Documents in the Project File ................................................................................... 169 Annex 13: Statement of Loans and Credits ................................................................................ 171
Annex 14: Countries at a Glance ................................................................................................ 179 Annex 15: Maps .......................................................................................................................... 191
i
AFRICA
EAST AFRICA PUBLIC HEALTH LABORATORY NETWORKING PROJECT
PROJECT APPRAISAL DOCUMENT
AFRICA
AFTHE
Date: April 29, 2010 Team Leader: Miriam Schneidman
Acting Director: Richard Scobey
Sector Manager/Director: Eva Jarawan/
Tawhid Nawaz (Acting)
Sectors: Health (100%)
Themes: Other communicable diseases (P); Health
system performance (P); Tuberculosis (P)
Project ID: P111556 Environmental screening category: B (Partial
Assessment)
Lending Instrument: Specific Investment Loan
Project Financing Data
[ ] Loan [X] Credit [X] Grant [ ] Guarantee [ ] Other:
For Loans/Credits/Others:
Total Bank financing (US$ million equivalent): 63.66
Proposed terms: IDA terms, with a maturity of 40 years, including 10 year grace period
Financing Plan (US$ million)
Source Local Foreign Total
BORROWER/RECIPIENT 0.0 0.0 0.0
International Development Association (IDA)
Republic of Kenya (credit) 10.80 12.70 23.50
United Republic of Tanzania (credit) 6.90 8.15 15.05
Republic of Uganda (credit) 4.70 5.40 10.10
Republic of Rwanda (grant) 6.90 8.11 15.01
Sub-total 29.30 34.36 63.66
BORROWERS:
The United Republic of Tanzania
Ministry of Finance and Economic Affairs
Name: Mr. Ramadhani Khijjah, Permanent Secretary - Treasury
Address: P. O. Box 9111
Dar es Salaam, Tanzania
Tel: + 255-22-2112856/2111025 Fax: +255-22-2117790 Email: [email protected]
Republic of Kenya
Office of the Deputy Prime Minister and Ministry of Finance
Name: Mr. Joseph Kinyua, Permanent Secretary
Address: P. O. Box 30007-00100, Treasury Building
Nairobi, Kenya
Tel: +254-20-2252299 Fax: +254-20-2240045 Email: [email protected]
ii
Republic of Uganda
Ministry of Finance, Planning and Economic Development
Name: Mr. Chris M. Kassami, Permanent Secretary
Address: P.O. Box 8147
Kampala, Uganda
Tel. +256-414-4707000 Fax: +256-414-250005 Email: [email protected]
Republic of Rwanda
Ministry of Finance and Economic Planning
Name: Ms. Kampeta Sayinzoga, Permanent Secretary
Ministry of Finance and Economic Planning
Address: P. O. Box 158
Kigali, Rwanda
Tel. +250-252-596012 Fax: +250-252-571045 Email: [email protected]
Responsible Agencies:
The United Republic of Tanzania
Ministry of Health & Social Welfare
Name: Ms. Blandina Nyoni, Permanent Secretary
Corner - Samora Avenue/Mirambo St.
Address: P. O. Box 9083
Dar es Salaam, Tanzania
Tel: +255-22-2116684 Fax:+255-22-2139951 Email: [email protected]
Ministry of Public Health and Sanitation
Republic of Kenya
Name: Mr. Mark Bor, Permanent Secretary
Afya House, Cathedral Road
Address: P. O. Box 30016-00100
Nairobi, Kenya
Tel: +254-20-2717077 Fax: +254-20-2715239 Email: [email protected]
Ministry of Medical Services
Republic of Kenya
Name: Prof. James Ole Kiyiapi, Permanent Secretary
Afya House, Cathedral Road
Address: P. O. Box 30016-00100
Nairobi, Kenya Tel: +254-20-2717077 Fax: +254-20-2735236 Email: [email protected]
Ministry of Health
Republic of Uganda
Name: Dr. Nathan Kenya Mugisha, Acting Permanent Secretary
Address: Kitante Road, P.O. Box 7272
Kampala, Uganda
Tel: +256-414-340884 Fax: +256-414-340887 Email: [email protected]
iii
Ministry of Health
Republic of Rwanda
Name: Dr. Agnes Binagwaho, Permanent Secretary
Address: P.O. Box: 84
Kigali, Rwanda
Tel: +250-252 -577458 Fax: +250-252- 570541 Email: [email protected]
East, Central, and Southern Africa Health Community (ECSA-HC)
Name: Dr. Helen Lugina, Director General (Acting)
Plot 157 Oloirien, Njiro Road,
Address: P. O. Box 1009
Arusha, Tanzania
Tel: +255-27 -2508362/3, 2504105/6 Fax: +255-27- 2508292 Email: [email protected]
Estimated disbursements (Bank FY/US$ million)
FY 11 12 13 14 15 16
Annual 5.09 11.46 12.73 14.64 15.91 3.84
Cumulative 5.09 16.55 29.27 43.91 59.82 63.66
Project implementation period: Start: May 25, 2010 End: March 30, 2016
Expected effectiveness date: October 29, 2010
Expected closing date: March 30, 2016
Does the project depart from the CAS in content or other significant respects?
Ref. PAD I.C. [ ]Yes [X] No
Does the project require any exceptions from Bank policies?
Ref. PAD IV.G. Have these been approved by Bank management?
[ ]Yes [X] No
[ ]Yes [] No
Is approval for any policy exception sought from the Board? [ ]Yes [X] No
Does the project include any critical risks rated ―substantial‖ or ―high‖?
Ref. PAD III.E. [X]Yes [] No
Does the project meet the Regional criteria for readiness for implementation? Ref.
PAD IV.G. [X]Yes [ ] No
Project Development Objective Ref. PAD II.C., Technical Annex 3
To establish a network of efficient, high quality, accessible public health laboratories for the diagnosis
and surveillance of TB and other communicable diseases.
Project description Ref. PAD II. D., Technical Annex 4
The project includes three mutually reinforcing components which will assist Kenya, Rwanda,
Tanzania, and Uganda to diagnose communicable diseases of public health importance and to share
information about those diseases to mount an effective regional response.
Component #1-Regional Diagnostic and Surveillance Capacity will provide support to create and
render functional a regional laboratory network which aims to enhance access to diagnostic services
for vulnerable groups; improve capacity to provide specialized diagnostic services and conduct drug
resistance monitoring; and strengthen laboratory based disease surveillance to provide early warning of
public health events.
Component #2-Joint Training and Capacity Building aims to support training and capacity building
for laboratory personnel, in order to increase the pool of experts in the sub-region and to improve the
effectiveness of public health laboratories.
iv
Component #3-Joint Operational Research and Knowledge Sharing/Regional Coordination and
Program Management will finance operational research and knowledge sharing activities, which aim
to evaluate the impact of the new TB diagnostic technologies, assess drug resistance patterns for
endemic diseases, and ascertain feasibility of using mobile phone technologies for surveillance
reporting; and support regional coordination and program management functions.
Which safeguard policies are triggered, if any? Ref. PAD IV. F., Technical Annex 10
The project has triggered OP 4.01 (Environmental Assessment) due to the planned
rehabilitation/construction of laboratories as well as the generation of medical waste. In the case of
Kenya, the project has also triggered the Indigenous Peoples Safeguard (OP 4.10), and therefore an
Indigenous Peoples Policy Framework has been prepared.
Significant, non-standard conditions, if any, for:
Ref. PAD III.F.
Board presentation: N/A
Credit/grant effectiveness:
-The Subsidiary Agreement has been executed and delivered on behalf of the Recipient and ECSA-HC
(all four countries).
-Rwanda: The Memorandum of Understanding has been executed and delivered on behalf of the
Recipient and ECSA-HC.
-Uganda: The Recipient has assigned to the MoH an accountant, with qualifications, experience and
terms of reference satisfactory to the Association, to manage the project accounts.
Covenants applicable to project implementation: The following covenants apply to all participating countries:
-The Recipient shall not later than 18 months after the effectiveness date, carry out and complete a
joint study with other project countries, on public-private partnerships in laboratory and diagnostic
services, including a strategy for scaling-up such partnerships.
-The Recipient shall not later than three months after effectiveness, prepare and adopt in form and
substance satisfactory to the Association, an annual work plan for each public health laboratory
supported under the project, and thereafter during the implementation of the project review with the
Association and update the annual plan every 12 months.
-The Recipient shall during the period of the project regularly monitor the recurrent expenditures of all
the laboratories financed through the proceeds of the Credit (Grant), including the levels of absorption
of the personnel recruited to support such laboratories. To this end and as part of the progress reports
the Recipient shall submit reports, in form and substance satisfactory to the Association, on the status
of such expenditures (annual).
-Rwanda: The Recipient shall: (a) appoint independent auditors not later than three months after the
effectiveness date; and (b) recruit an accountant to the Project Management Unit not later than one
month after the effectiveness date.
-Tanzania: The Recipient shall not later than six months after credit effectiveness: (i) computerize
the accounting functions of the project; and (ii) recruit a procurement specialist for the duration of at
least two years.
-Uganda: The Recipient shall: (i) prepare and submit to the Association six-month internal audit
reports not later than 45 days after the end of such period; and (iii) recruit a Laboratory
Infrastructure Consultant with experience in TB and microbiology laboratory design not later than
three months after credit effectiveness.
5
I. STRATEGIC CONTEXT AND RATIONALE
A. Country and Sector Issues
Key Development Issues
1. The Africa region is ill prepared to deal with regional and global public health threats.
Rampant poverty and the search for new economic opportunities combined with political
instability in some countries has resulted in high levels of migration, refugee movements across
porous borders, and an elevated threat of communicable disease outbreaks (e.g. cholera,
meningitis). The emergence of drug resistant strains of TB also raises serious public health
concerns given the risk of cross border and global transmission. Finally, the region faces new
threats from emerging global epidemics (e.g. H1N1 influenza).
2. Laboratories are the weakest link in health systems in the region, seriously hindering
governments’ ability to confirm and respond in a coordinated manner to disease outbreaks.
Analytic work conducted in the context of project preparation documented the importance of an
efficient public health laboratory system for: (i) supporting integrated disease surveillance;
(ii) complying with International Health Regulations (IHR); and (iii) conducting clinical
diagnosis, guiding treatment, and managing the spread of drug resistance (e.g. TB, malaria).1
Lack of access to accurate lab services results in misdiagnosis, which in turn leads to higher
costs and compromised patient care.2
3. Well functioning laboratories with modern diagnostic technology are also critical for
the timely diagnosis of drug-resistant TB, particularly for people living with HIV/AIDS.
Liquid culture, drug susceptibility testing, and molecular diagnostics are at the cutting edge of
the battle to safeguard the regional and global public good of controlling the spread of drug
resistance. Regional capacity to conduct drug susceptibility testing and drug resistance surveys
is very limited. Putting in place such capacity for TB is expected to have benefits for other
communicable diseases which require the same skills and technology. Currently there is only
one regional reference laboratory in Sub-Saharan Africa which cannot respond to the demand
from countries for conducting External Quality Assurance (EQA), Drug Resistance Surveillance
(DRS), and training. Furthermore, most countries have limited or no capacity to diagnose HIV
related tuberculosis which requires more efficacious diagnostic techniques.
4. Effective laboratory networks are essential in the provision of public health goods. Networking is critical for: (i) sharing timely information across countries; and (ii) contributing
to joint investigations of disease outbreaks. Networks can ensure that capacity to diagnose
diseases, identify public health threats, and conduct surveillance is done more effectively.
Networks also serve as effective platforms for learning and knowledge sharing. TB control
programs have been pioneers in promoting tiered networks of laboratories providing a continuum
1 Boillot, et. al., A Weak Link to Improving Health Outcomes in Low-Income Countries: Laboratories (Health
Systems for Outcomes Publication, World Bank, October 2009). 2 For example, in Botswana one study found evidence of TB infection in only 52 percent of patients suspected with
TB (Petti, C., et. al., Laboratory Medicine in Africa: A Barrier to Effective Health Care, Laboratory Medicine in
Africa, Clinical Infectious Diseases, 2006).
6
of quality assured services and hence provide a good entry point for broader lab strengthening.
While all participating countries have relatively good national networks of microscopy centers
supported by governments and partners, regional networking remains poorly developed.
5. A coordinated regional approach is critical for activities which have high positive
externalities with benefits accruing across borders, where individual countries may not have
the incentives and resources to invest. Given inherent market failures a regional approach to
communicable diseases is critical to delivering public goods. Any country that strives to control
or eliminate communicable diseases without engaging its neighbors is unlikely to attain or
sustain its efforts. As demonstrated by successes in eradicating small pox and progress in
elimination of Onchocerciasis and polio, collective regional action is needed to complement
national disease control efforts.
6. Collective action at the regional level hinges on country capacities. Hence, regional
action needs to be viewed in the context of nationally led efforts whereby governments:
(i) adhere to a negotiated set of norms and standards; (ii) strengthen their capacity for disease
control, including surveillance, prevention, and treatment; and (iii) engage in regional or
international dialogue, planning and information sharing. As illustrated by the example of
disease surveillance, national efforts are critical but insufficient. 3
7. There is strong ownership at the national and regional levels to adopt a coordinated
approach and governments have made important international commitments. Historically,
there has been long standing regional collaboration on public health issues in East Africa. Since
independence a number of important regional institutions have been established and are engaged
in regional disease control activities. While virtually all African countries have signed the IHR
committing them to early identification of public health emergencies of international concern,
progress remains slow 4
In order for the IHR to be fully effective, countries are required to put in
place core surveillance and response capacities by June 2012.
8. There is an urgent need to demonstrate the operational feasibility of regional
approaches to improving access to critical services for vulnerable populations, such as
migrants, and rural dwellers in cross border areas. Developing cross border activities and
establishing a regional laboratory network are essential for containing the spread of diseases, and
promoting regional and global public health security. The potential of public/private
partnerships needs to be further explored, in order to enhance efficiency, accountability, and
quality of public health laboratory services. Likewise, Information and Communication
Technologies (ICT) innovations (e.g. electronic messaging, health alerts, web-based knowledge
sharing; e-learning) have the potential to improve quality of data, facilitate sharing of
information, and promote e-Learning. Finally, there are also important economies of scale in the
3 For example, if one country is unable to collect data and identify a disease outbreak, this places other countries at
risk of importing disease resistant parasites or disease vectors. By contrast, countries with enhanced surveillance
and drug resistance monitoring capacities will be better positioned to provide timely disease outbreak information. 4 The International Health Regulations 2005, which came into force on June 15, 2007, is the new legal framework
that was adopted by WHO member states to ensure maximum protection against the international spread of
infectious diseases while minimizing restrictions on travel and trade.
7
adoption of a regional approach, and diseconomies in carrying out the same activities country by
country.
B. Rationale for Bank Involvement
9. In light of the institutional focus on global public goods, the Bank is well placed to
tackle the regional dimensions of communicable disease prevention and control. All criteria
set out in the global public goods framework for Bank engagement are met5:
There is an international consensus that global action is required. There is strong
demand from countries, as reflected in the 2008 Maputo Declaration on Strengthening of
Laboratory Systems and in the 59th
meeting of African Ministers of Health which called
for strengthening public health laboratories, and tackling the spread of drug resistance to
AIDS, TB, and malaria. There is also a call for public health action, as TB was declared
a global public health emergency in 2005. There are international commitments to
establish integrated disease surveillance systems (IDSR) and to alert neighboring
countries of disease outbreaks (IHR). The proposed project represents an important
contribution towards meeting these commitments and building public health capacity.
There are critical regional gaps that are not always adequately addressed. While the
Global Fund to Fight AIDS, TB and Malaria (GFATM) and bilateral donors finance
primarily disease specific and country-focused investments, the Bank is better placed to
tackle regional public health challenges. Despite an increase in funding, gaps persist in
many countries.6
The Bank has the capabilities and resources to be effective, as it has a growing body of
experience with regional investments and with innovative reforms. The Bank‘s ability to
broker partnerships with regional institutions has facilitated the design of this proposed
project. The Bank‘s expertise with innovations, such as performance contracting can be
brought to bear to attract and retain high quality laboratory personnel.
The Bank can provide flexible financing to tackle both health systems and
communicable disease challenges, in line with the 2007 Health, Nutrition and
Population Strategy. Recognizing ongoing risks of communicable disease pandemics the
Bank has a unique opportunity to assist African countries to prepare for such emergencies
rather than react when outbreaks arise. The proposal to establish a robust, responsive,
and quality-assured network of laboratories is part of the Africa region TB control
strategy which was endorsed by senior management.
C. Higher Level Objectives to which the Project Contributes
10. The proposed project is fully in line with the Regional Integration Assistance Strategy
(approved by the Board in April 2008) and the Africa Action Plan. The proposed project fits
under Pillar III of the RIAS (Coordinated Interventions to provide Regional Public Goods), to
5 Global Public Goods: A Framework for the Role of the World Bank, Development Committee, September 28,
2007. 6 Africa has a projected annual funding gap for TB control of US$1351 million, with country gaps ranging from
US$17.8 million in Rwanda; US$32.6 million in Tanzania; US$41.6 million in Uganda and US$52.1 million in
Kenya (Global Tuberculosis Control, a Short Update to the 2009 Report, WHO, 2009).
8
the extent that it will: (i) bolster capacities to track communicable diseases using harmonized
policies, strategies, and protocols; (ii) share high quality and reliable information; and
(iii) promote coordinated cross-country responses.
11. The project will contribute to improving health outcomes in the participating countries
and in the sub-region. It will contribute to the achievement of Millennium Development Goal 6
(Combat HIV/AIDS, malaria and other diseases), and more specifically to the global targets to
―reduce the prevalence and death rates associated with TB‖ and to increase the ―proportion of
TB cases detected and cured‖. It will also contribute to poverty reduction (MDG1) as the poor
are disproportionately affected by communicable diseases (Annex 9).
12. At the regional level, the proposed project provides a vehicle for implementing key
disease control strategic priorities of regional institutions. The East African Community
(EAC) partner states (Burundi, Kenya, Rwanda, Tanzania, and Uganda) are fully committed to
utilizing a regional approach, as highlighted in their 2007- 2012 Regional Plan for Prevention
and Control of Human and Animal trans-boundary Diseases. The East, Central, and Southern
Africa Health Community (ECSA-HC) has a strategic focus which is closely linked to the
proposed project, a sound track record, and a long history of receiving funds from member states
since its establishment in the mid 1970s. Both institutions have strong mandates and ongoing
activities to combat cross-border diseases, which will be supported under the proposed project.
Rationale for Bank Involvement
Why Labs?
Critical for supporting disease surveillance and sharing information with neighboring countries.
Key to complying with IHR which aim to improve early identification of public health emergencies.
Important for accurate diagnosis, guiding treatment, and managing the growing problem of drug resistance.
Why TB?
Rise in drug resistant TB, which poses major public health risks regionally and globally.
High burden of TB; highest levels of infection; disproportionate share of global burden.
High expected rate of return, highly cost-effective, strong public good nature of TB control.
Why a Regional Approach?
Increase in risk of communicable disease transmission and pandemics due to global and regional trade,
international travel, and refugee movements which require a harmonized approach, to mitigate negative spillover
effects and maximize positive externalities.
Inherent market failures which imply that services may not otherwise be provided by countries.
Potential to reap economies of scale, lower costs, and achieve quality diagnostic services.
Why Bank support?
Investments in communicable diseases are in line with the institutional commitment to global public goods.
Comparative advantage to address broader systemic health systems issues.
Bank‘s comparative advantages (analytic capacity, convening power, knowledge sharing, intervening regionally).
13. The proposed project is also consistent with other activities at the country level, including: (i) health sector strategies of participating countries which recognize the burden of
communicable diseases and their regional nature; (ii) national laboratory policies and strategies
and the 2008 Maputo declaration on health laboratory systems; (iii) activities funded by other
partners who are supporting laboratory strengthening efforts, particularly at the lower levels of
the health system; (iv) Country Assistance Strategies of participating countries which aim to
strengthen health systems and promote regional integration; and (v) other IDA-funded projects in
the participating countries which support broader health sector interventions and systemic
9
reforms (Annex 4). For example, the US$130 Million Uganda Health Systems Strengthening
Project, prepared on a parallel track, supports the delivery of the Minimum Health Care Package,
focusing on maternal and newborn health, and implementation of systemic reforms (e.g. results
oriented management, incentive schemes for health workers) to enhance health sector
performance. By contrast, the mutually reinforcing regional project provides US$10 million to
Uganda to participate in the regional laboratory network and to mount a coordinated public
health effort with the neighboring countries.
14. The proposed project is also in line with the Africa Region’s Communicable Disease
Control and Preparedness Strategy of the Africa Region which provides a long-term
framework for combating communicable diseases. As discussed in Annex 1 the framework
includes a three-pronged approach for the control and/or elimination of priority communicable
diseases: (i) strengthening regional institutions for cross-border and inter-country collaboration;
(ii) developing regional capacity for integrated multi-disease surveillance and response; and
(iii) bolstering regional capacity to provide high quality laboratory services to support diagnosis
of infectious diseases.
II. PROJECT DESCRIPTION
A. Lending Instrument
15. The lending instrument to be used is a Specific Investment Loan (SIL). Financing of
activities under the regional operation will take place through an IDA credit (Kenya, Tanzania,
Uganda) or grant (Rwanda) to each participating country, depending on the financing terms that
each country is eligible to receive from IDA.
B. Project Development Objective and Key Indicators
16. The development objective of the project is to establish a network of efficient, high
quality, accessible public health laboratories for the diagnosis and surveillance of TB and other
communicable diseases. To this end, the project will: (i) strengthen capacity to diagnose
communicable diseases of public health importance and share information to mount an effective
regional response (Component I); (ii) support joint training and capacity building to expand the
pool of qualified laboratory technicians (Component II); and (iii) fund joint operational research
and promote knowledge sharing to enhance the evidence base for these investments and support
regional coordination and program management (Component III).
17. The proposed regional laboratory network aims to: (a) enhance access to diagnostic
services for vulnerable groups to contain the spread of diseases in cross border areas;
(b) improve capacity to provide specialized diagnostic services and conduct drug resistance
monitoring at regional level; (c) contribute to disease surveillance and emergency preparedness
efforts through the availability of timely lab data to provide early warning of public health
events; and (d) serve as a platform for conducting training and research. The lab network will
facilitate the adoption of harmonized policies, strategies, and protocols to ensure prompt and
high quality results. Priority attention will be given to networking intermediate or satellite
10
laboratories that serve cross border and migrant populations, and central public health labs that
provide specialized services.
18. Following broad based consultations, representatives from the participating countries
have agreed to function as a community of practice for public health laboratory development,
fostering cross country learning and knowledge sharing. The community of practice would
become an integral part of the Africa Region‘s Health Systems for Outcome (HSO) initiative and
contribute to knowledge sharing with other countries. Countries developed a common vision
towards preventing and controlling the spread of communicable diseases in the Eastern Africa
Region where heads of state recently signed an agreement to establish a common market which
will lead to broader collaboration in all areas, including health. They acknowledged the
importance of developing harmonized approaches, promoting specialization, and expanding
information sharing about public health issues. The countries have agreed to provide regional
leadership in key technical areas where each has a comparative advantage and would serve as a
center of excellence, as follows:
KENYA: Integrated Disease Surveillance and Response & Operational Research Building on its relatively strong IDSR system Kenya will serve as a center of excellence
for disease surveillance and operational research. It will lead the development of
harmonized tools; promote cross border surveillance and joint outbreak investigations;
share lessons from the successful field epidemiology fellowship program and offer
training programs to build regional surveillance capacities. Kenya will also lead a
regional working group on operational research and work closely with ECSA-HC to
develop standardized research protocols.
UGANDA: Lab Networking and Accreditation Uganda will provide leadership in
establishing the East Africa public health regional lab network which will involve:
(i) development of common standards; (ii) standardization of quality assurance systems;
(iii) introduction of peer review mechanisms; and (iv) application of the WHO-AFRO
Five-Step Accreditation process to accredit all laboratories in the proposed network to
progressively meet the international certification with clearly defined parameters for
turnaround time, quality, and proficiency, as described in Annex 3.
TANZANIA: Training and Capacity Building Tanzania will provide high quality
training in laboratory techniques at its new state of the art National Quality Assurance
Laboratory and Training Centre and at the Muhimbili University of Health and Allied
Sciences. Tanzania will use a phased approach: (i) initially offering short term courses;
(ii) sharing training curricula and programs with other countries; (iii) providing Technical
Assistance (TA) to other countries to develop continuing education programs; and
(iv) developing e-learning approaches for distance learning.
RWANDA: Information and communication Technologies (ICT), Performance Based
Financing (PBF), Multidrug Resistant Tuberculosis (MDR-TB) Rwanda has agreed to
take a regional lead in expanding use of ICT and promoting PBF approaches for
laboratory services, building on its well recognized successes in these areas. Cross
cutting ICT innovations will be promoted to improve the quality of laboratory and
surveillance data; facilitate the sharing of information; and promote e-learning and web-
based knowledge sharing across countries. Rwanda will: (i) share its tools (e.g. standards
and guidelines, reporting forms, request for proposals); (ii) provide related training,
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capacity building, and technical support as well as organize site visits; and (iii) take a
lead in determining the applicability of the PBF approach to public health laboratories
and document and share lessons. Rwanda will also share lessons in MDR-TB as it has
been selected by KNCV (Dutch TB Foundation) and will be supported by USAID to
become a center of excellence for MDR-TB for the Africa region.
19. The proposed project focuses on four out of the five members of the EAC, which were
ready to participate in the regional project. Burundi, the fifth member, has recently expressed
interest to join the project, and will be considered for participation based on the initial
implementation performance of the project and completion of the same preparation and appraisal
requirements followed with the four other countries. To enhance readiness Burundi will be
associated in knowledge sharing activities organized by the EAC and ECSA-HC.
Performance Indicators
20. To monitor results a core set of performance indicators has been agreed upon:
Reduced average turn-around time for TB liquid culture tests (days).
Satellite laboratories awarded two-star status under regional accreditation program based
on WHO-AFRO five-step accreditation process (number, percent).
Number of beneficiaries (direct and/or indirect; out of which x percent female).
People receiving TB drug susceptibility tests among Directly Observed Treatment Short
Course (DOTS) treated TB cases not responding to treatment (number, percent).
Share of reported communicable disease outbreaks having laboratory confirmation of
etiological agent (percent).
Outbreaks for which cross border investigations undertaken (number).
C. Project Components
Component I: Regional Diagnostic and Surveillance Capacity (US$44.9 million)
21. The first component will provide targeted support to create and render functional the
regional laboratory network. Uganda, working in close collaboration with ECSA-HC, will lead
the establishment of the network. Component I includes three sub-components:
22. Diagnostic Services for Vulnerable Populations in Cross Border Areas (US$21.2
million) The first sub-component will support five satellite laboratories in each country and six
in Tanzania to expand access to diagnostic services for vulnerable groups in cross border areas
and to serve as sentinel surveillance sites to monitor hot spots for disease transmission. Bank
financing will promote a systems approach to laboratory development and include: (i) support
for rehabilitation, expansion, and/or construction of laboratories at existing hospitals;
(ii) provision of laboratory equipment and materials, including waste management equipment
and protective gear to ensure the safety of laboratory personnel; (iii) acquisition of computer
equipment, software, and technical support for integrated laboratory information systems to
improve the quality of data generated and videoconferencing capacity to allow personnel across
sites to consult each other and to have access to timely information about disease outbreaks; and
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(iv) provision of operating funds to render the laboratories functional, including strengthening
human resources.
23. The satellite laboratories are based at regional or district hospitals in strategic cross
border areas and/or in densely populated peri-urban areas where poverty is rampant and slum
conditions serve as a breeding ground for the spread of diseases. Each country has carefully
selected these sites based on the following criteria: (i) hospitals which are located in high
transmission areas with large numbers of migrants or refugees; (ii) regional teaching hospitals
which can serve as centers of excellence for conducting training and research; and (iii)
commitment to collaborate and coordinate efforts within and across countries. The list of
satellite laboratories is included in Annex 4. The satellites are essential to optimize surveillance
efforts and contain the spread of communicable diseases in the region.
24. Countries will adopt a phased approach with a results focus based on standardized quality
practices. In an initial phase, human resources would be bolstered, training would be conducted,
and proficiency testing would be carried out to ensure that basic microscopy and other core lab
functions are performed according to set standards. During a second phase, specialized
diagnostic services would be introduced once the physical infrastructure has been upgraded.
Underpinning the phased approach will be the accreditation of all satellite laboratories using the
WHO/AFRO five-step accreditation process, with the goal of reaching a two-star status by
project completion. Accreditation instills continuous learning, affords confidence in lab results
by clinicians and patients, and provides evidence of quality.
25. Reference and Specialized Services and Drug Resistance Monitoring (US$22.5 million) The project will bolster the capacities of the Central Public Health Laboratories in the
participating countries and network them to share information, conduct joint training and
research, and collaborate in harmonizing policies and strategies. This process will focus on the
TB laboratory functions (which have been relatively neglected), supporting one of the labs to be
upgraded to a Supranational Regional Laboratory (SRL). The project will finance:
(i) rehabilitation/construction and lab equipment and materials for central public health
laboratories, including TB reference laboratories; (ii) acquisition of computers and
videoconferencing capacity to facilitate sharing of information and link into existing
telemedicine installations where appropriate; (iii) TA to support accreditation of satellite labs and
standardization of procedures and protocols to ensure that diagnostic procedures are performed
by appropriately trained technicians against clear regional and international proficiency and
quality standards; and (v) provision of operating funds to support inter-laboratory external
quality assessments among the four participating countries and recruitment of additional
personnel to provide mentorship to personnel at satellite laboratories.
26. As national capacities are enhanced and the network becomes fully functional, one of the
four labs would play the role of a regional laboratory for East Africa, providing services (e.g.
quality control; support with drug resistance surveys; higher-level testing, including second line
drug susceptibility testing and molecular diagnostics) to other laboratories in neighboring
countries, thus reducing the need to ship specimens to laboratories on other continents. The
process of accreditation is being led by the WHO and other technical partners. Once a decision
is taken on which laboratory will play the SRL role, the project will be used to develop the
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financial arrangements and operational modalities for the regional lab to provide services and for
other countries to acquire those services.
27. Disease Surveillance and Preparedness (US$1.3 million)The proposed project will
complement ongoing regional and global initiatives to improve Integrated Disease Surveillance
and Response (IDSR) country systems. It will support the IDSR strategic goals to improve
availability of quality information by: (i) strengthening competence of lab and facility personnel
to collect, analyze, and use surveillance data; (ii) reinforcing lab networking and district capacity
(particularly those in border areas) to report, investigate, and adequately respond to disease
outbreaks; and (ii) strengthening communications and data sharing to respond rapidly to
outbreaks. Kenya will take a lead in this area and work closely with the EAC health desk to
harmonize tools, offer training and technical support, and serve as a center of excellence,
documenting and sharing good practices in disease surveillance.
28. The strategy is to start gradually and prioritize a few diseases for Bank support, including
those which are: (a) outbreak prone (cholera, meningitis, hemorrhagic fever), (b) endemic
(multi-drug resistant TB), or have (c) pandemic potential (influenza). The project will also
provide complementary support to the EAC for the East Africa Integrated Disease Surveillance
Network to enhance its effectiveness, and facilitate the production of quarterly regional
surveillance bulletins.
29. Bank funding will assist the countries to comply with their commitments under the
International Health Regulations. To this end, the project will support laboratory-based disease
surveillance efforts by: (i) strengthening etiological confirmation of pathogens and promoting
active participation of laboratory and other health personnel in disease surveillance and disease
outbreak investigations; (ii) establishing and maintaining an integrated data management system;
and (iii) facilitating sharing of relevant data across the sub-region, including publication of
periodic newsletters and quarterly and annual disease surveillance reports. These activities will
be funded through the provision of TA, operating costs, ICT services and training.
Component II: Joint Training and Capacity Building (US$9.9 million)
30. The project will support training in a range of institutions in the four countries and across
the region. Tanzania will provide leadership in this area and establish a regional training hub. It
will provide practical training at its state of the art National Health Laboratory Quality Assurance
and Training Centre and in-service training and post-graduate mentorships at the Muhimbili
University of Health and Allied Sciences. Other regional training programs (such as the
International Tuberculosis course on TB control organized by the International Union Against
Tuberculosis and Lung Disease, The Union, in collaboration with the Tanzanian National
Tuberculosis/Leprosy Program) and other training centers like the African Center for Integrated
Laboratory Training in Johannesburg will be supported, particularly for training of trainers.
31. Each country has prepared and finalized a training plan which provides details of short
and long term programs, including regional and longer term training in identified areas of
laboratory sciences and field epidemiology. It was agreed that the scope of all critical training
programs supported under the project such as laboratory management, infection control and bio-
14
safety, and disease outbreak investigation would be nation-wide, ensuring synergies with
activities provided by other partners, while training programs linked to specific inputs provided
under the project, such as rapid TB diagnosis and cultures, will be limited to staff working at the
laboratories supported by the project. In addition, a three-month certificate program with credits
on leadership will be developed and introduced for laboratory managers to enhance career
prospects. Trainees will include staff from private laboratories. The project will support
fellowships in field epidemiology through the flagship Field Epidemiology and Laboratory
Training Program (FELTP). By project completion over 2000 laboratory specialists will have
received training and a professional cadre of laboratory managers will be established in the sub-
region.
32. The Bank project will finance: (i) attendance at training courses at national and regional
institutes; (ii) laboratory attachments, fellowships, and regional exchanges at recognized centers
of laboratory excellence; (iii) selective graduate training required to support specialized services;
(iv) TA to review and develop standards and training curricula; and (v) regional workshops to
facilitate knowledge sharing.
Component III: Joint Operational Research, Knowledge Sharing/Regional Coordination, and
Program Management (US$8.7 million)
33. Joint Operational Research The project will finance relevant operational research which
is related to activities supported under the project. The three main research priorities identified
by countries relate to the need to: (i) evaluate the effectiveness of the new TB related diagnostic
technologies at the programmatic level, (ii) assess drug resistance patterns for endemic diseases,
and (iii) ascertain the feasibility of using mobile phone technologies for weekly surveillance
reporting of selected priority diseases. The evidence generated through this joint operational
research will help inform public policy and the scale up of these interventions in the participating
countries and in the region. As agreed during project preparation, Kenya would set up an
operational research working group, and work closely with ECSA-HC. The project will fund:
(a) TA to support operational research; (b) operating costs to organize workshops to share
results; and (c) training to boost capacities to conduct research.
34. Knowledge Sharing & Regional Coordination ECSA-HC will play a coordinating and
convening role and be responsible for the following activities at the regional level:
Convene Technical Experts and Policymakers: The organization will support the
country-led working groups by providing a forum for discussions and deliberations. The
ECSA-HC Secretariat will facilitate the work of technical partners which will assist in
harmonizing laboratory operating procedures and quality assurance systems. ECSA-HC
will use its existing mechanisms (e.g. conference of health ministers; advisory committee
of permanent secretaries) to share results from the regional project, and advocate for
policy change at both the technical and policy levels.
Facilitate Capacity Building and Training: The ECSA-HC will support countries to
implement regional studies on human resources (HR) for laboratory services and
public/private partnerships7 with a view to identifying options for enhancing the quality
7 As discussed in Annex 4, the PPP assessment will document innovative approaches and suggest options for expanding these
arrangements, including operating specialized lab services in public hospitals, and providing maintenance services.
15
and efficiency of laboratory services; prepare policy briefs on HR and PPP issues; take
stock of training institutions offering higher level training; and facilitate networking of
laboratory managers by organizing bi-annual professional meetings.
Establish a Forum for Learning and Knowledge Sharing: The organization will facilitate
exchanges of experiences; document best practices in laboratory networking in the
region; work with their health journalist network to report on achievements and lessons;
establish a peer review mechanism for reviewing research findings; and drawing policy
conclusions to be brought to the attention of policy makers; maintain a repository of
information on activities supported under the project which can be shared regionally; and
prepare a regional communications strategy for disseminating main lessons from the
project, and informing the public on related public health issues.
Facilitate Regional Surveillance Efforts: The ECSA-HC Secretariat will support the
EAC to: implement the strategic plan for developing the East Africa Integrated
Surveillance Network as a model regional network and producing quarterly surveillance
bulletins; work with country surveillance focal points and technical partners to develop
standardized reporting tools and protocols for sharing information on selected
communicable diseases (e.g., Cholera, Meningitis, MDR TB, Influenza, Polio) in the
region; and facilitate cross border outbreak investigations when satellite laboratories
report disease outbreaks.
35. The project will fund: (i) operating costs to organize regional workshops to share
research and programmatic results, and explore policy implications; (ii) establishment of a small
team to coordinate activities at the regional level and a focal point at the EAC;
(iii) videoconferencing capacity; (iv) development of a website to serve as a platform for sharing
of information and results of research; and (v) TA.
36. Program Management At the national level the project will support program
management through the provision of funds for the establishment of project coordinating teams,
operating costs, and procurement of office equipment, vehicles, and internet access.
D. Lessons Learned and Reflected in the Project Design
37. It is well recognized that regional projects are inherently more challenging to design and
implement but have the potential to generate results which are not easily attained through
national investments. Drawing on the recent review of regional projects by the Quality
Assurance Group, the 2009 IDA 15 Mid-Term Review of the IDA Regional Program, and the
2007 Independent Evaluation Group (IEG) review of regional programs, the following key
lessons have been incorporated into the design:
Conduct analytical work Project design has been informed by analytical work conducted
during project preparation, including a study on the importance of laboratories (A Weak
Link to Improving Health Outcomes in Low-Income Countries: Laboratories); and
country specific assessments conducted by the US Center for Disease Control and
Prevention which documented gaps, and proposed the rationale for the proposed
activities, as noted in Annex 1.
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Ensure ownership Project preparation has benefited from high-level support from
ministers, and permanent secretaries who have welcomed this initiative and provided
strong leadership; program managers, partners, and civil society groups who have
contributed actively to the preparation process. The project builds on long standing
cooperation on health issues within the East African Community (EAC), and ongoing
collaboration between ECSA-HC, EAC, and participating countries.
Promote partnerships The preparation of the operation was conducted in close
collaboration with key partners involved in lab strengthening and TB control to take
advantage of global expertise and country knowledge and to identify opportunities for
complementary support.
Adopt coordinated approaches As seen during the eradication of smallpox, in progress
towards elimination of Onchocerciasis, and in control of meningitis, a high level of
regional collaboration and collective action is critical to successful public health
initiatives. For example, it is widely recognized that stepped up regional surveillance
efforts, cross border collaboration, information sharing among laboratories, and regional
stockpiling of vaccines have been critical in equipping countries to better cope with
frequent meningitis outbreaks.
Ensure design simplicity The project has three components. It will rely and strengthen
existing implementation structures and not create new ones.
Leverage national institutions Drawing on lessons from successful regional operations,
the project promotes the concept of ―design regionally--implement nationally‖ by relying
on national institutions for execution and implementation of project interventions at the
country level, and on regional institutions for supportive services that cannot be
performed efficiently by national agencies, such as coordination.
Develop a strong Monitoring and Evaluation framework The project design has a strong
focus on M&E which is critical to enhancing the evidence base for rolling out new
technologies and approaches. Drawing on lessons from regional projects, the main
research topics were agreed up front and a Regional Advisory Panel will be established to
facilitate multi-country learning.
Plan for sustainability The team adopted a health systems approach which focuses
attention on how this regional program will add value to service delivery at the country
level, what will be required to sustain activities and country commitment, and how the
Bank‘s annual sector and budget reviews can be used to foster support. Countries will
monitor and report on the availability of resources for laboratories supported under the
project and ensure that personnel recruited under the project are absorbed into the civil
service or funded by other partners.
E. Alternatives Considered and Reasons for Rejection
38. A first option considered was to integrate the regional program activities into relevant
projects which are on-going or under preparation. While this option was appealing in terms of
limiting the number of operations the nature of the proposed activities called for the
establishment of a strong regional platform for harmonizing strategies and promoting learning
and knowledge sharing. Second, a disease specific program focused only on TB lab
strengthening was considered and rejected. While TB lab strengthening will be supported, the
project has adopted a systems approach which will involve: (i) introduction of standardized
17
systems (e.g. quality assurance, information and communication) that will have broader benefits;
(ii) promotion of an integrated model for providing diagnostic services in border areas that cuts
across diseases; and (iii) laboratory based disease surveillance which will focus on diseases
which are epidemic prone, endemic, or have pandemic potential.
III. IMPLEMENTATION
A. Partnership Arrangements
39. The Bank has established partnerships with several development partners, including the
World Health Organization (WHO), the International Union Against Tuberculosis and lung
Disease (Union), US Centers for Disease Control (CDC), United States Agency for International
Development (USAID), and the International Drug Purchase Facility (UNITAID). The Stop TB
Department of the WHO was instrumental in providing guidance throughout the preparation
process. The Global Lab Initiative Secretariat, which is hosted by the Stop TB Department,
assisted to lay out the rationale for many of the proposed activities and prepared simulations to
document the TB diagnostic gaps across Africa. The Union provided a forum for discussing the
Bank-funded regional initiative in its October 2008 annual conference which brought together
leading experts from around the world. The Union country offices in Uganda participated
actively in project preparation. The US Centers for Disease Control and Prevention mobilized a
team of experts from headquarters who assisted in carrying out the initial scoping missions in
Kenya, Tanzania and Uganda. The Rwanda and Tanzania CDC country offices supported the
preparation process. USAID played an important role supporting the preparation in Uganda and
Kenya by providing technical support through TB Control Assistance Program (TB-CAP) with
Dutch Tuberculosis Foundation (KNCV) as the lead partner. Partners have been extensively
involved in a series of video conferences and at a key meeting in Nairobi which brought together
all stakeholders in December 2009.
40. Partnerships are also expected to guide the implementation phase. This will be important
for continuing to harmonize activities, minimize duplication, and tap technical expertise.
Partners will provide technical support for: lab accreditation; technical training; lab assessments;
and facility design. Key partners will participate in the Regional Advisory Panel as discussed
below. The bulk of this technical support will be provided as part of on-going bilateral
arrangements between countries and these technical agencies. However, funding for more
complex and lengthy consultations will be provided through the regional project. Parallel
financing for specialized TB diagnostic equipment and reagents will be provided through a
UNITAID grant for the EXPAND-TB Project which is a collaborative effort of WHO/Global
Laboratory Initiative (GLI), the Foundation For Innovative New Diagnostics (FIND), and the
Global Drug Facility (GDF).
B. Institutional and Implementation Arrangements
41. National arrangements Though institutional arrangements vary from country to country,
the basic principles are the same, namely to rely and strengthen existing institutional and
implementation structures. Technical aspects of project implementation will be fully integrated
into the appropriate operating divisions of Ministries of Health (MOH). Within each ministry
18
there will be one lead office which will coordinate and monitor implementation of project
activities at the national level. Other sections responsible for implementing specific activities
(e.g., health infrastructure) will be strengthened to deal with the additional workload.
42. At the country level the implementation arrangements are as follows: (i) annual work
plans will be prepared by satellite laboratories and by the central public health laboratories
working closely with other key stakeholders responsible for curative and public health services;
(ii) national project coordination teams will review the plans and prepare consolidated annual
work plans of all project activities; (iii) national steering committees under the overall guidance
of the Permanent Secretaries of the Ministries of Health will review and approve the
consolidated plans; (iv) project management units and other structures of Ministries of Health
will be responsible for fiduciary aspects and preparing quarterly and annual consolidated
technical and financial reports. To ensure readiness for implementation, as part of project
preparation all four countries and the ECSA-HC Secretariat have elaborated Project
Implementation Plans for the first year of the project which were finalized during appraisal.
43. In Kenya, the project will use existing government structures as far as possible and no
new implementation structures will be created for the project. The overall responsibility for
project implementation will be with the Ministry of Public Health and Sanitation (MoPHS)
assisted by Ministry of Medical Services (MoMS). At the national level the Director Public
Health and Director Medical Services will jointly provide leadership and ensure effective inter-
ministerial coordination. They will be responsible for strategic oversight for the project and
recommend annual work plans to their respective Permanent Secretaries. A Project Coordination
Committee will be constituted to provide oversight for project implementation and will be led by
the Head, Disease Prevention and Control, MoPHS who will be assisted by the Head,
Department of Diagnostics and Forensic Services, MoMS.
44. A dedicated Project Coordination Team will support the Head, Disease Prevention and
Control who is assisted by the Head, Department of Diagnostics and Forensic Sciences in the
implementation of the Project. The team will include a project officer, epidemiologist, IT expert,
operations officer and designated accountant for the project. Out of these positions the posts of
IT expert and operations officer will be contractual. The Project Coordination Team will review
and consolidate work plans.
45. In Rwanda the overall implementation responsibility for the project will rest with the
Ministry of Health (MoH). The Permanent Secretary (PS) will have overall oversight. The
project activities will be coordinated by the ministry‘s Project Management Unit which
successfully managed the recently closed Bank-funded HIV/AIDS project and numerous Global
Fund grants. The PMU will handle day to day management of the project and will be reinforced
with an additional accountant and project officer. The project will strengthen the NRL and
TRAC+ through the recruitment of an epidemiologist, and a microbiologist. The project team,
comprising of the project officer, accountant, epidemiologist, and microbiologist, will ensure
effective coordination of project activities. The team will work under the overall guidance of the
PS, as well as the head of the TRAC + (Center for Treatment and Research on AIDS, Malaria,
TB, and Other Epidemics, MoH) and the National Reference Laboratory (NRL) in their technical
position as the main sub recipients of the grant. The NRL will take leadership in laboratory
19
networking and systems development while the TRAC+ will focus on improving laboratory
linkages with integrated disease surveillance. Both the NRL and TRAC Plus will report directly
to the PS and share the technical updates with the PMU which will be responsible for preparation
of consolidated quarterly and annual technical and financial reports.
46. The Directors General of the NRL and TRAC Plus and Directors of the central teaching
hospitals (CHUK & CHUB) will provide technical oversight for the project and will be
responsible for reviewing and approving the consolidated annual work plan of participating
laboratories as well as the training and procurement plans. At the peripheral level, coordination
in the 5 districts where the satellite labs are located will be achieved by the heads of the subunits
of TRAC Plus working in conjunction with the directors of district hospitals and heads of the
referral and district laboratories. Members of the district coordination teams will include the
hospital director, clinical officer/nurse-in-charge of health centers, environmental health officer
and biotechnologist-in-charge of district laboratory. The risk of having weak core accounting
and reporting at decentralized levels will be addressed by maintaining the fiduciary functions of
procurement and Financial Management (FM) at the Ministry‘s Project Management Unit which
has worked in the recent past with the district hospitals where the satellite labs are located.
47. In Tanzania, no new structures will be established for the proposed project. As is the
case for other Bank funding outside the pooled funds, the project will be fully embedded within
the ongoing coordinated support for the health sector under existing implementation structures of
the Ministry of Health and Social Welfare (MoHSW). The PS will provide overall leadership
with day to day management provided by the Health Sector Reform Secretariat (HSRS) under
the Directorate of Policy and Planning (DPP). A Steering Committee, including the Program
Manager (NTLP), Assistant Director (Diagnostic Services), and Assistant Director
(Epidemiology and Disease Control), will be established within the MoHSW to provide technical
direction and oversight and approve the satellite laboratory annual work plans annually. The
HSRS will be responsible for day to day project management, FM, procurement, Monitoring and
Evaluation (M&E), and preparation of consolidated quarterly and annual technical and financial
reports. A full time project coordinator/public health specialist, an accountant, and an operations
officer/training coordinator will be appointed to coordinate the activities under the regional
project, within three months after credit effectiveness.
48. In Uganda, the proposed project will be fully embedded within the MoH, to respect the
Long-Term Institutional Arrangements (LTIA) which aim to strengthen ministry structures and
ensure broad based ownership. The PS, MOH, will have the overall responsibility for the
project. The Assistant Commissioner, National Disease Control, has been designated as the
Project Coordinator and the Head, National TB Program as the Deputy Project Coordinator. A
small Project Coordination Team, comprising of the Head, CPHL; Head, NTRL, and Assistant
Commissioner, Health Services, Epidemiological Surveillance Division, will be established to
lead implementation of their respective components/sub-components under the project. In
addition, it was agreed that an M&E Specialist, and Project Officer would be recruited. The
MOH Technical Working Group on Communicable Disease Control represented by the clinical,
disease control, and planning departments of MoH will provide overall direction for
strengthening health laboratory services, and will review and approve the consolidated annual
work plan for the project. A national technical advisory committee, including DPs, will provide
20
support to the technical working group, and will ensure harmonization of donor inputs for
laboratory services.
49. Regional arrangements While countries will have the overriding responsibility for
implementing activities at the national level and providing leadership at the regional level in key
thematic areas ECSA-HC will play a critical convening and coordinating role, supporting
knowledge sharing and advocacy efforts. The assessment of ECSA-HC‘s governance structures,
capacities, and track record is summarized in Annex 6. The rationale for using ECSA-HC is
based on the availability of multi-disciplinary and cross cutting set of skills and the
organization‘s capacities to facilitate knowledge sharing regionally.
50. ECSA-HC will set up a small team to provide oversight at the regional level. The team
will consist of a Senior Laboratory Specialist with a background in public health, an M&E
Specialist who would support ECSA-HC‘s M&E section, and short term consultants in key areas
(e.g. website development, ICT). In addition, the Administrative Officer being recruited by
ECSA-HC will provide administrative support and handle procurement. The Senior Laboratory
Specialist would report directly to the Director General and would coordinate closely with other
sections of the ECSA-HC Secretariat, particularly the M&E, Research, Information and
Advocacy, as well as Human Resources for Health, Health Systems, and HIV/AIDS and TB.
The M&E Manager at ECSA-HC will serve as the key focal point for these activities at the
regional level, and will be assisted by an M&E Specialist to be recruited under the proposed
project. The ECSA-HC Secretariat will prepare consolidated semi-annual and annual project
status reports based on inputs from countries, organize annual meetings of participating countries
to discuss key achievements, main issues, and lessons learned, and facilitate governmental and
inter-governmental actions that may be required under the project.
51. ECSA-HC will establish a Regional Advisory Panel (RAP) which will meet annually (or
more often as needed in the initial years) to facilitate learning among participating countries.
This will enable countries to take stock of progress, discuss challenges, share experiences, and
draw lessons. The RAP will be chaired by a high-level representative of the EAC to ensure
consistency with broader health and economic policies and initiatives in East Africa. The RAP is
expected to serve as a vehicle for multi-country and multi-stakeholder expert engagement and
dialogue.
52. The financing of the activities at the regional level will come from the four participating
countries. Each country will sign a Subsidiary Agreement with ECSA-HC and, in addition,
Rwanda will sign a Memorandum of Understanding with ECSA-HC, under terms and conditions
approved by the Association, as detailed in the Financing Agreements. Each Subsidiary
Agreements will stipulate the activities to be carried out and the financial arrangements, namely
providing to ECSA-HC on a grant basis about US$125,000 annually or a total of US$625,000
over the life of the project. The regional institutional arrangements will be reviewed and
amended, as may be necessary, during the Mid Term Review.
21
C. Monitoring and Evaluation of Outcomes/Results
53. The countries are committed to using a common framework for monitoring performance
of the project as described in Annex 3. Support to improving the availability, reliability, and
timeliness of routine laboratory information is an important part of the project. The development
and introduction of standardized lab and surveillance information is expected to facilitate the
task of data collection and monitoring. The Results Framework focuses on accountability for
results and places a strong emphasis on intermediate and final outcomes. To the extent possible,
the Results Framework uses existing indicators and data to measure the progress of both the
project and its contribution to the overall national program, not only for efficiency, but also to
strengthen existing data collection mechanisms. Countries will be responsible for coordinating
data collection, including preparation for routine project reporting. Regional-level responsibility
will be located at ECSA-HC. The implementation of the M&E framework will be tracked during
implementation, and will be a central part of project supervision.
D. Sustainability
54. In the medium to long term, several sustainability enhancing measures are proposed:
Institutional At the national level, the strategy of relying and strengthening existing
structures and elevating laboratory issues in policy dialogues will improve chances of
sustainability. At the regional level, sustainability will be sustained through high-level
policy discussions during the ECSA-HC and EAC annual meetings of Ministers of Health
and Permanent Secretaries. There is strong and broad based ownership in the four
countries of the proposed project. The recent endorsement by Ministers of Health of both
the ECSA-HC and EAC member states during the February and March 2010 annual
Ministers of Health Meetings augurs well for sustainability. ECSA-HC capacities will be
further strengthened, so that the knowhow for supporting regional harmonization will be
available on a sustained basis following project completion. The establishment of an
SRL in East Africa will further strengthen ownership and enhance the chances of
sustainability in the long-term. Involvement of civil society groups will strengthen
accountability and boost ownership. Furthermore, strong technical backstopping by the
Bank and other development partners will enhance chances of sustainability.
Financial Sustainability will also hinge on making adequate and timely provision for
recurrent cost financing associated with the proposed activities at both the national and
regional levels. The main recurrent costs relate to the maintenance of laboratory facilities
and equipment, consumables, and personnel recruited under the project. These costs are
estimated at roughly US$2.6 million at project completion for the four countries. The
financial impact of the project on government health spending is expected to be modest,
particularly to the extent that the project covers up to seven laboratories in each country,
maintenance of new equipment will be built into contracts, development partners are
committed to providing consumables and drugs as part of global efforts to combat TB,
and with the exception of the national laboratories which perform core public health
functions most laboratories are an integral part of existing hospitals. A phased exit
strategy is proposed to ensure sustainability of key inputs provided under the project. The
22
project supports existing national strategic plans for strengthening medical laboratory
services in line with the Maputo declaration to which all participating countries have
committed. Countries have agreed to create additional technical staffing positions or to
recruit additional personnel, making a concerted effort to progressively absorb these
experts or making provisions for other partners to fund them at project closure. As
reflected in the Financing Agreements, recipients will monitor recurrent expenditure of
the laboratories financed by the project, including levels of absorption of the personnel
recruited and submit reports to IDA to facilitate an ongoing dialogue on these important
issues. The Bank will ensure that these issues are elevated in annual sector and budget
reviews and will support ongoing efforts to elaborate human resource strategies for
bolstering the public health laboratories in these countries.
Human Resources Development of human resource capacity will be critical to providing
the required manpower for laboratory facilities supported under the project. One of the
key intermediate outcomes of the project is to strengthen the availability of critical
manpower and to bolster motivation. The new regional certificate program for laboratory
managers will enhance career and professional development prospects and improvements
in the safety of the work environment and in lab capacity more broadly will enable
laboratory technicians to deliver high quality services. As a condition of negotiations
policy letters were prepared by each country, confirming government commitment to
strengthen public health laboratory services and to sustain the human resources supported
under the project, including confirmation on inclusion of the project in the FY10/11
budget of the respective Ministries of Health.
E. Critical Risks and Possible Controversial Aspects
Risk factors
Description of risk Risk
Rating Risk Mitigation Measure
Rating of
residual
risk
Sector/Regional Level Risks
Difficulties sustaining
commitment at national
level to work within a
regional framework.
Participating countries face
competing demands and
may have difficulties
engaging at the regional
level and carrying out their
roles and responsibilities.
H With recent outbreaks of Meningitis and
H1N1 Pandemic there is increased
appreciation of regional mechanisms for
containment of communicable diseases.
The recent endorsement of the project by
the EAC and ECSA-HC Ministers of
Health augurs well for national ownership.
The EAC and ECSA-HC will conduct
activities to mobilize additional support
and brief ministers of health annually on
implementation progress and policy
implications. The Bank will adopt an
intensive and proactive supervision
approach with strong technical
backstopping from regional Bank offices.
S
23
Risk factors
Description of risk Risk
Rating Risk Mitigation Measure
Rating of
residual
risk
Inadequate coordination
capacity at regional level.
Capacity to coordinate
activities at the regional
level is limited and
fragmented.
S The participating countries have identified
ECSA-HC as the main partner for this
regional operation. ECSA-HC has a clear
mandate, good track record, and relatively
strong coordinating capacity. ECSA-HC
will be further strengthened and has agreed
to collaborate with other relevant regional
bodies, such as the EAC, in coordinating
disease surveillance activities. In addition,
technical agencies (e.g. CDC, WHO) will
be strongly involved during
implementation. The EAC will chair the
Regional Advisory Panel, facilitating
coordination with other health and
economic policies and initiatives.
M
Shortage of skilled and
motivated lab and health
personnel.
Variable training
opportunities, lack of
incentives, inadequate
career paths.
H The project will promote regional training
at centers of specialization; will assess
feasibility of introducing performance
incentives to enhance accountability and
motivation; and assist in developing and
introducing a certificate program for
laboratory managers. The regional project
will benefit from the Bank‘s broader
health policy dialogue in these countries,
including on human resources issues, and
from strong government commitment, as
outlined in the Policy Letters.
S
Duplication of efforts
between various
development agencies.
CDC, USAID, and WHO
are key players in
laboratory strengthening,
thus there is a risk of
duplication of efforts.
S Each of these organizations has provided
assistance in the development of the
project to minimize risk of duplication and
maximize synergies. In addition, several
countries have or are establishing
mechanisms to better coordinate donor-
funded activities. Participation of partners
on the Regional Advisory Panel will also
facilitate coordination.
M
Operation Level Risks
Potential disconnect with
other Bank-funded health
projects.
Regional activities may be
perceived as disconnected
with other Bank-funded
health activities and SWAp
processes.
M The regional project will be implemented
through established institutional and
implementation arrangements for Bank-
funded national projects to ensure
synergies and minimize duplication. No
new structures will be created in line with
the Paris declaration on aid harmonization.
Provision for further strengthening
existing structures has been made for
relevant units within Ministries of Health
to assume additional responsibilities.
L
Limited private sector
involvement.
Project design focuses on
strengthening public sector
facilities and may not
S The public good nature of the proposed
activities requires a priority focus on key
public structures. The Recipients have
M
24
Risk factors
Description of risk Risk
Rating Risk Mitigation Measure
Rating of
residual
risk
always tap the potential of
the private sector.
agreed to conduct a joint study of public-
private partnerships in laboratory services
to better understand the potential of the
private sector and to agree on a strategy
for scaling up such partnerships.
Inherent difficulties in
implementing regional
projects.
Regional projects are more
complex to manage and
implement.
H The innovative nature of the proposed
operation makes it high risk/high reward.
The team has incorporated lessons from
earlier regional health and non-health
projects into the design. It has ensured that
implementation at country level is through
existing structures to foster ownership,
made provisions for further strengthening
regional institutions, and will continue to
leverage field-based staff during
supervision and technical support phase.
S
Mixed prospects for
sustainability of
investments.
Inadequate provision of
recurrent financing for
proposed investments may
impede sustainability, as
governments have shifting
priorities and budgetary
constraints.
H Discussions of sustainability of
investments will be mainstreamed into the
Bank‘s health policy and budgetary
dialogue with participating countries, so
that staffing and recurrent cost issues are
discussed and monitored annually through
health sector and budget reviews, and an
exit strategy will be agreed upon with each
participating country.
S
Weaknesses in Financial
Management capacities.
-Inadequate numbers of
accounting personnel and
insufficient training in
Bank procedures.
-Lack of adequate FM
manuals.
-Inadequate accounting
information systems.
- Weaknesses in internal
control systems as
highlighted in the external
audit reports of ministries
implementing the project.
-Weaknesses with audit
committees which do not
follow up efficiently to
resolve audit issues.
S -Rwanda to recruit a qualified and
experienced accountant not later than one
month of effectiveness and Uganda to
assign an accountant by effectiveness; and
ECSA-HC staff to be trained in World
Bank Financial Management and
Disbursement Guidelines.
-Kenya has prepared a FM manual which
was reviewed during negotiations and will
be finalized based on comments received
from the Bank.
-Uganda is preparing an operational
manual (including FM arrangements) to
cover both this project and the Health
Systems Strengthening Project.
- Tanzania will complete the
computerization of the accounting system
within 6 months after effectiveness.
-Internal audit functions of the 4 Ministries
to monitor the issues identified in the audit
report to ensure they are followed up and
addressed by the project. In addition, in
Uganda, the Recipient will prepare and
submit to the Association 6 month internal
audit reports during the implementation of
the project.
-Audit committees in Kenya and Tanzania
S
25
Risk factors
Description of risk Risk
Rating Risk Mitigation Measure
Rating of
residual
risk
to be strengthened through ongoing Public
Financial Management reform programs.
The Bank will also liaise with the
ministries to work with the audit
committees to strengthen their capacities.
Procurement Risks
Inadequate procurement
capacity of implementing
agencies.
Implementing agencies
have inadequate
procurement capacity in
terms of procurement
skills, experience with
Bank procedures, and
filing and record keeping
systems are inadequate.
H Borrower will designate (Kenya) or recruit
procurement specialist (Tanzania) to carry
out procurement transactions, provide
hands on coaching to procurement staff,
and establish filing and record keeping
systems.
S
Overall Risk Rating H S
F. Loan/Credit Conditions and Covenants Credit/grant effectiveness:
-The Subsidiary Agreement has been executed and delivered on behalf of the Recipient and ECSA-HC
(all four countries).
-Rwanda: The Memorandum of Understanding has been executed and delivered on behalf of Recipient
and ECSA-HC.
-Uganda: The Recipient has assigned to the MoH an accountant, with qualifications, experience and
terms of reference satisfactory to the Association, to manage the project accounts.
Covenants applicable to project implementation:
The following covenants apply to all participating countries:
-The Recipient shall not later than 18 months after the effectiveness date, carry out and complete a joint
study with other project countries, on public-private partnerships in laboratory and diagnostic services,
including a strategy for scaling-up such partnerships.
-The Recipient shall not later than three months after effectiveness, prepare and adopt, in form and
substance satisfactory to the Association, an annual work plan for each public health laboratory
supported under the project, and thereafter during the implementation of the project review with the
Association and update the annual plan every 12 months.
-The Recipient shall during the period of the project regularly monitor the recurrent expenditures of all
the laboratories financed through the proceeds of the Credit (Grant), including the levels of absorption
of the personnel recruited to support such laboratories. To this end and as part of the progress reports
the Recipient shall submit reports, in form and substance satisfactory to the Association, on the status
of such expenditures (annual).
-Rwanda: The Recipient shall: (a) appoint independent auditors not later than three months after the
effectiveness date; and (b) recruit an accountant to the Project Management Unit not later than one
month after the effectiveness date.
-Tanzania: The Recipient shall not later than six months after credit effectiveness: (i) computerize the
accounting functions of the project; and (ii) recruit a procurement specialist for the duration of at least
two years.
-Uganda: The Recipient shall: (i) prepare and submit to the Association six-month internal audit
reports not later than 45 days after the end of such period; and (ii) recruit a Laboratory Infrastructure
Consultant with experience in TB and microbiology laboratory design not later than three months after
credit effectiveness.
26
IV. APPRAISAL SUMMARY
A. Economic and Financial Analyses
55. There is a strong economic rationale for investing in enhanced diagnostic techniques
for TB control. Investments in TB control have a significant economic impact on individuals,
households, economies, as well as neighboring countries. The economic cost of TB-related
deaths in sub-Saharan Africa would be about US$ 52 billion annually through 2015 in the
absence of effective TB treatment.8 If these countries were to offer treatment to TB patients, in
line with the global plan to halve the prevalence and death rates by 2015 (relative to 1990
figures), the economic benefits would exceed costs by up to 9 times in the most afflicted
countries. Mitigating the spread of drug resistant TB is critical to fostering health security at the
regional and global levels and will result in substantial economic and social benefits. The
potential adverse economic impact on the health sector and on economies which thrive on
tourism, such as Kenya and Tanzania, is significant. It is critical to act early and forcefully to
avoid the high costs incurred by other countries during disease outbreaks. 9
56. In light of inherent market failures there is also a strong economic justification for a
regional approach to control of communicable diseases. As noted in the 2002 “Global Public
Goods for Health‖ report by the Commission on the Macroeconomics of Health, acting
independently each country may have limited motivation to invest in communicable disease
control efforts, as benefits accrue to neighboring countries. This highlights the need for
strengthening provision of public goods, through: (i) control and prevention of cross border
spread of communicable diseases; (ii) standardized data collection efforts; and (iii) research,
which are all areas of support under this regional project.
57. Finally, there are important efficiency gains to be reaped from introducing modern
diagnostics for treating HIV related and drug resistant TB and promoting an integrated health
care model for co-infected individuals. The state of diagnostics in participating countries
implies that many patients go undiagnosed for long periods, continuing to infect others, and
ultimately leading to premature death. Lack of diagnostic capacity also contributes to high drug
prices for treating MDR-TB, as suppliers have few incentives to invest in light of the low
number of patients being diagnosed. With the introduction of culture techniques and expansion
in drug susceptibility testing, the turnaround time for getting results will be reduced from months
to days, and individuals can be placed on treatment more promptly. Strong laboratory networks
with well trained and well protected staff will be able to respond quickly and reliably to public
health threats, reducing the risk of transmission, and assisting providers to deal more efficiently
with patients, ultimately reducing morbidity and mortality.
8 Laxminarayan, R., Klein, E., Dye, C., Floyd, K., Darley, S., Adeyi, S., Economic Benefit of Tuberculosis Control,
Policy Research Working Paper 4295, The World Bank, August 2007.
9 The Mexican government estimated that the H1N1 outbreak had devastating effects on tourism and economic
growth with an estimated loss of roughly .3 percent of GDP or US$2.3 billion. The economic cost of the 2006
Chikungunya epidemic in Mauritius and other Indian Ocean countries was substantial in terms of losses to the
tourist industry.
27
B. Technical
58. There is a sound rationale for investing in laboratory and diagnostic capacity and
bolstering surveillance efforts in the region. While strengthening diagnostic capacity is
important, it is not sufficient. Building partnerships with other donors, as has been done, will
ensure that diagnostic capacity translates into greater access to specialized services, particularly
for poor people who are disproportionately affected.
59. There is also a strong business case for promoting public-private partnerships and
strengthening collaboration with the private sector. The private sector plays an important and
growing role in the provision of health and diagnostic services across participating countries.
While recognizing that some services (e.g. control of disease vectors, surveillance, and
information) are pure public goods because of inherent market failures, other services, such as
laboratory testing, may be publicly funded but privately delivered. There is a movement toward
greater collaboration with the private sector, including accrediting private laboratories and
strengthening regulatory capacities (e.g. Kenya), sub-contracting the postal service to handle
specimen transport (Uganda), and public-private partnerships (e.g. Tanzania). Building on these
achievements, the Bank in collaboration with the International Finance Corporation (IFC), will
continue to assist countries to identify such opportunities through the proposed PPP study, as
discussed in Annex 4.
C. Fiduciary
60. The Financial Management (FM) and procurement assessments of the national
implementing agencies and of ECSA-HC were carried out by the Bank with details provided in
Annex 7 and Annex 8 and summarized below:
61. Financial Management (FM) The FM assessments covered the MoPHS in Kenya,
Ministry of Health & Social Welfare (MoH&SW) in Tanzania, the MoH in Uganda, and the
MoH in Rwanda as well as the East, Central and Southern Africa Health Community (ECSA-
HC). The assessment also covered other institutions involved in the implementation of the
project, including some of the satellite laboratories that will benefit from the project which are
based in district and regional hospitals.
62. Public Expenditure and Financial Accountability (PEFA) assessments have been done in
Kenya, Tanzania, Uganda and Rwanda. These assessments provide details about country
strengths and risks which are presented in Annex 7. All four countries have Public FM Reform
Programs that are addressing the risks identified in these assessments. The details of the FM
assessments pertaining to the project are summarized below.
63. All implementing entities were found to have: (i) adequate budgeting arrangements;
(ii) adequate number of accounting personnel except for Uganda and Rwanda which need to
assign and recruit, respectively, a qualified and experienced accountant for the project; (iii)
adequate FM manuals for the project except for Kenya which prepared a draft manual that was
ready by negotiations and will be finalized based on comments from the Bank; and in the case of
Uganda, the MoH will sign an agreement with Lacor Hospital which is a Non-Governmental
28
Organization (NGO) to ensure there are adequate FM arrangements in place; (iv) adequate
accounting information systems to prepare the project accounts except for Tanzania that has to
finalize the installation of a computerized accounting system; (v) strong internal audit functions
except for Tanzania and Kenya that need to strengthen the capacities of the audit committees in
order to be more effective in following up audit recommendations; (vi) adequate fund flow
arrangements except for the challenge of slow disbursements which will be addressed through
capacity building with the project teams and staff from the Ministries of Finance; (vii) adequate
financial reporting arrangements except for concerns over the timely provision of information
from district and regional hospitals which could delay the finalization of the Interim Financial
Report (IFR)s; (viii) adequate external auditing arrangements except for the risk related to the
quality of audits which was addressed by agreeing on audit terms of reference by negotiations
and use of private external audit firms acceptable to the Bank where the capacity of public audit
institutions needs strengthening.
64. To address the shortcomings outlined above an action plan has been prepared to
strengthen FM capacities of the implementing entities. These actions include: (i) agreeing on
the formats of the Interim Financial Reports and audit Terms of Reference for all implementing
entities which was completed by negotiations; (ii) assigning by effectiveness (Uganda) or
recruiting (Rwanda) within one month after effectiveness a qualified accountant for the project;
(iii) strengthening the financial management manuals in Kenya; (iv) preparing six-month internal
audit reports in Uganda to strengthen fiduciary controls and conducting a value for money audit
after the construction of the laboratories; (v) completing the installation of the accounting
information system in Tanzania; (vi) strengthening the audit committees in Kenya and Tanzania
to effectively address issues raised in both internal and external audit reports; and (viii) training
staff of ECSA-HC in World Bank FM and Disbursement Guidelines. These proposed mitigation
measures are adequate to provide reasonable assurance that accurate and timely information on
the status of the project required by IDA will be provided to satisfy the minimum requirements
under OP/BP 10.02.
65. In conclusion, the proposed FM arrangements meet the Bank‘s minimum requirements
for project FM, as per OP/BP 10/02, and therefore are adequate to provide, with reasonable
assurance, accurate and timely information on the status of the project required by IDA. The
implementing entities are compliant with the Bank‘s FM requirements and there are no overdue
audit reports and IFRs from these entities. The conclusion of the assessment is that the FM
arrangements have an aggregate residual risk rating of moderate for ECSA-HC and substantial
for the ministries implementing the project in Kenya, Rwanda, Tanzania and Uganda.
66. Procurement The procurement functions in Kenya, Rwanda, Tanzania and Uganda are
governed by recent Procurement Laws adopted in the context of procurement reforms between
2003 and 2007. As indicated in the Country Procurement Assessment Reports (CPARs), the new
procurement regulations in these countries are generally satisfactory. Public procurement
regulatory authorities have been established, with oversight and monitoring functions, and
modernized institutional arrangements for the handling of procurement have been put in place,
with training programs provided, as needed. Procurement for the proposed project would be
carried out in accordance with the World Bank‘s "Guidelines: Procurement under IBRD Loans
and IDA Credits," dated May 2004, revised October 2006, and "Guidelines: Selection and
29
Employment of Consultants by World Bank Borrowers," dated May 2004, revised October 2006.
Likewise, the ―Guidelines on Preventing and Combating Fraud and Corruption in Projects
Financed by IBRD Loans and IDA Credits and Grants‖, dated October 15, 2006, shall apply to
the project.
67. Procurement assessments of the implementing agencies and of the ECSA-HC were
conducted by Bank staff. The assessments reviewed the organizational structures and functions,
past experience, staff skills, quality and adequacy of control systems, and legal and regulatory
frameworks. All four countries have procurement laws which are generally consistent with IDA
procurement guidelines but enforcement still requires additional efforts. The main risk to
procurement is the limited compliance with procurement laws. The aggregate risk for
procurement is high because a number of implementing agencies (Kenya and Uganda Ministries
of Health) have limited or no experience with procurement under Bank-funded projects.
Capacity of many of the implementing agencies or their procurement units is being enhanced
under other IDA-funded projects. To further strengthen capacities of both the national
implementing agencies and ECSA-HC the Bank review teams have recommended a number of
additional measures as detailed in Annex 8. These actions include: recruiting additional staff to
respond to growing workloads (i.e., Tanzania) and providing additional training in Bank
procurement procedures for all concerned institutions.
D. Social
68. The project's poverty reduction and social development outcomes are anticipated at two
levels. First, the poverty and social impacts are significant for the anticipated poorest
beneficiaries who will avail of timely response to outbreaks, especially among the densely
populated peri-urban poorest settlements and remote rural villages in border areas of Kenya,
Tanzania, Uganda, and Rwanda. Early diagnosis and treatment will reduce stigma and improve
quality of life. Since most of the disease-affected populations are vulnerable groups such as
slum dwellers, migrants, refugees, who live in households subsisting on less than two dollars a
day, the preventive and curative approaches to TB and other communicable diseases supported
by the project will improve health conditions. Second, the widespread benefits from improved
diagnostic services for highly vulnerable HIV positive individuals, including those afflicted with
drug resistant strains of TB would cover the poorest populations, especially women and children.
69. Based on field work in assessing the potential project sites, the project does not involve
land acquisition because rehabilitation of current laboratories is within the existing footprint and
the potential sites within the footprint involve no resettlement. IDA will not finance civil works
on land for which there is involuntary resettlement and/or any claims. The ESMF contains
guidelines for assessing and mitigating environmental and social impacts and risks. OP 4.10 is
triggered in Kenya, and a separate Indigenous Peoples Policy Framework (IPPF) was prepared
and disclosed to ensure that the development process of this project fully respects the dignity,
rights, economies, and cultures of vulnerable indigenous communities and that the project is able
to gain the broad community support of affected indigenous peoples and other marginalized
groups. As part of the project‘s public consultation and disclosure process, key stakeholder
groups have been consulted throughout project preparation.
30
70. Further, the design of the project incorporates a participatory approach, including civil
society groups that promote patient rights and conduct advocacy among vulnerable groups. Civil
society groups which have been closely associated in the preparation process have been highly
supportive of the proposed activities which address a major gap in the care of TB/HIV co-
infected patients. During implementation, the project will support its partner institutions in-
country to take advantage of the broader participation of civil society to strengthen
accountability by citizens, community groups, and afflicted communities. In line with the new
Bank policy on civil society engagement and related independent oversight and governance, the
project makes provision for: (i) inclusion of representatives of civil society in district
coordination teams; and (ii) incorporation of messages on diagnostic and surveillance in district
civic activities in the project areas where the satellite laboratories will be located, so that
community and civil society groups can assume greater responsibility for these activities. These
civil society groups can provide oversight, strengthen accountability to the community, and
support Information, Education and Communication (IEC) messages at local level. Strong
involvement of civil society groups will be critical to strengthening ownership of the activities
supported under the project and enhancing chances of sustainability once the project ends.
E. Environment
71. The regional project has triggered OP 4.01 due to the planned construction/rehabilitation
of laboratories as well as the generation of medical waste at laboratories and has been assigned
the environmental category B, and OP 4.10 is triggered in Kenya, as noted above. To ensure
proper assessment and mitigation of potential adverse environmental and social impacts, an
Environmental and Social Management Framework (ESMF) has been prepared for the project
and will be applied to all four countries. Kenya has elaborated an IPPF. The ESMF outlines the
steps in the environmental and social screening process, and includes Environmental Guidelines
for Contractors, a summary of the Bank‘s safeguard policies, an Environmental and Social
Checklist, generic Environmental Assessment (EA) terms of reference to be applied in the event
that the screening results indicate the need for a separate EA report, and an Environmental and
Social Management Plan (ESMP).
72. During negotiations the delegations from the four participating countries confirmed that
proposed construction and renovations will be done on land owned by the respective
governments and that there will be no involuntary displacement of any individuals since there are
no squatters or other vendors at these sites. In cases involving construction, such as a new health
laboratory or an annex to existing structures, the ESMF contains appropriate checklists and
diagnostic procedures to assess risks and identify appropriate mitigation measures. As agreed
during negotiations and as stipulated in Schedule 2 D (Environmental and Social Safeguards) of
the four Financing Agreements the project will not fund activities that would involve involuntary
resettlement. Countries have also revised their waste management plans which focus on
laboratory waste generation as well as segregation, storage, collection, transport, and final
disposal practices; technologies for waste disposal; public awareness programs; and relevant
national legislation.
31
F. Safeguard policies
Safeguard Policies Triggered by the Project Yes No
Environmental Assessment (OP/BP 4.01) [X] [ ]
Natural Habitats (OP/BP 4.04) [ ] [X]
Pest Management (OP 4.09) [ ] [X]
Physical Cultural Resources (OP/BP 4.11) [ ] [X]
Involuntary Resettlement (OP/BP 4.12) [ ] [X]
Indigenous Peoples (OP/BP 4.10) a/ [X] [ ]
Forests (OP/BP 4.36) [ ] [X]
Safety of Dams (OP/BP 4.37) [ ] [X]
Projects in Disputed Areas (OP/BP 7.60)* [ ] [X]
Projects on International Waterways (OP/BP 7.50) [ ] [X]
a/ For Kenya only.
G. Policy Exceptions and Readiness
73. The project complies with all Bank policies and no policy exceptions are requested. The
institutional arrangements are the same as those for other Bank-funded health operations, which
should facilitate implementation. During appraisal and negotiations the readiness for
implementation was confirmed in each country and at the regional level.
All four countries have finalized implementation and training plans, and ECSA-HC has
prepared an implementation plan which was reviewed and approved.
The country and ECSA-HC procurement plans were finalized and approved.
Further specific actions were taken to accelerate readiness, such as: (i) designating an
accountant to manage the project funds, a procurement specialist, and internal auditor
(Kenya); (ii) initiating the preparation of a Project Implementation Manual using the
Project Preparation Advance from the Uganda Health Systems Strengthening Project
(Uganda); and (iii) designating an accountant to handle the project while initiating the
recruitment of an additional accountant (Rwanda).
* By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the
disputed areas
32
Annex 1: Country and Sector or Program Background
Africa: East Africa Public Health Laboratory Networking Project
1. This annex is divided into three sections. The first section provides information on the
tuberculosis situation in sub-Saharan Africa, highlights the TB diagnostic gaps, and provides a
summary of analytic work conducted in the context of project preparation on the importance of
public health laboratory systems. The second one discusses the importance of regional
networking for effective integrated disease surveillance. The final section provides the links
between the project and the broader Africa Regional Framework for Communicable Disease
Control and Preparedness.
I. TB in Africa: Epidemiological Situation
2. Background: Sub-Saharan Africa has the highest rates of tuberculosis and the worst
treatment outcomes in the world. The resurgence of TB has been fuelled by the spiraling HIV
epidemic with 2.8 million new TB cases and roughly 735,000 deaths annually. In southern
Africa, drug resistant TB is becoming a major issue, as it is costly to treat and harder to cure.
With the growth in migration and travel and the emergence of lethal forms of the disease, TB
poses a serious health and development threat.
3. Africa accounts for 11 percent of the world‘s population but a disproportionate 31
percent of the world‘s burden of TB and 34 percent of its deaths.10 While other regions have
made rapid progress in the last 5 years in fighting the spread of TB, Africa‘s progress has been
much slower, constrained by the triple-threat of high HIV/TB co-infection rates, the spread of
particularly lethal forms of drug-resistant TB, and weak health systems that are ill-equipped to
address these challenges. Between 1990 and 2007, Africa‘s TB burden increased by 245
percent.11
4. Globally, the World Health Organization has identified 22 ‗High-Burden Countries‘
(HBCs) that together account for 80 percent of the world‘s TB cases. There are 9 in Africa:
Nigeria, South Africa, Ethiopia, Democratic Republic of Congo, Kenya, Tanzania, Uganda,
Mozambique, and Zimbabwe. In addition to this classification of overall numbers of TB cases,
the WHO has identified 15 ‗High-Incidence Countries‘ where the greatest concentrations of TB
patients per 100,000 population are located. 13 of the 15 are in Africa: Swaziland, South Africa,
Namibia, Lesotho, Zimbabwe, Zambia, Botswana, Sierra Leone, Mozambique, Cote d‘Ivoire,
Congo, Rwanda, and Djibouti.
5. Many of these countries have experienced increases in their TB burdens of between 200-
400% since 1990. In addition, the number of people dying from TB in Africa each year has
more than tripled in the last 15 years. Epidemiologic profiles of the participating countries
(Kenya, Rwanda, Tanzania, and Uganda) can be found in the table at the end of this document.
10
New England Journal of Medicine, ―Tuberculosis in Africa: Combating an HIV-driven Crisis‖
Chaisson, R., p.1089, March 13th
2008 11
According to WHO‘S Global TB Control Report 2009, the 1990 incidence of TB in Africa was 829,337 cases and
in 2007 it was 2,879,000.
33
6. The TB and HIV co-epidemic in Africa: One third of the world‘s population (more
than 2 billion people) carries TB in latent form – that is, their body‘s natural immune system is
able to ‗wall-off‘ the bacillus and prevent it from developing into active TB disease. For such
TB ‗carriers‘ there is a 10-15 percent lifetime risk of developing active TB disease. When
something happens to undermine the body‘s immune system such as HIV infection, diabetes, and
even old age – this creates a deadly symbiosis that enables the dormant TB to multiply and
spread making the patient infectious and sick.
34
7. The HIV epidemic of the 80s and 90s set off a chain reaction that sent TB rates spiking to
unprecedented levels in Africa. With HIV, a person is 50 times more likely to develop active
TB. Not surprisingly, TB is the leading cause of death among people living with HIV (PLHIV)
in Africa and a major cause of death elsewhere. It is also the most common presenting illness
among PLHIV on Antiretroviral Therapy (ART) worldwide and is compromising investments
and programmatic gains made in the fight against HIV/AIDS. According to Michel Sidibe,
Executive Director of UNAIDS, TB is a "preventable plague inside a devastating epidemic".
8. Roughly 378,000 Africans died of HIV associated TB in 2007 (82% of all HIV
associated TB deaths globally).12
WHO further estimates that without proper treatment, 90
percent of PLHIV typically die within months of being infected with active TB. Of the 22.5
million HIV+ people in Africa then, we can estimate that at least 1/3 of them (7.5 million people)
are infected with the TB bacillus and at high risk of developing active TB.
WHO Global TB Control Report 2009
9. It is particularly difficult to diagnose TB in PLHIV using the main diagnostic technology
of Sputum Smear Microscopy (SSM). The reason for this is that SSM depends on detecting TB
in the lungs which requires high concentrations before TB can be confirmed. HIV disseminates
the TB throughout the body which makes it much more difficult to diagnose resulting in high
death rates and ongoing transmission among PLHIV. Increasing country capacity to diagnose
TB in these vulnerable groups by strengthening the laboratory function will play a key role in
improving health outcomes for these highly vulnerable groups.
12
Global TB Control Report, WHO, 2009
35
10. The following table classifies African countries facing high and low TB and HIV rates.
TB infection rate
Low High
HIV Rate
Low
Angola, Benin, Burkina Faso, Cape
Verde, Chad, Comoros, Equatorial
Guinea, Eritrea, Gambia, Ghana,
Guinea, Guinea-Bissau, Madagascar,
Mali, Mauritania, Mauritius, Niger,
Sao Tome & Principe, Senegal,
Seychelles.
Liberia, Sierra Leone, Togo
High
Cameroon
Botswana, Burundi, CAR, Congo, Côte
d'Ivoire, DRC, Ethiopia, Gabon, Kenya,
Lesotho, Malawi, Mozambique, Namibia,
Nigeria, Rwanda, South Africa, Swaziland,
Tanzania, Uganda, Zambia.
*countries in bold are targeted under the Regional Project
11. Impact on Women and Children: TB is a leading cause of death among women of
reproductive age and is estimated to cause more deaths among this group than all causes of
maternal mortality.13
Annually, about three-quarters of a million women die of TB, and over
three million contract the disease, accounting for about 17 million Disability Adjusted Life Years
(DALY).14
As tuberculosis affects women mainly in their economically and reproductively
active years, the impact of the disease is also strongly felt by their children and families. The
mortality, incidence, and DALY indicators do not reflect this hidden burden of social impact.
12. For pregnant women living in areas with high TB infection rates, there are increased
chances of transmission of TB to a child before, during delivery or after birth. Over 250,000
children die every year of TB. Children are particularly vulnerable to TB infection because of
frequent household contact.15
The disease, especially if associated with HIV, also accounts for a
high incidence of maternal and infant mortality.
13. Slow progress in Africa: Africa lags behind other regions in achieving the global
targets of detecting 70 percent of TB cases and successfully treating 85 percent of them. The
following graph shows trend in progress among all the 22 high TB burden countries and shows
that for the most part, it is African countries that lag the furthest behind. With the exception of
Kenya achieving the target for Case Detection (CD), the other countries have stagnated due in
part to the health systems weakness of an inadequate diagnostic platform.
13 World Health Report 2001, Geneva: World Health Organization.
14
http://www.who.int/tb/challenges/gender/page_1/en/index.html
15
"Tuberculosis and children", The Stop TB Partnership/ IPA, 2001.
36
DOTS Progress in high burden countries 2006-200716
14. The spread of Drug-resistant TB in Africa: To further confound efforts to fight TB in
an environment of high HIV, the spread of multi-drug resistant TB (MDR-TB which is resistant
to first line drugs) and extensively drug resistant TB (XDR-TB which is resistant to second line
drugs) is an emerging threat to global health. There are an estimated 500,000 MDR-TB patients
each year globally and 40,000 with XDR-TB.
15. As a result of incorrect treatment, some strains of the TB bacterium can no longer be
treated with inexpensive, first-line drugs. Growing drug resistance, including MDR and XDR-
TB and the increasing number of patients co-infected with HIV/AIDS, are joining forces to make
the pandemic more deadly and more costly to treat.
16. Not only is it a challenge for those with drug-resistant TB to obtain accurate diagnosis
due to the previously mentioned challenges of 1) weak laboratory infrastructure and health
systems 2) high co-infection rates in some settings – but also the main diagnostic tool –
microscopy, cannot determine whether or not the identified TB is drug-resistant or drug
susceptible. What this means in practice is that many MDR and XDR-TB patients are put on
first-line TB drugs which are useless in their case. Their condition worsens, they continue to
transmit (now drug-resistant) TB, and in most cases – they die.
16
Global TB Control Report, WHO, 2009. In the graph, Treatment Success refers to patients registered in 2005 or
2006, and evaluated respectively by the end of 2006 or 2007. Arrows mark progress in treatment success and
DOTSCase Detection rate. Countries should enter the graph top left and proceed rightwards to the target zone.
Countries from AFR, EMR, EUR, AMR are shown in red while countries from WPR and SEAR are in black.
37
17. Timely diagnosis of drug-resistant TB, particularly for PLHIV, depends on having well-
functioning laboratories with modern diagnostic technology. Liquid culture, drug sensitivity
testing, and molecular diagnostics17
are at the cutting-edge of the battle to safeguard the regional
and global public good of controlling the spread of drug-resistance. Currently, less than 5
percent of those estimated to have MDR-TB are being diagnosed.
Regional Project Country-Specific Epidemiology18
COUNTRY
Pop’n,
million
(2006)
INCIDENCE MORTALITY INCREASE DETECTION TREATMENT
New Cases per
Year (all
forms)
New
Cases per
Year /
100k
Pop’n (all
forms)
TB Death
per Year
(HIV-
neg)
TB Deaths
per Year
(HIV pos)
TB
Death
per
Year
(all
forms) /
100k
Pop’n
% Change
since 1990 -
new cases per
year
DOTS, new
smear-positive
case detection
(CD) rate (%)
DOTS new
smear-positive
treat’
success (MDG
indicator 24)
(%)
Kenya 37.5 132,000 353 10,000 15,000 65 384% 72% 85%
Tanzania 40.4 120,000 297 12,000 20,000 78 164% 51% 85%
Uganda 30.9 102,000 330 13,000 16,000 93 250% 51% 70%
Rwanda 9.7 39,000 397 6,000 7,000 128 217% 25% 86%
TOTAL
Africa 792.40 2,879,000 363
357,000 378,000
93 247% 46% 76%
Regional Dimensions of TB Laboratory Network in Africa
18. The current global network of laboratories comprises 29 Supranational Reference
Laboratories (SRL) that provide service to over 150 National Reference Laboratories (NRL).
SRLs are highly proficient facilities accredited by WHO that provide a variety of services to
NRLs at country level. Each country has one NRL for TB that serves a variety of functions
including the provision of higher level diagnostic tests (e.g. Polymerase Chain Reaction, PCR,
liquid and solid culture, Drug susceptibility testing, DST) as well as providing services to
Intermediate Labs (ILs).
17
Molecular diagnostics in tuberculosis have enabled rapid detection of Mycobacterium tuberculosis complex in
clinical specimens, identification of mycobacterial species, detection of drug resistance, and typing for
epidemiological investigation. Whereas the turn-around time for standard diagnostic technology from sample to
result is 6-7 weeks, molecular diagnostic technology can deliver results in days. This time savings can be the
difference between life and death for those with drug-resistant TB. 18
Compiled from WHO Country Profile Reports, 2009
38
19. The organization of TB labs varies across countries. In Rwanda, there is one National
Reference Laboratory which covers all diseases, including TB. In Kenya, Tanzania, and Uganda
the TB reference laboratories have separate management structures and in some cases are
physically at different locations from the Central Public Health Laboratories. In the past,
targeted support for disease specific lab strengthening has resulted in relative neglect of the
central public health labs. Governments and DPs are now consolidating public health laboratory
capacity across diseases and supporting integrated approaches.
Supranational Reference Laboratory Network
TB Laboratory Networking
Facility Serves Services Provided
Supranational
Regional
Laboratory (SRL)
Multiple NRLs. Quality control (e.g. panel testing), TA, training,
support with drug-resistance surveys, higher-level
testing (e.g. second line DST, molecular
diagnostics).
National Reference
Laboratory/ Central
Public Health Laboratory
(CPHL)
Intermediate labs which
are located at regional
level in the countries
(such as regional
hospitals).
Policy development and planning.
Development of standardized manuals and
guidelines.
Training
Operations research
Quality assurance
Diagnostic services: culture, DST
Supervision
Intermediate Laboratory (Satellite Labs)
Peripheral level facilities
(primary health centers or
district hospitals.
Quality control, quality assurance/supervision,
diagnostic services (culture, microscopy).
Peripheral Laboratory Sputum collection
Smear microscopy
Slide collection for EQA
39
20. Diagram 1 below depicts diagrammatically the building blocks of the TB Laboratory
Network and their inter-relationships: Supranational Reference Lab (SRL), National Reference
Labs (NRL) and Intermediate Labs (IL).
21. The chain is only as strong as the weakest link, and a functional, efficient network
depends on each level having the capacity to fulfill its functions. If it lacks that capacity, the
level above is compelled to deliver replacement services. This leads to longer diagnostic delays,
inefficient use of resources, and limited capacity to perform higher level functions.
22. The laboratory network in Sub-Saharan Africa (SSA) is not so much a chain as an
inefficient series of weak and missing links. There is only one SRL in SSA (in South Africa)
and as a consequence, ad-hoc arrangements between African countries and other SRLs for key
lab services have been set-up with facilities as far away as Australia (e.g. in Kenya, some
samples are sent to Brisbane‘s SRL for diagnosis). This leads to lengthy delays in diagnosing
patients and getting them on appropriate treatment.
23. At the NRL level, there is a wide range of functionality across Africa from barely
functional, to well-performing. However, most NRLs are plagued with infrastructure, human
resources, equipment, and training gaps and are not functioning optimally. As a result, this has
knock-on impacts on the entire quality assurance network in the country at the intermediate level
and beyond. An acute area of weakness is the absence of common regional standards, strategies,
and operating procedures, as well as mechanisms for collaboration on regional public goods
issues like the spread of drug-resistant TB.
24. Analytic work conducted as part of project preparation highlighted the importance of
laboratory issues, critical factors in their linkage with health services delivery, and their potential
contribution to achieving greater health outcomes on the road to the Millennium Development
Goals, as summarized below. The analytic work also examined the constraints and opportunities
to investing in laboratories from a regional perspective.
40
A Weak Link to Improving Health Outcomes in Low-income Countries: Laboratories
Key Lessons
Medical laboratories perform key functions
Laboratories provide objective data that enable diagnosis, document treatment results,
and generate critical public health information.
Laboratories are critical to identifying new threats to human health, such as exposure to
toxic substances, or antimicrobial resistance and to complying with the International
Health Regulations.
Laboratory services at peripheral and referral levels are essential for the management of
the most frequent causes of child morbidity and mortality (MDG4).
Quality of laboratory services can be strengthened through accreditation, assisting
facilities to comply with formalized laboratory standards and guidelines.
A public health laboratory is the national focal point for quality assurance, and assures a
reference laboratory function for all public health programs.
Reference laboratories play a key role in maintaining the quality of services by
independently controlling the quality of tests.
Laboratory networks are essential to the provision of public health goods
Networking laboratories is critical to assess the quality of tests, participate in disease
surveillance, and ensure a prompt response to public health emergencies of international
concern or share specialized tests and reap economies of scale.
Regional laboratory networking are important for addressing the growing needs in cross-
border disease prevention and control, and preparedness for emerging disease outbreaks,
and maintaining proficiency on specialized tests. The need to assure quality of diagnoses
in national networks requires a supra-national level of quality assurance.
Tuberculosis control programs in low income countries have been pioneers in defining
the functions of laboratories at all levels of a tiered network, providing a continuum of
services from the periphery to the supranational level, and establishing quality assurance
systems for smear microscopy and sustained support from the World Health Organization
and International Union Against Tuberculosis and Lung Disease have permitted EQA of
drug susceptibility testing.
Laboratory services have a critical impact on other aspects of health systems
Improved laboratory capacity will enable health care workers to deliver more effective
treatment, enhance efficiency in use of resources, and improve quality of care.
Investments in laboratory capacity can boost productivity. For example, during the
preparatory phase it was found that strengthening a zonal laboratory in Tanzania resulted
in a 30-fold increase in laboratory tests performed.
Diagnostic services are a potential driver of healthcare costs and hence clinicians need to
make judicious use of laboratory tests, and cost-effectiveness considerations need to be
taken into account in introducing new technologies.
41
Laboratory challenges remain inadequately addressed in low-income countries, including in
Kenya, Rwanda, Tanzania and Uganda
The major developments in health system thinking of the past decades have paid only
marginal attention to the place of diagnostic services in health packages.
Laboratories suffer from a lack of dedicated budgets to finance their contribution to
public health interventions.
Few low-income countries have so far invested in developing and forcefully
implementing national laboratory and diagnostic policies.
The availability of qualified staff remains a critical bottleneck to service provision. For
example, forecasts developed according to the recommendations of the Commission on
Macroeconomics and Health reveal that Tanzania has a current gap in laboratory
personnel above 80 percent.
Quality assurance systems throughout laboratory networks are embryonic in many
countries.
Despite the implementation of modern tests in the field, provision for preventive and
curative maintenance remains inadequate even in Kenya which has a strong policy.
Laboratory information systems are inadequate to address the volume of activity to
manage, the participation in disease surveillance, and the requirements for quality impose
on laboratories to manage a substantial volume of information.
Opportunities for an investment by and role of the World Bank
The World Bank has an institutional mandate to address health systems issues, and its
convening power can be used to elevate importance of laboratory issues in health policy
dialogues. This convening power can also be used to promote partnerships, to engage the
private sector, and to bring in technical partners (CDC, WHO, Union, KNCV), policy
makers, and financing organizations at macro level.
At country level, it can be used to promote comprehensive approaches to diagnostic
systems strengthening by convening technical programs, laboratory systems, financiers,
and planning departments, and strengthening the leadership of ministries of health.
The World Bank‘s analytic capacity can also be mobilized to strengthen the research
agenda around laboratory issues and promote evidence based approaches and knowledge
sharing.
Through its set of various financing instruments, the Bank can provide flexible financing
to fill gaps not funded by other partners, and contribute to restore the value of public
investment programs for developing sound national strategies, and establishing the
required physical infrastructure.
42
II. Surveillance of Other Communicable Diseases
25. Integrated Disease Surveillance and Response (IDSR): The IDSR was adopted by the
WHO regional committee for Africa in 1998, in part as a result of the increased number of severe
outbreaks of meningococcal disease, cholera, viral hemorrhagic fevers and measles and the
expansion of diseases outbreaks across national borders in sub-Saharan Africa. The long-term
vision of the IDSR is to establish a functional disease surveillance system for timely provision of
information for prompt public health action, thus contributing to the improvement of epidemic
preparedness and response and to the control of communicable diseases.
26. The functions of the IDSR are to support countries in: (i) development, adaptation and
implementation of an integrated communicable disease surveillance strategy; (ii) development of
a computerized database for the surveillance of priority communicable diseases; (iii) generation
of information on communicable diseases; (iv) information sharing through the publication of
periodic feedback and epidemiological bulletins.
27. Given the regional dimensions of communicable diseases, especially the frequent
outbreaks of meningitis, cholera, measles and hemorrhagic fevers, there is urgent need for
reactivating the IDSR to facilitate prompt identification of communicable disease outbreaks and
harmonized responses among the countries. Such a network in addition to ensuring appropriate
and standardized response across the countries will help in prompt information exchange
between countries to make them better prepared for any impending communicable disease
outbreak. The recent developments in information and communication technology such as
messaging over mobile phones offer new opportunities to improve the information networking
which is critical for integrated disease surveillance.
28. Collective action at the regional level requires the participating governments to adhere to
a mutually agreed set of norms and standards; strengthen country capacity for disease
surveillance to ensure prompt identification and appropriate local response for prevention and
control through routine and complimentary efforts; and, engage actively in regional and
international dialogue, planning and information sharing.
29. There are ongoing regional efforts to improve cross border disease prevention and control
efforts in East Africa. The most important among them are the East Africa Integrated Disease
Surveillance Network (EAIDSNet) and the broader African Field Epidemiology Network
(AFENET).
30. Established in 2000 with initial support from the Rockefeller Foundation, the EAIDSNet
is a collaborative effort of the Ministries of Health of Kenya, Tanzania, and Uganda as well as
national health research, and academic institutions. The overarching objective of the Network
aims to improve the quality of data on communicable diseases and the flow and sharing of
information to improve the health of the East African population. Specifically the Network aims
to:
Enhance and strengthen cross-country and cross-institutional collaboration through
regional coordination of activities.
Promote exchange and dissemination of appropriate information on Integrated Disease
43
Surveillance (IDS) and other disease control activities.
Harmonize disease surveillance systems in the region.
Strengthen capacity for implementing disease surveillance and control activities.
Ensure continuous exchange of expertise and best practices for disease surveillance.
31. Phase II of EAIDSNet was established under the auspices of East Africa Community and
the Rockefeller Foundation has provided a grant of US$0.5 million to support this network for a
period of 4 years (2008-2011) with emphasis on promoting cross border prevention and control
of human and animal diseases. In addition, the African Development Bank (ADB) is developing
a US$ 21 million project to support regional e-health and IDS.
32. The AFENET, established in 2005 with support from USAID, has been providing critical
assistance in disease surveillance and response in Africa. AFENET members investigated and
responded to urgent disease outbreaks, including, among others, Rift Valley fever in Kenya and
Tanzania, avian influenza in Ghana, and Marburg hemorrhagic fever in Uganda. AFENET also
developed and distributed outbreak investigation laboratory kits to Ghana, Kenya, Uganda, and
Zimbabwe to facilitate timely laboratory diagnosis of suspected disease outbreaks.
33. The demand for field epidemiology and laboratory training programs (FELTPs) is
increasing rapidly, as countries recognize critical human resource gaps in infectious disease
surveillance and response. AFENET provided TA to eight countries in Sub Saharan Africa to
develop FELTPs. These programs are competency-based applied epidemiology training
programs and provide critical technical resource for ministries of health. These two networks
filled the critical gaps in building country capacities in disease surveillance and initiated efforts
towards better harmonized regional integrated disease surveillance programs in Sub Saharan
Africa. It is now important to consolidate these efforts and address the critical missing gaps.
International Commitments
34. International Health Regulations: The IHR 2005 which came into force on June 15,
2007 represents the new commitment made by WHO member states to ensure maximum
protection against the international spread of infectious diseases while minimizing restrictions on
travel and trade. With the support of WHO, 194 states have become parties to the IHR
(including all participating countries) and have begun implementing global rules to enhance
national, regional and global public health security. In order for IHR 2005 to be fully effective,
countries are required to ensure that their national health surveillance and response capacities
meet core functional criteria by June 2012. Many developing countries lack the financial
resources to build core surveillance and response capacity and this project will play an important
role in funding these activities.
44
III. Regional Framework for Communicable Disease Control and Preparedness
35. The proposed project fits into the Regional Framework for Communicable Disease
Control and Preparedness, prepared by the Africa Region, which provides an overarching
umbrella for sub-regional projects aimed at strengthening regional surveillance and control of
communicable diseases (MDG 6). Achievement of this objective will contribute to higher level
development objectives, including decreased morbidity and mortality (MDG 4/5), poverty
reduction (MDG1), and economic growth in the region. The framework covers the four
epidemiological zones of the African continent south of the Sahara (West, East, Central and
Southern Africa), starting with East and West Africa, as they are currently well organized at the
regional level, and eager to move forward in strengthening disease control efforts.
36. To achieve the primary objective of the framework, three sub-objectives have been
defined to guide the development of projects. The first sub-objective addresses the capacity of
regional institutions and networks to: (a) monitor epidemiological, ecological and other data in
order to identify changes in disease patterns, new or emerging pathogens and changes in the
effectiveness of interventions (i.e. drug and insecticide resistance); and (b) based on these data,
respond rapidly to control disease outbreaks, prevent resurgence and epidemics and contain drug
and insecticide resistance. The second addresses the capacity of the region to provide high
quality laboratory services to support research and the diagnosis of endemic, epidemic and
emerging infectious diseases; as well as to strengthen the linkages between the individual patient
at village level and supra-national reference laboratories. The third addresses the capacity of
regional organizations that have either a mandate to set norms and standards, identify best
practices, or provide technical guidance to countries in the region.
37. Each project will contain a set of activities that addresses the needs for capacity
strengthening and actions, specific to and identified by the group of countries and regional
institutions involved, with the ultimate objective to deliver concrete results. The following list of
potential activities illustrates the types of interventions to be supported:
Cross-border Activities: Given the ecological distribution of communicable diseases
and the porosity of international borders, it is imperative that neighboring countries work
together to combat them. Any country that strives to control or eliminate a
communicable disease without engaging its neighbors is unlikely to attain or sustain its
objectives. This framework provides an opportunity for groups of neighboring countries
to initiate or strengthen priority cross border activities for disease control, including but
not limited to disease surveillance, drug and insecticide resistance monitoring, vector
control, epidemic preparedness and outbreak control.
Intergovernmental Institutions: Intergovernmental institutions are of particular
importance in facilitating agreement, collaboration and harmonization of policies and
program efforts among countries, having both a political and legal mandate to act in this
capacity on behalf of member states. These institutions are often lacking in capacity in
the health sector and management functions. It is anticipated that the projects will
involve capacity strengthening for intergovernmental institutions to facilitate the
necessary inter-country collaboration which is a hallmark of the framework.
45
Regional Reference Laboratories: For reasons of economic efficiency and human
resource requirements it is rational for countries in a sub-region to share high level and
costly resources for which they have an important but volume-limited demand. For this
reason, it is anticipated that projects under the framework will support the establishment
or strengthening of regional reference laboratories to support diagnosis and research. At
present there is only one level 3 laboratory in all of Africa south of the Sahara.
Centers of Excellence: Throughout the region there are examples of public and private
institutions with the potential to provide regional leadership in a specialized area of
disease control, including support and services for national programs (training, distance
learning, TA). In almost all cases the regional resources are under-funded, under-staffed
and their potential under-exploited. Within projects developed utilizing the framework,
groups of countries could invest in the strengthening of these centers of excellence to the
benefit of all.
46
Annex 2: Major Related Projects Financed by the Bank and/or other Agencies
Africa: East Africa Public Health Laboratory Networking Project
Relevant World Bank Projects
Country Project Name Project ID
Latest
PDO
Rating
Latest IP
Rating
Total
Commitment
(US$ millions)
Kenya
KE-Total War Against HIV/AIDS-
TOWA (FY07)
P081712 MS MS 80.0
Rwanda
RW-Second Community Living
Standards Grant (FY10)
P117758
S MS
30.0 (IDA: 18.0;
Health Results
Innovation Fund:
12.0)
Tanzania
TZ-Health Sector Development II
(FY04)
P082335 S S 125.0
Uganda
Health Systems Strengthening
Project (FY10)
P115563 130.0
47
Annex 3: Results Framework and Monitoring
AFRICA: East Africa Public Health Laboratory Networking Project
1. The Results Framework for this project is strongly informed by the advances in
Monitoring and Evaluation (M&E) thinking in the Bank,19
and in particular by the criticisms of
M&E in Health Nutrition and Population (HNP).20
The Results Framework focuses on
accountability for results (i.e., moves beyond the usual tracking of inputs and outputs, and places
a strong emphasis on intermediate and final outcomes). In addition to the accountability function
of evaluation, this Results Framework also emphasizes the learning function of evaluation (see
section on Operational Research in paragraphs 24 and 25).
2. Because this project is a regional project the Results Framework is fundamentally
dependent on complementary inputs, many beyond the control of the project (e.g., national
activities implemented by Ministries of Health and donors in the participating countries). To
mitigate this risk close and careful monitoring of the complementary actions will be needed.
While these will not be formally part of the Results Framework for this project, project
implementation will pay careful attention to these complementary inputs during project
supervision (see discussion on Additional Indicators in paragraph 7).
3. A non-trivial part of the project is devoted to financing infrastructure (civil works and
equipment). Such operations are usually procurement-heavy and there is often a tendency to
focus on tracking procurement (i.e., inputs) during supervision rather than the achievement of
outcomes. For this reason specific attention will be paid to tracking the outcome indicators in
this project.
M&E Design
4. Selection of Indicators. 21
In support of this project objective, six project outcome
indicators and seven intermediate outcome indicators have been identified that constitute the
project‘s Results Framework for which the project will be accountable. Table 2 shows the
selected indicators, and Table 5 demonstrates the consistency of indicators with project
objective, the components and activities.
5. The indicators include: (i) indicators that are dependent on regional inputs linked to
development of regional capacity for monitoring and management of communicable diseases,
and (ii) indicators that reflect national capacities in support of regional efforts to improve access,
quality, and efficiency of public health laboratory services and their linkages with disease
surveillance. Countries will rely on national program and laboratory information systems which
are being upgraded and standardized. The East, Central and Southern Africa Health Community
(ECSA-HC) and the health desk of the Easy African Community (EAC), with support from the
19
IEG, 2009a. 20
In support of the 2009 IEG HNP Evaluation, a background paper on M&E quality in HNP investment operations raised concerns about: (i) the
poor quality of results frameworks, (ii) the absence of baseline data; (iii) poor or failure to collect baseline data or within first year of the project approval; (iii) unrealistic indicator targets; and (iv) poor data quality. 21
The choice of indicators has been informed by generally accepted criteria in evaluation, namely: (i) clear (precise and unambiguous); (ii)
relevant (appropriate to the subject at hand); (iii) economic (available at reasonable cost); (iv) adequate (able to provide sufficient basis to assess performance); and (v) monitorable (amenable to independent validation) (Schiavo-Campo, 1999).
48
revitalized East African Disease Surveillance Network will support information gathering on
indicators at the regional level.
6. Consistency with sector core indicators.22
While the project is not directly involved in
service delivery, three of the core indicators are relevant: (i) Health facilities constructed,
renovated, and/or equipped (number); (ii) Health personnel receiving training (number); and (iii)
Number of beneficiaries (direct and/or indirect) (out of which x% female).
7. In addition to the set of indicators identified to be formally part of the Results
Framework, (i.e., for which the project will be held accountable), additional indicators have been
identified that the project will track, in order to inform decision-making, course-correction and
also to track indicators that are dependent on inputs that are beyond the control of the project, but
to which the project aims to contribute. There are two types of indicators that can be found in
these additional indicators. As illustrated in Table 5, there are: (i) lower level complementary
inputs on which the project success is dependent, but over which the project has limited control;
and there are (ii) higher level indicators that the project aims to contribute to, but again are
dependent on other inputs that the project has limited control over. The motivation for these
indicators is that:
There are uncertainties and risks that even the best project preparation and design cannot
resolve. These uncertainties can only be mitigated by early and good quality data
collection in order to inform the necessary course-corrections. This is the function that
the lower level additional indicators will serve.
It is also important not to lose sight of why we are improving health systems (i.e., to
improve health outcomes).23
For this reason this project will also monitor higher level
outcome indicators such as CD rate24
and TB cure rate.
8. Together, the indicators in the Results Framework and the additional indicators constitute
the results chain that underpin the line of reasoning for the expected changes (more formally
known as the theory of change). Identifying this theory of change is particularly important for
projects that aim to strengthen health systems in order not to lose sight of the impacts that the
project ultimately aims to contribute to, but may not be fully within the control of the project.
9. Level of indicators. 25
Beyond the three IDA-15 indicators that are output indicators, the
indicators in the Results Framework are mainly outcome indicators. Specifically, the indicators
are mainly Level III pertaining to capacity, and Level II pertaining to service delivery
functioning. The predominance of level II and level III indicators reflect the fact that this project
is fundamentally about strengthening health systems in support for service delivery—in this case,
laboratory services. The results chain (Table 5) illustrates this fact.
22
OPCS. 2009. Core Sector Indicators and Definitions - Health. OPCS, World Bank, Washington, DC. 23
The second important goal (where appropriate) is to increase financial risk protection. 24
It is important to note that improved Case Detection may initially cause the indicator, Case Detection rate, to
worsen (because the system is making a better effort at finding cases). 25
These levels refer to the AFTHE HNP Results Chains (AFTHE. 2009. HNP Results Chains).
49
10. Definition of indicators. The denominator and numerator, as well as the reference period
for each indicator are clearly specified in Table 5. Where necessary a target group is specified.
11. Disaggregation of data. Within each of the participating countries the activities being
financed will likely have national-level results, and there are activities that will have results at
the sub-national level. For this reason, the indicators that have been identified will be national
averages as well as allowing for sub-national disaggregation to make a closer link with the sub-
national activities. So, 3 levels of indicators will be collected: regional, national and sub-
national.
12. In one of the participating countries, Kenya, indigenous populations are likely to be
present in or have collective attachment to some of the project areas. These groups are: (i) the
Ogiek population mostly residing in and around the Mau forest in Rift Valley Province and some
around Mt. Elgon in Western Province; and (ii) Sengwer living in and around the Cherangany
Hills and in the Rift Valley Province. The data collection will have to allow for disaggregated
data provision on the identified indigenous groups.
13. Data sources. Table 5 shows the data source for each of the indicators, and where there
is variation by country this is noted. The data sources are mainly from laboratory information
systems. Data quality varies across the participating countries, and efforts will be made to
enhance data quality over the project‘s lifespan.
14. Use of existing data collection mechanisms. To the extent possible, the proposed results
framework uses existing indicators and data to measure the progress of both the project and its
contribution to the overall national program, not only for efficiency, but also to build on and
strengthen existing data collection mechanisms.
15. Targets for the indicators. End of project targets have been identified in Table 7. Close
attention has been paid to ensure that the targets are feasible.
Planning for M&E Implementation
16. A key determinant of successful M&E implementation is the quality of data planning
during the project preparation26
and the resources and responsibility for data collection and
analysis. To this end a detailed M&E plan has been developed as part of each country‘s
Implementation Plan that identifies the following information for each indicator:
The source of the data or data collection mechanism;
The frequency of the data collection;
An assessment of the quality of the data collection mechanism;
Where necessary, some comment on the concerns about data collection methodology
especially where a non-standardized data collection mechanism is used;
Responsibility for data collection and analysis (where an external source has been
identified, the contact within the MOH is listed);
26
Uribe-Villar. 2009. Assessment of M&E in HNP operations, 1997-2009, Background Paper, HNP Evaluation,
IEG, World Bank, Washington, DC.
50
Level and source of resources available for data collection and the project costs allocated
to facilitate successful implementation of M&E.
17. The methods of data collection are mainly laboratory information systems and
surveillance systems. As far as possible, standardized data collection methods will be used.
Indicators for which there are no standardization, data collection methodology and analysis have
been agreed to. For example, for the process indicators, appropriate check-lists will be
developed.
18. Responsibility for M&E. Responsibility will be at the country-level and regional-level.
Country-level. Responsibility will be at the country-level and regional-level. In each
country an M&E specialist will be identified27
who will also be responsible for
overseeing the coordinating the data collection processes, including steps needed for
procurement such as definition of TORs, participate in technical reviews, and reviewing
consultant reports or analytical products for M&E that have been procured. This person
will also serve a quality assurance role for the project‘s M&E, or solicit expert opinion as
necessary. This person will work closely with the project leader in each country because
the success of the use of the data will ultimately depend on the extent to which it feeds
into decision-making processes.
Regional-level. Regional-level responsibility will be located at ECSA-HC.28
These are
two dimensions to the regional role: Coordination and Quality assurance. These
functions are summarized in Table 1.
Table 1: Regional-level coordination of M&E
Coordination
Convene process for establishing common reporting requirements for
the project.
Convene a network of M&E officers.
Agree on reporting tools, formats of reporting (including IT system
formats), frequency of reporting, channels of reporting etc.
Develop a common database29 and system that can collate reporting
from countries in a timely and accurate manner, produce analytic reports
and provide feedback to countries on multi-country performance.
Data Quality Assurance
The Regional M&E office will serve a M&E quality
assurance function, complementary to the inputs from
the country-level M&E specialists. Annually and
especially at MTR, the Regional M&E office with
inputs from country-level M&E specialists will
review the experience with definition of indicators,
data collection systems, analysis, and other
methodological aspects.
Regional M&E officer will track and facilitate timely reporting of data
flow that needs to occur monthly, quarterly and annually.
Prepare for quarterly and annual reporting.
Consolidate baseline data.
Quarterly reporting: Quarterly submission will be made to Regional
M&E office.
Annual reporting: Based on quarterly reports submitted, the Regional
M&E office will compile a consolidated Annual Report which is one of
the inputs into the Annual Joint Review. (Note that at the Annual
Review countries will present and defend their own progress and
performance).
Coordinate preparation for MTR
Coordinate and facilitate implementation of the end
of project evaluation.
Contribute to the process of learning and knowledge
sharing. This will be—in part—through linkages
with the Technical Working Groups.
27
While this person may not have a dedicated responsibility for this role, agreements have been reached with the
relevant authorities in each country to free time if the identified individuals. 28
ECSA has established M&E capacity, and has an established M&E Unit, headed by an M&E Manager. The
project will place an M&E Officer within this unit with full-time dedicated responsibility for the project‘s M&E. 29
Database needs to function at the country and regional level, and have to be accessed by all participating
countries.
51
19. Resources for M&E. The resources that have been set aside for M&E in the project costs
agreed at appraisal are summarized in the project costs. The Implementation Plan clearly reflects
the resources that would be used to finance M&E-related activities (although they may not be
necessarily identified as such). Examples include: the procurement of information and
communications technology (hardware and software), the hiring of technical advisors for process
monitoring, ICT operational costs (web-page, internet access etc). Several of the projects are
also putting resources into quality assurance, and the performance against agreed benchmarks is
in several instances included in the results framework, e.g., turnaround time for selected tests
(POI#1), laboratories reaching certain level under regional accreditation program (PO#2) etc.
Some countries have identified a post for an M&E officer (e.g., Uganda) while others have
assigned specific responsibility to program staff.
20. At the regional level the inputs that will be financed through the project are: M&E
Officer appointed at ESCA-HC; equipment for the M&E officer and database and statistical
software; consultant services to develop a database and common reporting formats; and ICT
links (web-based or otherwise) with countries. As indicated in Table 1, the role of ECSA-HC
will be of critical importance in the coordination of M&E, data quality assurance, and end of
project evaluation.
Planning for M&E Use
21. The implementation of the M&E framework will be tracked during implementation, and
will be a central part of project supervision. The opportunity of the mid-term review will be used
to also assess some fundamental M&E design issues, and make adjustments accordingly. There
will be a strong results-orientation during supervision, with adequate attention devoted to
progress with data collection, data quality and the actual use of data in tracking project
implementation in Aide Memoires and Implementation Status Report (ISR)s.
22. Annual review meetings, organized under the auspices of ECSA-HC, would provide a
forum for sharing implementation experiences, proposing recommendations on programmatic
changes, and generating additional demands for information and analysis. The opportunity of
the MTR will be used proactively to: (i) assess progress to date and continued relevance/realism
of the targets; (ii) review the experience with definition of indicators, data collection systems,
analysis, and other methodological aspects.
Country-level M&E systems and capacity building strategies
23. M&E capacity. Table 8 provides a brief description of the laboratory information
systems in each of the participating countries. By implication this gives a sense of the M&E
capacities because there is a strong reliance on a functioning laboratory information system in
the M&E implementation. In some countries (e.g., Tanzania) an electronic system has just been
introduced and will require support. In other systems, there are quality weaknesses that need to
be addressed. Any remaining gaps will be identified and the associated costs will be reflected in
the Implementation Plan.
52
Operational Research
24. The proposed Project offers substantial opportunities for operational research, which by
its very nature will have a strong evaluation dimension. Annual review meetings, organized
under the auspices of ECSA-HC, provide a forum for sharing findings from the operational
research. The intention is to build local capacity to carry out operational research and
evaluation, and involve not only the laboratories, but also stakeholders beyond the national
laboratories such as research institutions, academic institutions etc.
25. The process for selecting research topics will be a combination of topics identified by the
TB and other communicable disease program managers, but will also include competitively
selected topics through a peer-review process to select proposals, followed by peer review of
research findings. To avoid conflict of interest, individuals involved with selection will be
ineligible as recipients of research awards. Ethical review will be required depending on the
content of the proposal. The criteria for selection of research proposals will be clearly stated and
will include: (i) relevance of the proposal to diagnosing, treating, and managing TB and other
communicable diseases, including efficacy and cost-effectiveness of alternative implementation
approaches; (ii) rigor of the methodology; (iii) involvement of research groups from more than
one of the countries as a way of building regional capacity; (iv) cost of the proposal;
(v) anticipated use of the findings for new regional policies for prevention and control of
communicable diseases. One of the participating countries (Kenya) is taking the lead in this
area. This entails, amongst others, support for protocol development, organizing training in
relevant topics, and facilitating the peer review process for proposal selection and quality
assurance of analytical products. Further details are provided in Annex 4.
53
Table 2: Results Framework30
PDO Project Outcome Indicators (POI) Use of Project Outcome Information
To establish a network of
efficient, high quality,
accessible public health
laboratories for the
diagnosis and
surveillance of TB and
other communicable
diseases.
POI# 1. Average turn-around time for TB liquid culture
tests (days).
This indicator will be used to track efficiency of TB diagnostic
services. Currently solid culture tests are mainly used but these have
a much longer turnaround time compared to the liquid culture tests
that will be introduced under the proposed Project.
POI#2. Satellite laboratories awarded two star status under
regional accreditation program based on WHO/AFRO five-
step accreditation approach (number, percent).
This indicator will be used to track improvements in laboratory
processes and performance. Independent assessors will determine
whether the labs are able to meet at least 50% of established standards
by the regional accreditation program.
POI# 3. Number of beneficiaries (direct and/or indirect)‖
(out of which x% female).
Core indicator.
POI#4. People receiving TB drug susceptibility tests
among DOTS treated TB cases not responding to treatment
(number, percent).
This indicator tries to indentify drug resistant TB cases.
POI#5. Share of reported communicable disease
outbreaks31
having laboratory confirmation of etiological
agent (percent).
This indicator measures the quality of diagnostic services for
communicable disease outbreaks such as cholera, malaria, hepatitis,
salmonella, typhoid, hemorrhagic fevers etc.
POI#6. Outbreaks for which cross border investigation
under taken (number).32
This indicator reflects the cross-border responses to control
communicable disease outbreaks in the border districts where satellite
labs are located.
30
The definitions of the denominator and numerators for each of the indicators are given in Table 5. 31
Examples of the disease outbreaks include: cholera, malaria, hepatitis, salmonella, typhoid etc. 32
An absolute measure (number) rather than a proportion was chosen because the denominator for the proportion would be really hard to define with precision
and consistency over time. The result may be that improvements (or worsening) over time are observed in a proportion measure that are not necessarily related
to improvement (or worsening) in performance.
54
Table 3: Results Framework (continued)
Intermediate
Outcomes Intermediate Outcome Indicators (IOI) Use of Intermediate Outcome Monitoring
Component 1:
Improved laboratory
quality monitoring
IOI# 1. Satellite laboratories compliant with regionally
harmonized SOPs (percent).
This indicator will be used to track the quality of laboratory services.
Improved availability of
skilled laboratory staff.
IOI# 2. Satellite laboratories meeting approved staffing
norms (percent).
This indicator tracks the availability of human resources for lab
services, a key constraint in all the participating countries particularly
at the level of satellite laboratories located in the rural areas.
Increased availability of
necessary laboratory
reagents.
IOI# 3. Number of days the national reference laboratory
reporting stock-out of tracer reagent for TB liquid culture
in past quarter (days).
This indicator assesses the quality of laboratory management and the
management of the supply-chain for reagents at the level of national
referral laboratories.
IOI# 4. Satellite laboratories reporting stock-outs of tracer
reagent for stools culture (percent).
This indicator assesses the quality of laboratory management and the
management of the supply-chain for reagents at the level of satellite
laboratories.
Improved infrastructure. IOI# 5. Health facilities constructed, renovated, and/or
equipped (number).
Core indicator.
Increased compliance
with environmental
safeguards.
IOI# 6. Share of national and satellite laboratories that
comply with Biomedical Waste Management requirements
(number, percent).
This indicator captures compliance with environmental safeguards,
and is also an important indicator of laboratory quality.
Improved regional
networking for improved
quality of surveillance.
IOI# 7. Quarterly publication of a regional surveillance
bulletin by East Africa integrated disease surveillance
network with country-specific data (yes/no).
This indicator will track the timely dissemination of regionally
relevant disease surveillance information which in turn reflects the
improved efficiency of country surveillance systems.
Component 2:
Improved availability
of skilled labor.
IOI# 8. Health personnel receiving training (number). Core indicator.
55
Intermediate
Outcomes Intermediate Outcome Indicators (IOI) Use of Intermediate Outcome Monitoring
IOI# 9. Proportion of lab staff trained in liquid culture testing
found to be proficient (percentage).
This indicator complements IOI#8 and measures the quality of the
training provided to laboratory staff.
Component 3:
Increased joint
operational research
and knowledge sharing
activities.
IOI#10. Operational Research studies approved by the peer
review panel completed (Percent).
This indicator reflects the contributions from the proposed Project to
enhance regional knowledge about communicable diseases.
IOI#11. Development of regional lab standards, SOPs, and
recording and reporting formats acceptable to the Regional
Technical Advisory Group (yes/no).
This process indicator is an important precursor to the achievement of
IOI#1.
Table 4: Indicators associated with the higher level objective to which the project contributes
Additional Indicators (AI) Use of Outcome Monitoring
AI# 1. TB Case Detection (CD) rate (percent). This indicator tracks the impact indicator that the laboratory systems
strengthening inputs financed by the project aims to contribute to.
AI# 2. TB Treatment success rate (percent). This indicator tracks the impact indicator that the laboratory systems
strengthening inputs financed by the project aims to contribute to.
56
Table 5: Project Outcome Indicators and Intermediate Outcome Indicators (Results Chain)33
PDO: To establish a network of efficient, high quality, accessible public health laboratories for the diagnosis and surveillance of TB and other communicable diseases.
Impact or
Outcome
Indicators
Intermediate Outcome Indicator
Output Indicators Inputs Level I –
Coverage Level II – Service Delivery Level III – Capacity
AI# 1. TB
Case
Detection
(CD) rate
(percent).
AI# 2. TB
Treatment
success rate
(percent).
POI#4. People
receiving TB drug
susceptibility tests
among DOTS
treated TB cases
not responding to
treatment
(number, percent).
POI# 3. Number of
beneficiaries (direct and/or
indirect)‖ (out of which x%
female).
IOI# 5. Health facilities
constructed, renovated, and/or
equipped (number).
Infrastructure
- Upgrade, expand, or construct
laboratories for provision of
specialized diagnostic services.
- Procure equipment for introduction
and expansion of modern diagnostic
technologies.
- Procure information systems in
support of information and
communications systems for lab
management, lab logistics and
commodity management,
surveillance.
- Courier services for culture
transportation.
IOI# 3. Number of days the
national reference laboratory
reporting stock-out of tracer
reagent for TB liquid culture in
past quarter (days).
IOI# 4. Satellite laboratories
reporting stock-outs of tracer
reagent for stools culture
(percent).
Drugs, Supplies and Consumables
- Procure reagents and consumables
for introduction and expansion of
modern diagnostic technologies
(e.g., liquid culture, molecular tests)
IOI# 2. Satellite laboratories
meeting approved staffing
norms (percent).
IOI# 9. Proportion of lab staff
trained in liquid culture testing
found to be proficient
(percentage).
IOI# 8. Health personnel
receiving training (number).
Human Resources
- Train laboratory staff, conduct
regional exchanges, and introduce
lab staffing issues in HR policy
dialogues
33
Unless otherwise indicated, the period over which the reference period for the indicators is the preceding year.
57
POI# 1. Average turn-around
time for TB liquid culture tests
(days).
POI#2. Number of beneficiaries
(direct and/or indirect)‖ (out of
which x% female).
POI#5. Share of reported
communicable disease
outbreaks34
having laboratory
confirmation of etiological agent
(percent).
POI#6. Outbreaks for which
cross border investigation under
taken (number).
IOI# 1. Satellite laboratories
compliant with regionally
harmonized SOPs (percent).
IOI# 6. Share of national and
satellite laboratories that
comply with Biomedical Waste
Management requirements
(number, percent).
IOI# 7. Quarterly publication
of a regional surveillance
bulletin by East Africa
integrated disease surveillance
network with country-specific
data (yes/no).
IOI#10. Operational Research
studies approved by the peer
review panel completed
(Percent).
IOI#11. Development of
regional lab standards, SOPs,
and recording and reporting
formats acceptable to the
Regional Technical Advisory
Group (yes/no).
Accountability and Institutional
Capacity
- Introduce systems for quality
assurance and tracking standard
operating procedures.
- Establish regional technical groups
to standardize lab procedures and
systems and organize external.
- Introduce systems for lab
management and surveillance (lab
data management, communications,
lab logistics and commodity
management systems, SOPs)
- Train and support staff to do
operational research, prepare good
practice case studies, organize
regional knowledge sharing events
- Establish regional technical groups
to standardize lab procedures and
systems and organize external.
34
Examples of the disease outbreaks include: cholera, malaria, hepatitis, salmonella, typhoid etc.
58
Table 6: Definition of Project Outcome Indicators and Intermediate Outcome Indicators35
Indicator Numerator Denominator Source of Data
Comments
(pertaining to methods – measurement,
collection and analysis)
Project Outcome Indicators
POI# 1. Average turn-around
time for TB liquid culture
tests (days).
Time between the laboratory
receiving the sample and
delivering the results to the
health facility.
Number of samples. Laboratory information
system.
POI# 2. Satellite laboratories
awarded two star status under
regional accreditation
program based on
WHO/AFRO five-step
accreditation approach
(cumulative number, percent).
Number of satellite labs that
are awarded 2 two star status
by the regional accreditation
program. Two star status is
defined as >50% attainment
of regional standards).
Number of satellite
laboratories.
Annual Progress Reports
from participating countries
Development of regional accreditation
program will be required for this indicator.
Independent assessors approved by the
regional accreditation program will undertake
the assessment.
POI# 3. Number of
beneficiaries (direct and/or
indirect) (out of which x%
female).
Number of beneficiaries
(direct and/or indirect) (out of
which x% female).
Not applicable. Laboratory information
system.
POI# 4. People receiving TB
drug susceptibility tests
among DOTS treated TB
cases not responding to
treatment (number, percent).
Number of people receiving
TB drug susceptibility tests
among the number of DOTS
treated TB cases who are not
responding to TB treatment.
Number of DOTS compliant
TB cases who are not
responding to TB treatment.
Laboratory information
system.
POI# 5. Share of reported
communicable disease
outbreaks36
having laboratory
confirmation of etiological
agent (percent).
Number of communicable
disease outbreaks for which
the etiological agent had
laboratory confirmation.
Number of reported
communicable disease
outbreaks.
Laboratory information
system and disease
surveillance system.
POI# 6. Outbreaks for which
cross border investigation
under taken (number).
Number of communicable
disease outbreaks for which
cross border investigations
were undertaken.
Number of outbreaks reported
in border districts served by
satellite laboratories.
Annual Progress Report of
Health Desk of East Africa
Community prepared with
technical support from
reactivated East Africa
Integrated Disease
Surveillance Program.
Prompt sharing of information on outbreaks in
border districts by participating countries will
be critical for achieving this indicator.
35
Unless otherwise indicated, the period over which the reference period for the indicators is the preceding year. 36
Examples of the disease outbreaks include: cholera, malaria, hepatitis, salmonella, typhoid etc.
59
Indicator Numerator Denominator Source of Data
Comments
(pertaining to methods – measurement,
collection and analysis)
Intermediate Outcome Indicators
IOI# 1. Satellite laboratories
compliant with regionally
harmonized SOPs
(cumulative number, percent).
Number of satellite
laboratories compliant with
SOP.
Total number of satellite
laboratories.
Laboratory information
system. Supportive
supervision reports.
A checklist that will be used in supportive
supervision should be developed.
IOI# 2. Satellite laboratories
meeting approved staffing
norms (percent).
Number of satellite compliant
with staffing norms.
Total number of satellite
laboratories.
Laboratory facilities survey. This indicator is also supported by the
covenant on lab human resources.
This indicator refers to the satellite
laboratories supported under the project.
IOI# 3. Number of days the
national reference laboratory
reporting stock-out of tracer
reagent for TB liquid culture
in past quarter (days).
Number of days the national
reference laboratory reporting
stock-outs of tracer reagent
for TB liquid culture in past
quarter.
Not applicable. Laboratory information
system and Laboratory
facilities survey.
The exact reagents need to be identified.
Examples include: media (egg and liquid),
stains (Ziehl Nielsen and fluorescent
microscopy), DNA probes.
IOI# 4. Satellite laboratories
reporting stock-outs of tracer
reagent for stools culture
(percent).
Number of satellite
laboratories reporting stock-
outs of tracer reagent in past
quarter.
Number of satellite
laboratories.
Laboratory information
system and Laboratory
facilities survey.
The exact reagents need to be identified.
This indicator refers to the satellite
laboratories supported under the project.
IOI# 5. Health facilities
constructed, renovated, and/or
equipped (number).
Sum of the number of health
facilities constructed,
renovated, and equipped.
Not applicable. Project documentation.
IOI#6: Share of national and
satellite laboratories that
comply with Biomedical
Waste Management
requirements (cumulative
number, percent)
Number of satellite and
national laboratories that meet
the requirements for
Biomedical Waste
Management.
Total number of satellite and
national laboratories.
Laboratory information
system and Laboratory
facilities survey.
IOI# 7. Quarterly publication
of a regional surveillance
bulletin by East Africa
integrated disease
surveillance network with
country-specific data
(yes/no).
Quarterly regional
surveillance bulletins
published on time (within 15
days of completion of quarter)
Not applicable. Annual Progress Report of
Health Desk of East Africa
Community prepared with
technical support from
reactivated East Africa
Integrated Disease
Surveillance Program.
IOI# 8. Health personnel
receiving training (number).
Number of laboratory
personnel receiving training.
Not applicable. Project documentation.
IOI# 9. Proportion of lab
staff trained in liquid culture
testing found to be proficient
(percentage).
Number of staff trained that
attained proficiency.
Number of lab staff trained at
regional training center.
ECSA-HC with the support of
the Regional Advisory Panel.
Proficiency test will be conducted 6 months
after completion of the training.
60
Indicator Numerator Denominator Source of Data
Comments
(pertaining to methods – measurement,
collection and analysis)
IOI#10. Operational
Research studies approved by
the peer review panel
completed (Percent).
Number of operational
research studies completed
Number of operational
research studies approved by
the Peer Review Panel
Annual Reports from East and
Central and South African
Health Community and
country providing lead for
operational research (Kenya)
IOI#11. Development of
regional lab standards, SOPs,
and recording and reporting
formats acceptable to the
Regional Technical Advisory
Group (yes/no).
Development of regional lab
standards, SOPs, and
recording and reporting
formats acceptable to the
Regional Technical Advisory
Group.
Not applicable. ECSA-HC
Additional Indicators
AI# 1. TB Case Detection
(CD) rate (percent).
Number of cases of TB
detected.
Number of estimated incident
TB cases.
National TB Program.
AI# 2. TB Treatment success
rate (percent).
Number of TB patients
successfully treated and
having negative sputum.
Number of sputum positive
patients beginning TB
treatment.
National TB Program.
61
Table 7: Plan for Data Collection and Arrangements for Results Monitoring
Regional (indicators with regional responsibility for compliance)37
Target Values Data Collection and Reporting
Project Outcome Indicators
Baseline
(state
year)
YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data
Collection
Instruments
Responsibility
for Data
Collection
POI# 6. Outbreaks for which cross border
investigation under taken (number).
See
country
specific
tables.
See
country
specific
tables.
See
country
specific
tables.
See
country
specific
tables.
See
country
specific
tables.
See
country
specific
tables.
See
country
specific
tables.
See country
specific
tables.
See country
specific tables.
Target Values Data Collection and Reporting
Intermediate Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data
Collection
Instruments
Responsibility
for Data
Collection
IOI# 7. Quarterly publication of a regional
surveillance bulletin by East Africa integrated
disease surveillance network with country-
specific data (yes/no).
No Yes Yes Yes Yes Yes Quarterly
Country
surveillance
report
EAC
IOI#10. Operational Research studies
approved by the peer review panel completed
(yes/no). NA No Yes Yes Yes Yes Annual
Annual
Project
Reports
EAC/ECSA-
HC, Country
Project
Coordination
Units
IOI#11. Development of regional lab standards,
SOPs, and recording and reporting formats
acceptable to the Regional Technical Advisory
Group (yes/no).
NA No Yes Yes Yes Yes Annual
Annual
Project
Reports
EAC/ECSA-
HC, Country
Reference
Laboratory
37
Note that these indicators are also reflected in the country-specific versions of this table because they also entail country-inputs and actions, in addition to action on the part of
the regional entities involved.
62
Table 8: Total Aggregated
Project Outcome Indicators38
Target Values Data Collection and Reporting
Project Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data Collection
Instruments
Responsibility
for Data
Collection
POI# 2. Satellite
laboratories awarded two
star status under regional
accreditation program based
on WHO/AFRO five-step
accreditation approach
(cumulative number).
0 0 1 8 13 18 Annual LIMS/Register PCUs
POI# 3. Number of
beneficiaries (direct)
144,887 149,208 156,690 163,190 172,987 182,557
Annual Project
Documentation
Respective
Project
Coordinators
POI# 4. People receiving TB
drug susceptibility tests
among DOTS treated TB
cases not responding to
treatment (number). 8,056 8,869 10,360 11,400 12,460 13,380
Quarterly LIMS/Register
Heads of TB
Control
Programs
POI# 6. Outbreaks for which
cross border investigation
under taken (number).
0 3 9 11 15 16 Annual LIMS/Register EAC, Health
Desk
38
Note that for POI#1 and POI#5 these indicators are reflected in the country-specific results frameworks. For POI#3 and POI#4 the baseline figures are not zero, as the existing
laboratories targeted for support already provide some level of services.
63
Kenya Target Values Data Collection and Reporting
Project Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data
Collection
Instruments
Responsibility
for Data
Collection
POI# 1. Average turn-around time for TB liquid
culture tests (days). 31 31 21 21 15 15 Quarterly LIMS/Register Head DLTLD
POI# 2. Satellite laboratories awarded two star status
under regional accreditation program based on
WHO/AFRO five-step accreditation approach
(cumulative number, percent).
0(0%) 0(0%) 0(0%) 2(40%) 3(60%) 4(80%) Annual LIMS/Register PCU
POI# 3. Number of beneficiaries (direct) (out of
which x% female).
81,254
(60%)
81,254
(60%)
83,000
(63%)
85,000
(68%)
87,000
(71%)
90,000
(75%) Annual
Project
Documentation Project Head
POI# 4. People receiving TB drug susceptibility tests
among DOTS treated TB cases not responding to
treatment (number, percent).
6,569
(61%)
6,569
(61%)
6,800
(68%)
7,000
(72%)
7,200
(75%)
7,400
(78%) Quarterly LIMS/Register Head DLTLD
POI# 5. Share of reported communicable disease
outbreaks39 having laboratory confirmation of
etiological agent (percent).
20% 30% 40% 50% 55% 60% Quarterly LIMS/Register Head
DDSR/NPHLS
POI# 6. Outbreaks for which cross border
investigation undertaken (number). 0 0 2 3 5 5 Annual LIMS/Register Head DDSR
Target Values Data Collection and Reporting
Intermediate Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data
Collection
Instruments
Responsibility
for Data
Collection
IOI# 1. Satellite laboratories compliant with
regionally harmonized SOPs (cumulative number,
percent).
0 0 0 1 (20%) 3 (60%) 5 (100%) Quarterly LIMS/Register Head DLTLD
IOI# 2. Satellite laboratories meeting approved
staffing norms (cumulative number, percent).
0
0 1 (20%) 2 (40%) 3 (60%) 4 (80%) Annual LIMS/Register PCU
IOI# 3. Number of days the national reference
laboratory reporting stock-out of tracer reagent for TB
liquid culture in past quarter (days).
0 0 0 0 0 0 Annual Project
Documentation Project Head
IOI# 4. Satellite laboratories reporting stock-outs of
tracer reagent for stools culture (percent).
100%
100% 80% 60% 40% 20% Quarterly LIMS/Register Head DLTLD
IOI# 5. Health facilities constructed, renovated,
and/or equipped (number). 0 0 1 3 2 1 Quarterly LIMS/Register
Head
NPHLS/DDFS
IOI #6. Share of national and satellite laboratories
that comply with Biomedical Waste Management
requirements (cumulative number, percent)
0 (14%) 1 (14%) 1 (14%) 4 (57%) 6 (86%) 7 (100%) Annual LIMS/Registers Head DDSR
IOI# 7. Quarterly publication of a regional
surveillance bulletin by East Africa integrated disease
surveillance network with country-specific data
(yes/no).
No No Yes Yes Yes Yes Quarterly LIMS/Register Head DDSR
IOI# 8. Health personnel receiving training (number). 0 920 1375 1045 234 64 Annual LIMS/Register PCU
39
Examples of the disease outbreaks include: cholera, malaria, hepatitis, salmonella, typhoid etc.
64
IOI# 9. Proportion of satellite lab staff trained in
liquid culture testing found to be proficient
(percentage).
13% 50% 55% 65% 75% 80% Annual Project
Documentation Head DLTLD
IOI#10. Operational Research studies approved by
the peer review panel completed (yes/no). NA No Yes Yes Yes Yes Annual Project Reports ECSA-HC/PCU
IOI#11. Development of regional lab standards,
SOPs, and recording and reporting formats acceptable
to the Regional Technical Advisory Group (yes/no).
NA No Yes Yes Yes Yes Yes Project Reports ECSA-HC/EAC
NA: Not applicable.
65
Rwanda Target Values Data Collection and Reporting
Project Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data
Collection
Instruments
Responsibility
for Data
Collection
POI# 1. Average turn-around time for TB liquid culture
tests (days). 35 35 30 28 21 21 Quarterly
Lab
information
system,
register
ICT Unit /
NRL
POI# 2. Satellite laboratories awarded two star status
under regional accreditation program based on
WHO/AFRO five-step accreditation approach
(cumulative number, percent).
0 0 0 2 (40%) 3 (60%) 4 (80%) Annual Assessment
report MOH/NRL
POI# 3. Number of beneficiaries (direct and/or
indirect)‖ (out of which 53% female). 10,633 12,954 15,190 17,190 19,987 22,557 Quarterly
Country
surveillance
report
NRL and
Satellite
laboratories
POI# 4. People receiving TB drug susceptibility tests
among DOTS treated TB cases not responding to
treatment (number, percent).
237 400 560 650 760 830 Quarterly LIS, and TB
register
NRL and TB
program
POI# 5. Share of reported communicable disease
outbreaks40 having laboratory confirmation of
etiological agent (percent). 0 30% 40% 50% 60% 70% Annual
Integrated
disease
surveillance
report
NRL and
TRAC Plus
POI# 6. Outbreaks for which cross border investigation
undertaken (number). 0 1 2 2 3 3 Annual
Integrated
disease
surveillance
report
TRAC Plus
and NRL.
Target Values Data Collection and Reporting
Intermediate Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data
Collection
Instruments
Responsibility
for Data
Collection
IOI# 1. Satellite laboratories compliant with regionally
harmonized SOPs (cumulative number, percent). 0 0 3 (60%) 4 (80%) 4 (80%) 5 (100%) Annual
Supervision
check list,
and report
NRL
IOI# 2. Satellite laboratories meeting approved staffing
norms (cumulative number, percent). 0 0 3 (60%) 4 (80%) 4 (80%) 5 (100%) Annual
Supervision
check list,
and report
NRL
IOI# 3. Number of days the national reference
laboratory reporting stock-out of tracer reagent for TB
liquid culture in past quarter (days).
0 <20 <15 <10 <5 <5 Quarterly
Stock
register and
stock report
NRL
IOI# 4. Satellite laboratories reporting stock-outs of
tracer reagent for stools culture (percent). 0 0 80% (4) 60% (3) 40% (2) 0(0) Quarterly
Supervision
check list,
and report
NRL
IOI# 5. Health facilities constructed, renovated, and/or
equipped (number). 0 0 4 1 0 0 Annual
Annual
Project
Reports
PMU (MOH)
and NRL
IOI #6. Share of national and satellite laboratories that 0 1 (20%) 2(40%) 3(60%) 4(80%) 5 (100%) Quarterly Supervisory NRL
40
Examples of the disease outbreaks include: cholera, malaria, hepatitis, salmonella, typhoid etc.
66
comply with Biomedical Waste Management
requirements (cumulative number, percent)
Check-list
and Report
IOI# 7. Quarterly publication of a regional surveillance
bulletin by East Africa integrated disease surveillance
network with country-specific data (yes/no).
No Yes Yes Yes Yes Yes Quarterly
Country
surveillance
report
TRAC Plus
and EAC
IOI# 8. Health personnel receiving training (number).
0 33 130 238 304 305 Annual
Annual
Project
Reports
NRL and
TRAC Plus
IOI# 9. Proportion of lab staff trained in liquid culture
testing found to be proficient (percentage). 0 50% 60% 70% 80% 90% Annual
Annual
Project
Reports
NRL
IOI#10. Operational Research studies approved by the
peer review panel completed (yes/no). NA No Yes Yes Yes Yes Annual
Annual
Project
Reports
EAC/ECSA-
HC and PMU
IOI#11. Development of regional lab standards, SOPs,
and recording and reporting formats acceptable to the
Regional Technical Advisory Group (yes/no).
NA No Yes Yes Yes Yes Annual
Annual
Project
Reports
EAC/ECSA-
HC and NRL
NA: Not applicable.
67
Tanzania
Target Values Data Collection and Reporting
Project Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data Collection
Instruments
Responsibility
for Data
Collection
POI# 1. Average turn-around time for TB
liquid culture tests (days). 28 28 26 21 21 21 Quarterly
Lab information
system CTRL
POI# 2. Satellite laboratories awarded two
star status under regional accreditation
program based on WHO/AFRO five-step
accreditation approach (cumulative number,
percent).
0 0 1 (20%) 3 (60%) 5(100%) 5 (100%) Annual External QAP External QAP
POI# 3. Number of beneficiaries (direct
and/or indirect)‖ (out of which x% female). 5000 5,000 6,500 7,000 10,000 10,000 Annual
Lab information
system CTRL
POI# 4. People receiving TB drug
susceptibility tests among DOTS treated TB
cases not responding to treatment (number,
percent).
450
(10%)
900
(20%)
1800
(40%)
2250
(50%)
2700
(60%)
3150
(70%) Annual
Lab information
system CTRL
POI# 5. Share of reported communicable
disease outbreaks41 having laboratory
confirmation of etiological agent (percent).
10% 20% 30% 45% 50% 55% Annual Lab information
system CTRL
POI# 6. Outbreaks for which cross border
investigation undertaken (number). 0 1 3 4 4 4 Annual
Disease
surveillance
system
Epidemiology
Dept
Target Values Data Collection and Reporting
Intermediate Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data Collection
Instruments
Responsibility
for Data
Collection
IOI# 1. Satellite laboratories compliant with
regionally harmonized SOPs (cumulative
number, percent).
0 0 0 2
(33.3%)
3
(50%)
5
(83.3%) Annual
Lab information
system CTRL
IOI# 2. Satellite laboratories meeting
approved staffing norms (cumulative number,
percent,).
1 (16.7%) 2 (33.3%) 5 (83.3%) 6 (100%) 6 (100%) 6 (100%) Annual HR MIS CTRL
IOI# 3. Number of days the national
reference laboratory reporting stock-out of
tracer reagent for TB liquid culture in past
quarter (days).
30 30 20 15 0 0 Quarterly Supportive
supervision CTRL
41
Examples of the disease outbreaks include: cholera, malaria, hepatitis, salmonella, typhoid etc.
68
IOI# 4. Satellite laboratories reporting stock-outs of
tracer reagent for stools culture (percent). 83.3% 83.3% 67.3% 33.3% 0 0 Quarterly
Supportive
supervision Project
IOI# 5. Health facilities constructed, renovated,
and/or equipped (number). 0 0 2 4 1 0 Annual Project data Project
IO I#6. Share of national and satellite laboratories
that comply with Biomedical Waste Management
requirements (cumulative number, percent)
0 1
(14%)
3
(28.5%)
4
(57.1%)
7
(100%)
7
(100%) Annual
External Quality
Assurance
Program
External
Quality
Assurance
Program
IOI# 7. Quarterly publication of a regional
surveillance bulletin by East Africa integrated disease
surveillance network with country-specific data
(yes/no).
No Yes Yes Yes Yes Yes Quarterly
Country
surveillance
report
Project
IOI# 8. Health personnel receiving training
(number). 0 256 685 1160 1324 1462 Annual Project data Project
IOI# 9. Proportion of lab staff trained in liquid
culture testing found to be proficient (percentage). 0 80% 90% 90% 90% 90% Annual Project reports Project
IOI#10. Operational Research studies approved by
the peer review panel completed (yes/no).
NA Yes Yes Yes Yes Yes Annual Annual Project
Reports
EAC/ECSA-
HC, Country
Project
Coordination
Units
IOI#11. Development of regional lab standards,
SOPs, and recording and reporting formats
acceptable to the Regional Technical Advisory Group
(yes/no).
NA No Yes Yes Yes Yes Annual Annual Project
Reports
EAC/ECSA-
HC, Country
Reference
Laboratory
NA: Not applicable.
69
Uganda Target Values Data Collection and Reporting
Project Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data Collection
Instruments
Responsibility
for Data
Collection
POI# 1. Average turn-around time for TB liquid
culture tests (days). 63 45 40 35 35 35 Quarterly
Lab information
system Head, NTRL
POI# 2. Satellite laboratories awarded at least two
star status under regional accreditation program based
on WHO/AFRO accreditation approach (cumulative
number, percent).
0 0 0 0 1
(20%)
4
(80%) Annual
Accreditation
Reports
Accreditation
Body
POI# 3. Number of beneficiaries (direct and/or
indirect)‖ (out of which x% female). 48,000 50,000 52,000 54,000 56,000 60,000 Annual Lab Information
System
Project
Coordination
Team
POI# 4. People receiving TB drug susceptibility tests
among DOTS treated TB cases not responding to
treatment (number, percent).
800
(34.7%)
1,000
(40.0%)
1,200
(48.0%)
1,500
(60.0%)
1,800
(72.0%)
2,000
(80.0%) Annual
TB Lab
Registers and
Lab Information
System
Head, NTRL
POI# 5. Share of reported communicable disease
outbreaks42 having laboratory confirmation of
etiological agent (percent). 10% 25% 40% 50% 50% 50% Annual
IDSR and CPHL
Lab Reports
Assist
Commissioner ,
ESD and Head,
CPHL
POI# 6. Outbreaks for which cross border
investigation undertaken (number). 0 1 2 2 3 4 Annual Project Data
Assistant
Commissioner,
ESD
Target Values Data Collection and Reporting
Intermediate Outcome Indicators Baseline
2009 YR1 YR2 YR3 YR4 YR5
Frequency
and
Reports
Data Collection
Instruments
Responsibility
for Data
Collection
IOI# 1. Satellite laboratories compliant with
regionally harmonized SOPs (cumulative number,
percent).
0 0 1
(20%)
3
(60%)
4
(80%)
5
(100%) Annual
Lab information
system
Head, CPHL
and Head
NTRL
IOI# 2. Satellite laboratories meeting approved
staffing norms (cumulative number, percent). 0 4 (80%) 5 (100%) 5 (100%) 5(100%) 5 (100%) Annual HR MIS
Head, CPHL
and Head
NTRL
IOI# 3. Number of days the national reference
laboratory reporting stock-out of tracer reagent for
TB liquid culture in past quarter (days).
21 15 15 7 7 5 Quarterly Supportive
supervision
Head, CPHL
and Head
NTRL
IOI# 4. Satellite laboratories reporting stock-outs of
tracer reagent for stools culture (percent). 80% 80% 60% 40% 20% 20% Quarterly Supportive
supervision
Head, CPHL
and Head
NTRL
IOI# 5. Health facilities constructed, renovated,
and/or equipped (number). 0 0 1 2 3 0 Annual Project data
Project
coordination
team
IO #6. Share of national and satellite laboratories
that comply with Biomedical Waste Management
requirements (cumulative number, percent)
0 2
(28.6%)
3
(42.9%)
5
(71.4% )
7
(100% )
7
(100%) Annual
External Quality
Assurance
Program
External
Quality
Assurance
42
Examples of the disease outbreaks include: cholera, malaria, hepatitis, salmonella, typhoid etc.
70
Program
IOI# 7. Quarterly publication of a regional
surveillance bulletin by East Africa integrated disease
surveillance network with country-specific data
(yes/no).
No Yes Yes Yes Yes Yes Quarterly
Country
surveillance
report
EAC Health
Desk
IOI# 8. Health personnel receiving training
(number). 0 116 150 150 113 3 Annual Project data
Project
coordination
team
IOI# 9. Proportion of lab staff trained in liquid
culture testing found to be proficient (percentage). 0 80% 80% 80% 80% 80%
Annual Project
Reports Head NTRL
IOI#10. Operational Research studies approved by
the peer review panel completed (yes/no).
NA No Yes Yes Yes Yes Annual Annual Project
Reports
EAC/ECSA-
HC, Country
Project
Coordination
Units
IOI#11. Development of regional lab standards,
SOPs, and recording and reporting formats
acceptable to the Regional Technical Advisory Group
(yes/no).
NA No Yes Yes Yes Yes Annual Annual Project
Reports
EAC/ECSA-
HC, Country
Reference Lab
NA: Not applicable.
71
Figure 1: Results Chain (graphic depiction)
72
Table 8: Brief description of laboratory information systems in participating countries
Kenya Data from peripheral health facilities are reported to the District Medical Laboratory
technologist who collates and reports to the central data unit at the National office. Currently
the District and Provincial laboratories use paper based formats to report. The central level
uses an electronic system which is interlinked through a common server. Plans are under way
to integrate District and Provincial Laboratories (peripheral laboratories) under this system.
The current server located at National Public Health laboratories in Nairobi serves three
laboratories i.e. central TB lab, central microbiology lab and HIV reference lab. The LIMS is
not interlinked with the HMIS but they are plans underway. The LIMS system has a systems
manager, ICT person and four support staff who collate the paper based information from
peripheral labs to the LIMS.
Tanzania Laboratory information systems are able to report on TB data reasonably well, and consistent
with WHO indicator definitions, and quarterly reporting is standardized. Laboratory-level
information on laboratory functioning (e.g., work processes, reagent requirements etc.) are
also captured but not in a systematic manner. Public health laboratory information systems
are less standardized. Integrated disease surveillance feeds into the HMIS. Outbreak data are
reported upon weekly, monthly, quarterly and annually feeds in to the HMIS annual report.
The TB and Public Health laboratory information systems are unable to communicate, and for
both systems there lacks agreement on the laboratory functioning data that needs to be
collected, and what data should be reported to higher levels beyond the laboratory-level.
Uganda The TB laboratory information system (LIS) connects peripheral laboratories (DTU) to the
National TB Reference Laboratory. The data repository is paper-based and recently converted
to an electronic database, although this is incomplete. The data obtained from the peripheral
TB laboratories include reagents consumption, status of equipment, EQA, peripheral
laboratory results and slides and specimen for Sputum culture and sensitivity data. Feedback
reports are provided (e.g., EQA, laboratory culture and sensitivity results) but there are
weaknesses in the system. Public health laboratory information system is separate from TB
laboratory information system, and also not linked to the HMIS, although the HMIS captures
some laboratory data collected through a separate mechanism. A data collection tool is
currently being revised so that the same data is collected at laboratories at various levels
(essential for aggregation of data). Once revision has been agreed, it will be converted to
electronic format and implemented in public health laboratories. TB and public health
laboratory information systems are not linked. In both information systems, the flow of data
to the center is much better than the feedback to the district level laboratories, providing no
information to district facilities to track performance.
Rwanda Rwanda does not yet have a Laboratory Information System (LIS) at the National Reference
Laboratory (NRL) in Kigali, but an RFP has been prepared and will be funded by
PEPFAR/CDC. The system is envisioned to be centrally managed and offer a sustained
solution in a resource-poor setting. There is the possibility to extend the LIS to the five
selected laboratories; however, the Ministry recognizes that these district facilities need more
than access to the LIS. They also need to manage and automate other hospital functions
which correlate with the laboratory; therefore the project will support the purchase of a Local
Area Network (LAN) and local cabling, and a District Hospital Management Information
System (DHMIS) which with an LIS module for each of the five remote laboratories. Data
must be able to flow between the LIS and the DHMIS, and using the international
telecommunications links, to the other countries in the project. In addition to this, the data
from the LIS will also flow into the Health Management Information System (HMIS)
currently running at the MoH.
73
Annex 4: Detailed Project Description
AFRICA: East Africa Public Health Laboratory Networking Project
1. The development objective of the project is to establish a network of efficient, high
quality, accessible public health laboratories for the diagnosis and surveillance of TB and other
communicable diseases. The project seeks to address common lab systems weaknesses in four
adjoining countries (Kenya, Rwanda, Tanzania, and Uganda) to diagnose communicable diseases
of public health importance and to share information about those diseases to mount an effective
regional response. It aims to do this through an effective public health laboratory network which
would follow regionally harmonized policies, strategies, and protocols to ensure prompt and high
quality results. The project also aims to strengthen linkages with ongoing regional initiatives in
East Africa to improve integrated disease surveillance. The project activities are fully consistent
with broader health strategies in the four countries (which include a strong emphasis on
strengthening diagnostic and surveillance capacities) and with interventions funded by other
partners (as summarized in tables 1/2 below). Partner support will include: lab accreditation
(WHO), SRL establishment (WHO, USAID), technical training and technical support (CDC,
FIND, WHO), facility design/rehabilitation/construction (USG/PEFPAR); and
e-health/integrated disease surveillance (African Development Bank, Rockefeller Foundation).
2. The proposed regional laboratory network aims to: (a) enhance access to diagnostic
services for vulnerable groups to contain the spread of diseases in cross border areas;
(b) improve capacity to provide specialized diagnostic services and conduct drug resistance
monitoring at regional level; (c) contribute to disease surveillance and emergency preparedness
efforts through the availability of timely lab data to provide early warning of public health
events; and (d) serve as a platform for conducting training and research. The lab network will
facilitate the adoption of harmonized policies, strategies, and protocols to ensure prompt and
high quality results. Priority attention will be given to networking satellite labs that serve cross
border and migrant populations, and central public health labs that provide specialized services.
The proposed activities aim to reinforce related activities at the national level in the participating
countries. While all four countries have national networks of microscopy centers supported by
governments and partners this project aims to expand networking to the regional level,
complementing national efforts. The network will be backed by strong national and regional
reference laboratories and institutions to build competencies of laboratory staff and to promote
quality assurance.
3. Following broad based consultations, representatives from the participating countries
have agreed to function as a community of practitioners or a community of practice for public
health laboratory development, fostering cross country learning and knowledge sharing. The
community of practice would become an integral part of the Africa region‘s Health Systems for
Outcome (HSO) initiative and would benefit from Bank support and contribute to knowledge
sharing with other countries and stakeholders. During regional consultations, participating
countries have developed a common vision and reconfirmed their commitment towards
preventing and controlling the spread of communicable diseases in the Eastern Africa Region
where heads of state recently signed an agreement to establish a common market which will lead
to broader collaboration in all areas, including health. They have acknowledged the importance
of developing harmonized approaches, promoting specialization, and expanding information
74
sharing about public health issues. The countries have agreed to provide leadership at the
regional level by leading working groups in key technical areas where each has a comparative
advantage and would serve as a center of excellence, as follows:
KENYA--Integrated Disease Surveillance and Response & Operational Research: Building on its relatively strong IDSR system Kenya has agreed to serve as a center of
excellence for disease surveillance as well as operational research. It will: (i) lead the
development of harmonized tools; (ii) promote cross border surveillance and joint
outbreak investigations; (iii) share lessons from the successful field epidemiology
fellowship program (FELTP), and offer training programs to build regional surveillance
capacities; and (iv) collaborate closely with the EAC to strengthen the East African
Integrated Disease Surveillance Network. Kenya will also lead a regional working group
on operational research and work closely with ECSA-HC to develop standardized
research protocols.
UGANDA--Lab networking and accreditation: Uganda will provide leadership in
establishing the East Africa public health regional laboratory network, working closely
with ECSA-HC and the Regional Advisory Panel. This will involve: (i) development of
common standards; (ii) standardization of quality assurance systems; (iii) introduction of
peer review mechanisms; and (iv) application of the WHO/AFRO five-step accreditation
process to accredit all satellite laboratories in the proposed network to progressively meet
the international gold standard certification with clearly defined parameters for
turnaround time, quality, and proficiency, as discussed in Annex 3.
TANZANIA--Training and capacity building: Tanzania will provide high quality
training in laboratory techniques at its new state of the art Quality Assurance Training
facility and diploma and degree programs at the Muhimbili University of Health and
Allied Sciences. Tanzania will use a phased approach: (i) initially offering short term
courses; (ii) sharing training curricula and programs with other countries; (iii) providing
TA to other countries to develop continuing education programs; and (iv) developing e-
learning approaches for distance learning.
RWANDA--ICT, Performance Based Financing, MDR-TB: Rwanda has agreed to
take a regional lead in expanding use of ICT and promoting PBF approaches for lab
services, building on its well recognized successes in these areas. The ICT aspects of the
project are presented in Box 1 below. Rwanda will: (i) share its tools (e.g. standards and
guidelines, reporting forms, request for proposals); (ii) provide related training, capacity
building, and technical support as well as organize site visits; (iii) take a lead in
determining the applicability of the PBF approach to public health laboratories and
document and share lessons. Rwanda has also been selected as a center of excellence for
MDR-TB for the Africa region by the Dutch TB Foundation (KNCV) and will also share
lessons in this area.
Component I: Regional Diagnostic and Surveillance Capacity (US$44.9 million)
4. The first component will provide targeted support to create and render functional the
regional laboratory network (Figure 1). Uganda, working in close collaboration with ECSA-HC,
will lead the establishment of the network. Component I includes three sub-components:
75
5. Diagnostic Services for Vulnerable Populations in Cross Border Areas (US$21.2
million) The first sub-component will support five satellite laboratories in each country (and six
in Tanzania) to expand access to diagnostic services for vulnerable groups in cross border areas
and to serve as sentinel surveillance sites to monitor hot spots for disease transmission. Bank
financing will promote a systems approach to laboratory development based on quality
management principles and include: (i) support for rehabilitation, expansion, and/or construction
of laboratories at existing hospitals; (ii) provision of laboratory equipment and materials,
including waste management equipment and protective gear to ensure the safety of lab
personnel; (iii) acquisition of computer equipment, software, and technical support for integrated
laboratory information systems to improve the quality of data generated and videoconferencing
capacity to allow personnel across sites to consult each other and to have access to timely
information about disease outbreaks; and (iv) provision of operating funds to render the
laboratories functional, including strengthening human resources which are the backbone of
quality diagnostics.
6. The satellite laboratories are based at regional or district hospitals in strategic cross
border areas and/or in densely populated peri-urban areas where poverty is rampant and slum
conditions serve as a breeding ground for the spread of diseases. Each country has carefully
selected these sites based on the following criteria: (i) hospitals which are located in high
transmission areas with large numbers of migrants or refugees; (ii) regional teaching hospitals
which can serve as centers of excellence for conducting training and research; and (iii)
commitment to collaborate and coordinate efforts within and across countries. The satellites are
essential to optimize surveillance efforts and contain the spread of communicable diseases in the
region. The list of satellite laboratories was confirmed during appraisal and is included below
(Tables 3-6)
7. Countries will adopt a phased approach with a results focus based on standardized quality
practices. In an initial phase, human resources would be bolstered, training would be conducted,
and proficiency testing would be carried out to ensure that basic microscopy and other core lab
functions are performed according to set standards. During a second phase, specialized
diagnostic services would be introduced once the physical infrastructure has been upgraded.
Underpinning the phased approach will be the accreditation of all satellite laboratories using the
WHO/AFRO five-step accreditation process, with the goal of reaching a two star status by
project completion. Accreditation instills continuous learning; ensures standardized quality
practices; affords confidence in lab results by clinicians and patients; increases efficiency; and
provides evidence of quality 43
8. Reference and Specialized Services and Drug Resistance Monitoring (US$22.5 million) The project will bolster the capacities of the Central Public Health Laboratories in the
participating countries and network them to share information, conduct joint training and
research, and collaborate in harmonizing policies and strategies. This process will focus on the
TB laboratory functions (which have been relatively neglected), supporting one of the labs to be
upgraded to a Supranational Regional Laboratory (SRL). The project will finance:
43
The WHO AFRO five-step accreditation process will operate under the guidance of the WHO Regional Office for
Africa and the U.S. President‘s Emergency Plan for HIV/AIDS Relief (PEPFAR) and will be implemented through
the U.S. Department of Health and Human Services/Centers for Disease Control and Prevention (HSS/CDC).
76
(i) rehabilitation/construction and lab equipment and materials for central public health
laboratories, including TB reference laboratories; (ii) acquisition of computers and
videoconferencing capacity to facilitate sharing of information and link into existing
telemedicine installations where appropriate; (iii) TA to support accreditation of satellite labs and
standardization of procedures and protocols to ensure that diagnostic procedures are performed
by appropriately trained technicians against clear regional and international proficiency and
quality standards; and (v) provision of operating funds to support inter-laboratory external
quality assessments among the four participating countries and recruitment of additional
personnel to provide mentorship to satellite laboratories.
9. The laboratories would serve as models for prevention, control, and treatment efforts
along with acting as centers for knowledge generation and sharing. This would be an effective
mechanism in the current absence of a Supranational Reference Laboratory. As national
capacities are enhanced and the network becomes fully functional one of the four laboratories
would play the role of a regional laboratory for East Africa, providing services (e.g. quality
control; support with drug resistance surveys; higher-level testing, including second line drug
susceptibility testing and molecular diagnostics) to other laboratories in neighboring countries,
thus reducing the need to ship specimens to labs on other continents. There is already an
international commitment to establish such a supranational structure in East Africa and both the
World Health Organization and the TB Union have established processes for accrediting one of
the labs which would meet international standards. The USAID is providing technical support
for this process through TB-CAP. The Bank will rely on the outcome of the technical
accreditation process, working in close collaboration with its partners. The Bank will assist
countries to develop the financial mechanisms and operational modalities for the regional lab to
provide services and for other countries to acquire those services once a decision is taken on
which one will be the SRL.
10. The US Center for Disease Control and Prevention is active in all four countries, and the
Bank has mobilized its support for the design of these activities, to take advantage of the
institution‘s technical expertise and to minimize risk of duplication. The strategy has been to
rely on PEPFAR/CDC Global AIDS Program to provide grant financing for national level
investments with the Bank project focusing on regional aspects. The level of resources and type
of support provided varies across the four countries as summarized below.
Table 1 KENYA CDC with through PEPFAR financing is supporting the construction of a new laboratory complex which will
consolidate the HIV and TB lab functions at the same location with the Bank project financing specialized
laboratory equipment for the central TB laboratory and rehabilitation of the Central Public Health Laboratory
(CPHL).
UGANDA CDC with PEPFAR financing is constructing a new Central Public Health Laboratory (CPHL) with the Bank
providing funding for the TB laboratory which will be situated at the same site.
TANZANIA The Bank regional project will render functional a National Health Laboratory Quality Assurance and Training
Center constructed with financing from PEPFAR/CDC Global AIDS Program which will become a regional
training center. The Government of Tanzania (GoT) has also requested Bank support under the regional project to
establish a Central Public Health Laboratory (CPHL) on the campus of Muhimbili University. The goal is to
establish within close proximity to the university a full complex of specialized diagnostic and referral services
which would serve both Tanzania and the region.
RWANDA Building on its long standing collaboration CDC and the Bank will provide complementary support to strengthen
the National Reference Laboratory.
77
Figure 1
11. Disease Surveillance and Preparedness (US$1.3 million). The proposed project will
complement ongoing regional and global initiatives to improve Integrated Disease Surveillance
and Response (IDSR) country systems. It will support the IDSR strategic goals to improve
availability of quality information by: (i) strengthening competence of lab and facility personnel
to collect, analyze, and use surveillance data; (ii) reinforcing lab networking and district capacity
(particularly those in border areas) to report, investigate, and adequately respond to disease
outbreaks; and (ii) strengthening communications and data sharing to respond rapidly to
outbreaks. Kenya will take a lead in this area and work closely with the EAC health desk to
EAST AFRICA PUBLIC HEALTH LABORATORY NETWORKThematic Regional Lead Roles/Centers of Excellence
ECSARAP/EAC
Kenya Tanzania
NTRL*
CPHL
CoE
Satellitelabs
Cross-border, migrant, refugee populations
NTRL*
CPHL
Quality assurance, surveillance, information systems
common standards, strategies, and protocols
Lab-based disease surveillance, early warning systems,
disease outbreak collaboration
CoE
Cross-border, migrant, refugee populations
Uganda
NTRL*
CPHL
CoE
Cross-border, migrant, refugee populations
Rwanda
NRL*
CoECross-border, migrant, refugee populations
Satellitelabs
Satellitelabs
Satellitelabs
•Coordination & Harmonization•Training and Capacity Building•Policy and Advocacy•Operations Research•Knowledge Sharing
COE: TrainingCOE: Surveillance &
Research
COE: ICT/PBFCOE: Lab Networking
COE: Center ExcellenceCPHL: Central Public Health Lab
NRL: National Reference LabNTRL: National TB Reference Lab
78
harmonize tools, offer training and technical support, and serve as a center of excellence,
documenting and sharing good practices in disease surveillance.
12. The strategy is to start gradually and prioritize a few diseases for Bank support, including
those which are: (a) outbreak prone (cholera, meningitis, hemorrhagic fever), (b) endemic
(multi-drug resistant TB), or have (c) pandemic potential (influenza). The project will also
provide complementary support to the EAC for the East African Integrated Disease Surveillance
Network to enhance its effectiveness, and facilitate the production of quarterly regional
surveillance bulletins. Bank funding will assist the countries to comply with their commitments
under the International Health Regulations. To this end, the project will support laboratory-
based disease surveillance efforts by: (i) strengthening etiological confirmation of pathogens and
promoting active participation of lab personnel in disease surveillance and disease outbreak
investigations; (ii) establishing and maintaining an integrated data management system; and
(iii) facilitating sharing of relevant data across the region, including publication of periodic
newsletters and quarterly and annual disease surveillance reports. These activities will be funded
through the provision of TA, operating costs, ICT services, and training.
Component II: Joint Training and Capacity Building (US$9.9 million)
13. The project will support training in a range of institutions in Tanzania and in the other
three countries and across the region. The recently constructed National Health Laboratory
Quality Assurance and Training Centre in Tanzania will be established as a regional training
center for the East Africa Community, providing up to date in-service training and post-graduate
mentorships. The Muhimbili University of Health and Allied Sciences will provide diploma and
degree programs. Other regional training programs (such as the Arusha training organized by
the International Union Against Tuberculosis and Lung Disease in collaboration with the
Tanzanian National Tuberculosis/Leprosy Program) and other training centers like the African
Center for Integrated Laboratory Training in Johannesburg will be supported, particularly for
training trainers.
14. Each country has prepared and finalized a training plan which provides details of short
and long term programs, including regional and longer term training in identified areas of
laboratory sciences and field epidemiology. It was agreed that the scope of all critical training
programs supported under the project such as laboratory management, infection control and bio-
safety, and disease outbreak investigation would be nation-wide, ensuring synergies with
activities provided by other partners, while training programs linked to specific inputs provided
under the project, such as rapid TB diagnosis and cultures, will be limited to staff working at the
laboratories supported by the project. In addition, a three-month certificate program with credits
on leadership will be developed and introduced for laboratory managers to enhance career
prospects. Trainees will include staff from private laboratories. In addition, the project will
support fellowships in field epidemiology through the flagship FELTP program. By project
completion over 2000 laboratory specialists will have received training and a professional cadre
of laboratory managers will be established in the sub-region. The training plans were reviewed
and finalized during the appraisal mission.
79
15. The Bank project will finance: (i) attendance at training courses at national and regional
institutes; (ii) laboratory attachments, fellowships, and regional exchanges at recognized centers
of laboratory excellence; (iii) selective graduate training to support specialized services;
(iv) TA to review and develop standards and training curricula and generic specifications for
equipment; and (v) regional workshops to facilitate knowledge sharing.
Box 1
Information and Communication Technologies
The project will deploy ICT to improve the quality of data generated, facilitate the sharing of information, and
promote eLearning and knowledge sharing. In order to attain economies of scale and ensure development and use
of systems and data which are inter-operable, the project will use common systems, standards, and approaches to
technology, as follows:
-Establishment of a regional ICT working group with participation from ICT officers and heath sector specialists
in each country. Headed by Rwanda, the working group will identify one ICT focal point and other ICT champions
from all four countries in data security, web development, inter-operability and extraction of data, and dissemination
techniques such as mobile alerts. Each country will contribute to ICT planning and share technical resources,
including expertise and specific local solutions.
-A preliminary study for the architectural design of the overall network and storage requirements for the system,
for the website, and for the specific telecommunications connections within each country will be undertaken.
Recommendations for the hardware, software, systems support, and training will be shared in the working group.
-Other technology projects will be leveraged to the fullest extent possible. Both the Regional Information and
Communications Infrastructure Project in Rwanda, Kenya, and Tanzania and the e-Rwanda Project have
components which either strengthen the telecommunications infrastructure, provide capacity building in technology,
and/or provide funding for applications such as telemedicine or mobile dissemination of information.
The main areas of ICT support under each component are summarized below:
Component 1: Information systems and telecommunications: Support will include funding for systems
development, hardware, and operating costs for telecommunications. The project will fund the design, development,
and expansion of Laboratory Information Systems (LIS) or District Hospital Management Systems (which contain
LIS modules). It will ensure that data can flow between the two systems and the Health Management Information
System, and will fund the Local Area Network in each location, local cabling, and other general office automation
software (e.g. e-mail), as may be needed. In addition, other technology projects will be leveraged, particularly to
facilitate access to the fiber optic network. For example, in Rwanda the RCIP will fund the last mile connections to
the satellite laboratories identified by the MoH. In Tanzania and Rwanda, RCIP support centers will provide
support for capacity building and installation of telemedicine and other applications.
Component 2: Platform for eLearning: To ensure effective deployment of ICT systems basic end user training will
be offered to laboratory personnel at local and regional institutions. Advanced training on the medical software will
also be given. ICT staff will require additional systems administration, LAN administration, and training in how to
support the end users. As Tanzania will take the lead on training and capacity building, the project will also provide
office automation and videoconferencing equipment to link ECSA-HC and EAC. This will help those coordinating
organizations to manage the overall project implementation and provide a common platform to house the eLearning
modules. In order to maximize the existing and planned infrastructure investments in telemedicine sites in Rwanda
and Tanzania (funded by the RCIP) the project will also fund additional videoconferencing equipment for the
laboratories/hospitals participating in the project, so that all sites may be brought into the eLearning and knowledge
sharing activities.
Component 3: Web-based Knowledge Sharing: An initial study will provide the overall plan for the website, and
this will include guidelines for the common main web page, including links to general project information, calls for
research papers, results of research, and overall data on the project and its results. Each country will have the
opportunity to contribute to the specific country pages, with exclusive data from each country as generated by the
project and any other appropriate information or links. Additional information on the site will include but not be
limited to: (a) bibliographies of relevant internationally peer reviewed research; (b) links to books and other
important websites; (c) an online library of full text and abstracts of articles; (d) links to the eLearning modules, (e)
results of research activities; (f) reports on indicators for the project; and (g) other project documents.
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Component III: Joint Operational Research & Knowledge Sharing and Regional
Coordination and Program Management (US$8.7 million)
16. Joint Operational Research and Knowledge Sharing The project will finance relevant
operational research which is related to activities supported under the project. The three main
research priorities identified by countries relate to the need to: (i) evaluate the effectiveness of the
new TB related diagnostic technologies at the programmatic level, (ii) assess drug resistance
patterns for endemic diseases, and (iii) ascertain the feasibility of using mobile phone
technologies for weekly surveillance reporting of selected priority diseases. The evidence
generated through this joint operational research will help inform public policy and the scale up
of these interventions in the participating countries and in the region. As agreed during project
preparation, Kenya would set up an operational research working group, and work closely with
ECSA-HC. The project will fund: (a) TA to support operational research; (b) operating costs to
organize workshops to share results; and (c) training to boost capacities to conduct research.
17. A tentative list of criteria have been identified and include: (i) relevance of proposal to
activities supported under the project; (ii) rigor of the methodology; (iii) involvement of research
groups from more than one participating country as a way to build regional capacity; (iv) cost of
proposal; and (v)potential of research to inform public policy and practice.
18. Knowledge Sharing & Regional Coordination: ECSA-HC will play a coordinating and
convening role and be responsible for the following activities at the regional level:
Convene Technical Experts and Policymakers: The organization will support the
country-led working groups by providing a forum for discussions and deliberations. The
ECSA-HC Secretariat will facilitate the work of technical partners (e.g. CDC, WHO)
which will assist in harmonizing laboratory operating procedures and quality assurance
systems. ECSA-HC will use its existing mechanisms (e.g. conference of health
ministers; advisory committee of permanent secretaries) to share results from the regional
project, and advocate for policy change at both the technical and policy levels.
Facilitate Capacity Building and Training: The ECSA-HC Secretariat will support
countries to implement a regional study on human resources for laboratory services and
one on public/private partnerships with a view to identifying options for enhancing the
quality and efficiency of laboratory services, as described below; prepare policy briefs on
HR issues; take stock of training institutions offering higher level training in laboratory
services; and facilitate networking of laboratory managers by organizing bi-annual
professional meetings.
Establish a Forum for Learning and Knowledge Sharing: The organization will facilitate
exchanges of experiences; document best practices in laboratory networking in the
region; work with their health journalist network to report on achievements and lessons;
establish a peer review mechanism for reviewing research findings; and drawing policy
conclusions to be brought to the attention of policy makers; maintain a repository of
information on activities supported under the project which can be shared regionally; and
prepare a regional communications strategy for disseminating main findings from the
project, documenting the state of laboratories (before/after), and informing the public on
related public health issues.
81
Facilitate Regional Surveillance Efforts: The ECSA-HC Secretariat will support the East
African Community health desk to: implement the strategic plan for developing the East
African Integrated Surveillance Network as a model regional network and producing
quarterly surveillance bulletins regularly; work with country surveillance focal points and
technical partners to develop standardized reporting tools and protocols for sharing
information on selected communicable diseases (e.g., Cholera, Meningitis, MDR TB,
Influenza, Polio) in the region; and facilitate cross border outbreak investigations when
satellite laboratories report disease outbreaks.
19. Project funds will be used to support: (i) operating costs to organize regional workshops
to share research and programmatic results, and explore policy implications; (ii) establishment of
a small team to coordinate activities at the regional level and a focal point at the EAC;
(iii) videoconferencing capacity; (iv) development of a website to serve as a platform for sharing
of information, results of research, and a database of relevant articles, books, and other materials;
and (v) TA.
20. Program Management. At the national level, the project will be managed through
existing structures of the Ministries of Health which coordinate Bank-funded health projects
which are on-going or under preparation. Limited additional support will be provided under the
project for improving coordination, ensuring fiduciary compliance, and providing supportive
supervision for the satellite laboratories. At the national levels, the Bank-funded regional project
will fund additional human resources, equipment, vehicles, supplies, and operating costs.
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Box 2
Key research priorities
LED microscopy versus conventional smears: As LED microscopy will not replace conventional Sputum
Smear Microscopy (SSM) it will be important to define the patient population to be provided this test and
to determine the optimal strategy for its use (e.g. sequential testing beginning with conventional smears
followed by LED microscopy for those testing negative; direct use of LED microscopy for HIV positive
TB suspects); it will also be important to document key aspects (e.g. additional yield, ease of use,
turnaround time, cost) compared to conventional SSM.
Liquid culture systems: The programmatic utilization of liquid culture systems for the diagnosis of TB in
this high HIV prevalent setting will need to be assessed, so that the roll out of this new technology is done
in a cost efficient and equitable manner. Recognizing that conventional SSM in HIV+ patients has a low
sensitivity and conventional culture takes too long to influence clinical care, the project will support the
introduction of liquid culture techniques for diagnosing TB in HIV infected persons. The operational
research will aim to address two key programmatic issues which have implications for clinical care and
health systems costs: (i) when should liquid cultures be performed (e.g. after conventional or LED
microscopy is negative or concurrently) and (ii) what is the optimal geographical distribution of this
technology (e.g. how to ensure equitable access to a maximum number of needy patients).
Molecular line probe assays: The programmatic utilization of molecular line probe assays for diagnosis
and surveillance of drug resistant TB also needs to be clearly defined. Operational research will be
critical to defining the patient population that will be provided with this test both for diagnosis and
surveillance of drug resistant TB, and the optimal distribution of this technology to ensure equitable
access.
Drug resistance: There is anecdotal evidence on increasing drug resistance to common antibiotics as well
as a growing concern about development of resistance to anti malaria drugs, especially ACT. However,
there are very limited number of systematically carried out studies in the region to inform national
policies for selection of antibiotics and improving standard treatment guidelines. The operational research
will support documentation of common pathogens for childhood diarrheas and meningitis and studying
the antibiotic resistance patterns. In addition, sentinel laboratories would contribute to ongoing
operational research on monitoring drug resistance for malaria.
Surveillance: Mobile phones are increasingly used for timely collection and dissemination of critical
information in the health sector, including tracking patient outcomes and drug supply availability. The
feasibility of using mobile phone technologies for transmitting short message service (SMS) for weekly
surveillance reporting needs to be assessed with respect to cost, speed of confirmation, response time, and
control of the outbreak.
Studies/Analytic Work
21. Public-Private Partnerships Private clinical laboratories are increasingly playing an
important role in the delivery of health services in the East Africa Region especially in the larger
cities and urban areas. Laboratories attached to health facilities operated by Faith Based
Organizations are actively engaged in providing laboratory services for important public health
programs like tuberculosis and malaria. Several countries in the region either have or are
preparing policies on Public Private Partnerships (PPPs) in health care. In addition to clinical
care, there are several areas where the private sector can partner with public sector and the
proposed East Africa Public Health Laboratory Networking Project will be supporting expansion
83
of some ongoing PPPs, such as specimen transportation, and will also encourage involvement of
FBOs in improving access to quality health laboratory services to underserved populations. The
private sector will also be encouraged to participate in the regional laboratory accreditation
program and training activities.
22. The project also proposes to support a ―comprehensive assessment‖ to suggest options
and innovative approaches for enhancing PPPs in health laboratory services with a view to
enhancing efficiency, accountability, and quality of public services which are frequently used by
the poor. The proposed assessment will suggest innovative options for PPPs in improving access
to quality clinical laboratory services, including broader support services to enhance the
effectiveness of laboratory networks such as maintenance, specimen transportation, and
communications. The proposed assessment will be undertaken in all four countries participating
in the East Africa Public Health Laboratory Networking Project countries and the scope will
include:
Mapping of the private and FBO clinical laboratories providing bacteriology (culture and
sensitivity) and specialized laboratory services like florescent/LED microscopy and
liquid culture for TB.
Documenting ongoing PPP arrangements in clinical laboratory and related support
services, such as specimen transportation and use of mobile technology for transmission
of information on communicable diseases.
Exploring the interest of the private sector to participate in the regional health laboratory
accreditation program.
Undertaking stakeholder consultations to identify potential new areas for PPP in clinical
laboratory services in the East Africa region, including operating specialized laboratory
services in public hospitals, hiring of automated laboratory equipment, and providing
maintenance services for laboratory equipment etc.
23. Human Resources Study One of the critical constraints faced in operating health
laboratory services is shortage of technical human resources especially laboratory technicians.
While several reasons are given for the situation, ranging from shortage of trained personnel to
absence of approved positions in the civil service, there has been no systematic assessment to
understand the labor market situation of laboratory personnel in the East Africa Region. Most
studies on Human Resources in Health tend to primarily focus on clinical staff like doctors and
nurses. The project proposes to support a comprehensive assessment of the labor market
situation of the laboratory personnel in the four countries participating in the project. Standard
methods and tools will be used to ensure cross country comparability as well as the emerging
larger East Africa common market which provides wider opportunities. The assessment will
specifically cover:
Current production of different cadres of laboratory personnel
Perceptions and aspirations of students enrolled to be trained as laboratory specialists and
technicians
Quality of laboratory personnel produced
Employment opportunities in countries and regions including policies and norms for
staffing health laboratories
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Career path for laboratory personnel
Role of private sector in employment as well as production of laboratory personnel
24. The ECSA-HC Secretariat will facilitate the execution of these two studies. It will
facilitate standardization of the tools working closely with consultants identified by the
participating countries. Based on the assessments, the two studies will propose policy options
for supporting PPPs in health laboratory services and for improving the availability of high
quality laboratory personnel, including creation of a career path. The results of these studies will
be first discussed at the national level and subsequently shared at regional platforms such as high
level technical and policy makers meetings to identify regional options for enhancing the quality
and efficiency of laboratory services.
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Table 2
Country and Sector Context
KENYA RWANDA TANZANIA UGANDA
National Health
Sector Strategy
The project is consistent with
the 2008-2012 Strategic Plan
of the Ministry of Public
Health and Sanitation
(MOPHS) which focuses on
equitable access to quality and
responsive public health and
sanitation services; and
highlights the regional public
health challenges and
increased risk of
communicable diseases
(measles & polio outbreaks)
due to influx of people from
neighboring countries,
especially those which are not
politically stable.
The project is consistent with the
2009-2012 Health Sector Strategic
Plan which aims to: (i) improve
geographical accessibility of the
population to health services; (ii)
ensure the highest attainable quality
of health services at all level; (iii)
promote and inculcate a culture of
research; (iv) improve the
availability, quality and rational use
of HR; and (v) use an integrated
approach for the prevention and
control of epidemic prone diseases
and neglected tropical diseases. 44
The project is consistent with the
national Health Sector Strategy which
aims to: (i) improve disease case
management in health facilities; (ii)
strengthen the quality of clinical
services in hospitals; (iii) address
management of MDR-TB; (iv) bolster
integrated disease surveillance to
strengthen provision of timely and
accurate information; and (v) promote
an integrated approach to disease
prevention and control.
The project is in line with the
Health Sector Strategic Plan
(HSSP II) which aims to reduce
morbidity and mortality from
major causes of illness by
delivering the national minimum
health care package. The plan
recognizes laboratory services as
one of the major supporting
functions needed for effective and
efficient delivery of the minimum
health care package
National Laboratory
Policy and Strategy
The draft National Medical
Laboratory Strategic Plan
states the importance of
improving diagnostic services
and sets a target of making 50
district labs to perform tests on
diseases of public health
importance by 2012. It also
sets targets for improving TB
The project is consistent with the
2006 National Medical Laboratory
Policy, which is comprehensive in
its scope.45
The overall mission is
to support the delivery of quality
assured laboratory services at all
levels of the health system and
support implementation of 8 major
policy objectives.46
The project is in line with the 2007 Act
for Health Laboratory Practitioners
In line with the 2008 Maputo
Declaration on Strengthening of
Laboratory Systems in Africa,
Uganda has outlined an appropriate
policy framework which calls on
all stakeholders (e.g. government,
donors, partners) to join efforts by
promoting support for integrated
for laboratory systems which is in
44
The plan is divided into 7 strategic areas and the project intersects with at least 5 of these areas, and is therefore fully consistent with the sector‘s strategic vision: (i)
institutional capacity;( ii) human resources; (iii) financial access to health services; (iv) geographical access to health services; (v) drugs, vaccines and consumables; (vi) quality
assurance; (vii) specialized services, national referral hospitals and research centers. 45
The policy covers: the infrastructure and design of medical laboratories, development of human resources, establishment of a quality assurance system, biosafety, establishment
of a professional code of ethics, standard laboratory equipment, reagents, and supplies; laboratory packages, research and development for laboratories; and partnership and
collaboration with other laboratories. 46 Key objectives are: (i) to establish and maintain a functional laboratory network (ii) to provide standard packages of laboratory tests at each level of care ,to promote rational use
of laboratories in order to ensure prevention, diagnosis, and treatment; (iii) to provide the necessary knowledge, competencies, and skills to support the packages of care and
maintain professionalism among laboratory personnel; (iv) to provide appropriate standardized equipment and supplies at each level of care; (v) to establish and maintain a quality
86
KENYA RWANDA TANZANIA UGANDA
diagnostic services at level 2
and 3 facilities as well as in-
country capacity building to
diagnose and treat MDR TB.
line with the project activities.
Support from Other
Partners
Kenya has an ongoing health
SWAP operation and this will
be further strengthened though
a Joint Financing Agreement
which will be the main vehicle
for external assistance to the
health sector. The project
activities will complement
ongoing support
provided/committed by DPs to
strengthen and network health
laboratories at national and
sub national levels, including
USAID financing (roughly
US$410/yr.); USG/PEPFAR
support for the Central PH and
Specialized Reference
Laboratories and provincial
laboratories, JICA support for
district labs, and UNITAID
financing of new TB
diagnostic technologies.
The health sector operates in
collaboration with other partners for
joint financing of various projects.
Key partners include: GF, CDC,
USAID, PEPFAR, Belgium
Technical Cooperation, WHO, and
UNICEF. Most of these partners
provide support to strengthen the
national laboratory network while
the Bank project will allow Rwanda
to be networked with other
countries in the region. Rwanda is
one of the countries supported by
FIND for the introduction of
innovative technologies for the
diagnosis of TB.
Project activities are complementary to
those supported under the Tanzania
Health SWAP which has been the main
vehicle for donor support. Project
interventions are also complementary
to other donor-supported lab
strengthening initiatives, building and
expanding on efforts of other partners,
including PEPFAR/CDC Global AIDS
Program, and an important
public/private partnership between the
MoH&SW and the Abott corporation.
Many of the satellite laboratories
targeted for support have or will benefit
from complementary support from
these partners. Tanzania is also
targeted for support from the UNITAID
grant for TB diagnostics.
-Uganda receives support from
numerous DPs, including the GF,
GAVI, USG/PEPFAR, CDC, and
the Union. Proposed project
activities are complementary to lab
strengthening efforts of other
donors such as USG/PEPFAR and
the Global Fund which are
strengthening the national
laboratory network. CDC through
PEPFAR funding will be
constructing a new CPHL, working
in close collaboration with the
Bank which will fund the
construction of the National TB
Reference Laboratory at the same
location to reap economies of
scale.
IDA Country
Assistance Strategy
(CAS)
The project is part of the draft
Country Partnership Strategy
which aims to support
Government efforts to Vision
2030, building on stakeholder
feedback and previous CAS
lessons. CPS highlights the
Bank‘s role in knowledge
sharing and best practice. The
proposed project aims to (a)
Reducing social vulnerability
through the delivery of basic
services is one of the 2009-2012
CAS strategic themes. The CAS
also commits the Bank to
facilitating learning and knowledge
sharing. Furthermore, the CAS
supports fuller integration into
Eastern and Southern Africa, and
takes special note of Rwanda‘s
The project is in line with the CAS
which aims to: (a) improve provision
and quality of health services; (b)
strengthen technical efficiency in health
care; (c) expand capacity to respond to
regional and global epidemics; and (d)
promote partnerships.
The regional project is part of the
new CAS which aims to assist
Uganda to achieve the targets in
the Poverty Eradication Action
Plan (PEAP) and to make progress
towards the health related MDGs.
assurance system in order to ensure quality laboratory services; (vi) to promote and strengthen research and development; (vii) to establish appropriate standardized laboratory
designs for each level of care; and (viii) to promote partnership and collaboration at local, regional, and international levels.
87
KENYA RWANDA TANZANIA UGANDA
bring global practices to
improve diagnostic services in
Kenya; and (b) build on
regional coalitions among
experts and country-based
partners complementing each
other‘s efforts.
membership in the EAC. Thus,
while this project is not explicitly
mentioned in the CAS, it is fully
consistent with it.
Links to GAC
Strategies
The project will ensure
transparency in information
sharing and active
involvement of key
stakeholders at the facility
level in the design and
implementation of lab
strengthening efforts. It will
also seek to ensure that all
Bank activities help to
improve governance by
building responsive, capable,
and accountable public health
laboratory services. KEMSA‘s
capacities will be strengthened
and governance reforms
accelerated under the proposed
health sector SWAP operation
which is under preparation.
The project builds on Rwanda‘s
strong governance record by
proposing mechanisms for civil
society engagement and related
independent oversight, including
inclusion of a representative of civil
society in district coordination
teams to strengthen oversight and
ownership.
The project will support the broader
goal of strengthening governance and
oversight in the MOHSW by ensuring
that implementation progress is
discussed in country annual health
sector and budgetary reviews.
Public sector management has
been singled out for improvement
with a focus on strengthening
accountability in service delivery.
Starting in 2009/2010,
implementing agencies receiving
external funds will be required to
provide detailed work plans. The
proposed project supports the
funding of annual work plans for
the laboratories supported under
the project which will promote
autonomy and accountability.
IDA-funded Health
Projects under
Implementation or
Preparation
The Health Sector Support
Project is scheduled for Board
presentation in September
2010. The implementation
arrangements of both proposed
projects will be well
coordinated. While the Health
Sector Support Project will
fund cross cutting reforms
(e.g. performance based
approaches; public/private
The main areas of Bank engagement
in the sector are: (i) CLSG which is
the second of a development policy
operation, and a related (ii) Health
Results Innovation Trust Fund
which supports the implementation
of the Community Performance-
based Financing scheme to increase
utilization of high impact child
health services, maternal and
reproductive health services and
The proposed project builds on broader
IDA health sector support by focusing
on lab strengthening, one of the most
neglected areas of health systems. To
minimize risk of duplication the
regional project will be coordinated by
the Health Sector Reform Secretariat
which manages the on-going IDA
health project.
The Bank-funded Uganda Health
Systems Strengthening Project,
running on a parallel track, aims to
improve national capacity to
deliver the minimum health care
package by supporting: (a)
improved health workforce
development; (b) enhanced
functionality of existing health
facilities, (c) improved
management and accountability;
88
KENYA RWANDA TANZANIA UGANDA
partnerships), the proposed
regional operation will support
an innovative regional
approach to lab strengthening.
selected nutrition interventions, and
related analytic work. 47
and (d) improved maternal,
newborn and family planning
services. It will fund a number of
innovative cross cutting reforms. 48
Role of the Private
Sector and Potential
for Public/Private
Partnerships
The private sector is an
important provider of health
services in Kenya, including
laboratory and specimen
transport services. An
assessment of the private
market will be undertaken
under the project to identify
options for promoting PPP for
medical laboratory services.
Faith-based health facilities play an
important role in the provision of
health services in Rwanda. The
private, for profit health care sector
is emerging slowly. Rwanda will
participate in the proposed PPP
study to determine additional
opportunities.
Tanzania has a national PPP policy and
legal framework in place and
experience with the Abott lab
strengthening partnership, which the
project will build on by supporting
some of the same regional hospitals to
further leverage private sector
resources.
Partnerships between public and
private laboratories are viewed as
critical for improving equity and
access to quality services.
Uganda‘s participation in the
regional study will provide an
opportunity to further explore PPP
options.
47
Reforms, such as Results Oriented Management, Client Charters, and incentive schemes for health workers will be deployed to remote areas, to strengthen overall
accountability and sector performance.
48
Analytic work includes: (i) Health Results Innovation Trust Fund: Provides some resources to support the implementation of the CLSG. (ii) GAVI-Health Systems
Strengthening TF: Provides two main areas of support: (i) TA to support the implementation of the CLSG; and (ii) TA in health financing and related issues.
89
Table 3
List of Satellite Sites—Centers of Excellence
KENYA
Location Type of Facility Ownership Catchment
Population
Potential Catchment
Countries
Services to date Human Resource
available
Epidemic Prone
Diseases
Participating
Partners
Malindi District Hospital Government Tanzania, Somalia,
Zanzibar
Lab services,
teaching
Lab technologists, lab
technicians
Malaria, cholera,
diarrhoeal ds, TB,
filiarisis, HIV
FHI, APHIA II
Wajir District Hospital Government Somalia, Ethiopia Lab Services Lab technologists, lab
technicians
Malaria, TB, cholera,
leishmaniasis, HIV
WHO, APHIA
II
Busia District Hospital Government Uganda Lab services Lab technologists, lab
technicians
Malaria, TB, leprosy,
cholera, HIV
MSF,
AMPATH,
APHIA II
Machakos District Hospital Government Tanzania Lab services,
Teaching
Lab technologists, lab
technicians
Cholera, Malaria, TB,
HIV
ICAP, APHIA
II
Kitale District Hospital Government Uganda, Sudan &
Rwanda
Teaching, lab
services
Lab technologists, lab
technicians
Malaria, Cholera,
Dysentry, H1N1,
HIV
APHIA II,
AMPATH
Nairobi National Public
health
laboratories
Government 5 Mil Tanzania, Uganda Teaching,
Research,
Reference Lab
Services
Microbiologists,
virologists,
pathologists, Lab
techs and lab
technicians
H1N1, Cholera, TB,
HIV
CDC,
MSH,KNCV,
USAID
90
Table 4
List of Satellite Sites—Centers of Excellence
RWANDA
Location Type of Facility/
Ownership
Catchment
Population
Potential
Catchment
Countries
Services to date Academic level of Human
Resource currently available
Epidemic Prone
Diseases
Participating
Partners
Gisenyi District Hospital/
Government
333, 624
East of the DR
Congo
General Lab
Service
Biomedical Technologist, diploma
level and lab technician certificate
level.
Cholera
malaria
ICAP, GF
Byumba District Hospital/
Government
576,000
Uganda-south west General Lab
Service
Biomedical Technologist, diploma
level and lab technician certificate
level.
Malaria
Food and
waterborne
infectious
Belgian
cooperation
Nyagatare District Hospital/
Government
290,819 Uganda-south east General Lab
Service
Biomedical Technologist, diploma
level and lab technician certificate
level.
Cholera
Malaria
Typhoid Fever
Intra health
Kibungo District Hospital/
Government
251,372
Tanzania-north
western and
Burundi-northern
General Lab
Service
Biomedical Technologist, diploma
level and lab technician certificate
level.
Malaria
EGPAF
Gihundwe District Hospital/
Government
378,423
DR Congo-western General Lab
Service
Biomedical Technologist, diploma
level and lab technician certificate
level.
Cholera
NRL National
Reference Lab/
Government
All the country
Teaching,
Research,
Reference Lab
Service
Diploma level, Graduate Biomedical
Technologist, MSC biomedical
science, MPH Medical Doctor, PhD.
CDC, ICAP, GF,
UMSOH
(Maryland
University,
USAID, FIND,
Clinton
Foundation,
UNICEF and
WHO
91
Table 5
List of Satellite Sites—Centers of Excellence
UGANDA
Location Type of Facility Ownership Catchment
Population
Potential
Catchment
Countries
Services to date Human Resource
available
Epidemic Prone
Diseases
Participating
Partners
Arua Regional
Referral Hospital
Government 3 Mil DR Congo,
Southern Sudan
Lab Services
Research MDR-TB
Grad Techn
PLT
Lab Asst.
Trypanosimiasis,
Plaque,
Meningitis
MSF, JRC,
CDC, FIND
Gulu -
Lacor
University
Teaching
Hospital
NGO/ Private-
not-for-profit
providers
(PNFP)
4 Mil Southern Sudan Teaching
Ref. Lab Services
PLT
Lab Asst.
Ebola,
Meningitis
AISPRO,
Italian
Cooperation,
CDC
Mbale Regional
Referral Hospital
Government 4 Mil Western Kenya Research
Teaching
Lab Services
PLT
Lab Asst
Cholera CDC, JCRC,
MJAP, FIND
Mbarara University
Teaching
Hospital
Government 5 Mil Rwanda,
Tanzania, DR
Congo
Teaching Research
Ref. Lab Services
Grad Techn
PLT
Lab Asst.
Malaria,
Cholera,
Dysentery,
H1N1
JCRC, CDC,
DSE, GTZ,
DAAD, FIND
Mulago National Referral
and University
Teaching
Hospital
Government 7 Mil Teaching Research
Ref. Lab Services
Grad Techn
PLT
Lab Asst.
H1N1, Cholera,
Ebola
IDI, CDC, SPH,
CWRU,
MUJHU,FIND
92
Table 6
List of Satellite Sites—Centers of Excellence
TANZANIA
Facility/
Location
Type of
Facility
Ownership Catchment
Population
Potential
Catchment
Countries
Services to
date
Human Resource
available
Epidemic Prone
Diseases
Participating
Partners
Kigoma Regional
Hospital,
Kigoma
Regional
Hospital
Government 1,647,047 Burundi
DRC
Lab services
Research
Advanced Diploma
Diploma
Lab Assistants
General Technicians
Meningitis
Sleeping sickness
PEPFAR/ICAP-CU
UNHCR
Abott
Musoma
Regional
Hospital,
Mara
Regional
Hospital
Government 1,363,397 Uganda
Kenya
Lab services
Teaching
Advanced Diploma
Diploma
Lab Assistants
General Technicians
Rift Valley Fever
H1N1
Cholera
Ebola
PEPFAR/AIDS
Relief
Ndanda
Hospital,
Mtwara
Regional
Hospital
FBO 1,124,481 Mozambique Lab services
Teaching
Diploma
Lab Assistants
General Technicians
H1N1
Cholera
PEPFAR/CHAI
Kibongoto
Hospital, Moshi
Regional
Referral
Hospital
(TB)
Government 1,376,702 Kenya Lab services
Research
Diploma
Lab Assistants
General Technicians
Rift Valley Fever
H1N1
TB Partners
PEPFAR/EGPAF
Mnazi Mmoja
Referral
Hospital,
Zanzibar
Referral
Hospital
Government 981,754 Comoros Lab services
Research
Teaching
Diploma
Lab Assistants
General Technicians
Cholera PEPFAR/ICAP-CU
Sumbawanga
Regional
Hospital,
Rukwa
Regional
Hospital
Government 1,136,354 Zambia
Democratic
Republic of Congo
Lab Services
Research
Teaching
Diploma
Lab Assistants
General Technicians
Ebola
Cholera
PEPFAR/DOD
Muhimbili
National
Hospital,
Dar es Salaam
National
Hospital
Government 2,487,288 Comoros Lab Services
Research
Teaching
Diploma
Diploma
Lab Assistants
General Technicians
Rift Valley Fever
H1N1
Cholera
Abbott Fund, MDH,
Dartmouth,CHAI,IC
AP-CU
93
Annex 5: Project Costs
AFRICA: East Africa Public Health Laboratory Networking Project
Project Cost By Component and/or Activity
Local
US
$million
Foreign
US
$million
Total
US $million
1.Regional Diagnostic and Surveillance Capacity 44.964
-Diagnostic Services for Vulnerable Populations 21.202
-Reference and Specialized Services 22.477
-Disease Surveillance and Preparedness 1.285
2.Joint Training and Capacity Building
-National Training
9.926
5.403
-Regional Training 4.523
3.Joint OR and Knowledge Sharing/Regional
Coordination and Program Management
8.770
-OR and Knowledge Sharing 3.721
-Regional Coordination-ECSA-HC 2.500
-Program Management 2.549
Total Project Costs 29.300 34.360 63.660
94
KENYA-Project Cost by Component
Project Cost By Component and/or Activity Local
US $million Foreign
US $million Total
US $million
1.Regional Diagnostic and Surveillance Capacity 16.287 -Diagnostic Services for Vulnerable Populations 5.78 -Reference and Specialized Services 10.063
-Disease Surveillance and Preparedness 0.444
2.Joint Training and Capacity Building
-National Training
4.224
3.154 -Regional Training 1.070 3.Joint OR and Knowledge Sharing/Regional Coordination
and Program Management 2.989
-OR and Knowledge Sharing 1.423 -Regional Coordination-ECSA-HC 0.625 -Program Management 0.941
Total Project Costs 10.800 12.700 23.500
KENYA--Project Cost by Disbursement Category (US$ million)
(1) Goods, Works, Consultants‘ services, Training and
Operating Costs for Part A, B, C.1 and C.2
(2) Goods, Consultants‘ services, Training and
Operating Costs for Part C.3
22.875
0.625
TOTAL 23.50
Estimated disbursements (Bank FY/US$ million)
FY 11 12 13 14 15 16
Annual 1.88 4.23 4.70 5.41 5.88 1.41
Cumulative 1.88 6.11 10.81 16.22 22.09 23.50
95
TANZANIA-Project Cost by Component
Project Cost By Component and/or Activity Local
US $million Foreign
US $million Total
US $million
1.Regional Diagnostic and Surveillance Capacity 9.629 -Diagnostic Services for Vulnerable Populations 5.738 -Reference and Specialized Services 3.353
-Disease Surveillance and Preparedness 0.538
2.Joint Training and Capacity Building
-National Training
3.530
0.875 -Regional Training 2.655
3.Joint OR and Knowledge Sharing and Regional
Coordination and Program Management
1.891 -OR and Knowledge Sharing 0.816 -Regional Coordination-ECSA-HC 0.625 -Program Management 0.450
Total Project Costs 6.900 8.150 15.050
TANZANIA-Project Cost by Disbursement Category (US$ million)
(1) Goods, Works, Consultants‘ services, Training and
Operating Costs for Part A, B, C.1 and C.2
(2) Goods, Consultants‘ services, Training and
Operating Costs for Part C.3
14.425
0.625
TOTAL 15.050
Estimated disbursements (Bank FY/US$ million)
FY 11 12 13 14 15 16
Annual 1.20 2.71 3.01 3.46 3.76 .92
Cumulative 1.20 3.91 6.91 10.37 14.13 15. 05
96
UGANDA--Project Cost by Component
Project Cost By Component and/or Activity Local
US $million Foreign
US $million Total
US $million
1.Regional Diagnostic and Surveillance Capacity 7.033 -Diagnostic Services for Vulnerable Populations 3.111 -Reference and Specialized Services 3.872
-Disease Surveillance and Preparedness 0.050
2.Joint Training and Capacity Building
-National Training
1.193
0.895 -Regional Training 0.298 3.Joint OR and Knowledge Sharing and Regional
Coordination and Program Management 1.874
-OR and Knowledge Sharing 0.705 -Regional Coordination-ECSA-HC 0.625 -Program Management 0.544
Total Project Costs 4.700 5.400 10.100
UGANDA--Project Cost by Disbursement Category (US$ million)
(1) Goods, Works, Consultants‘ services, Training and
Operating Costs for Part A, B, C.1 and C.2
(2) Goods, Consultants‘ services, Training and
Operating Costs for Part C.3
TOTAL
9.475
0.625
10.100
Estimated disbursements (Bank FY/US$ million)
FY 11 12 13 14 15 16
Annual .81 1.82 2.02 2.32 2.53 .61
Cumulative .81 2.63 4.65 6.97 9.49 10.10
97
RWANDA--Project Cost by Component
Project Cost By Component and/or Activity Local
US $million Foreign
US $million Total
US $million
1.Regional Diagnostic and Surveillance Capacity 12.015 -Diagnostic Services for Vulnerable Populations 6.573 -Reference and Specialized Services 5.189
-Disease Surveillance and Preparedness 0.253
2.Joint Training and Capacity Building
-National Training
0.979
0.479 -Regional Training 0.500 3.Joint OR and Knowledge Sharing and Regional
Coordination and Program Management 2.016
-OR and Knowledge Sharing 0.777 -Regional Coordination-ECSA-HC 0.625 -Program Management 0.614
Total Project Costs 6.900 8.110 15.010
RWANDA--Project Cost by Disbursement Category
(1) Goods, Works, Consultants‘ services, Training and
Operating Costs for Part A, B, C.1 and C.2
(2) Goods, Consultants‘ services, Training and
Operating Costs for Part C.3
TOTAL
14.385
0.625
15.010
Estimated disbursements (Bank FY/US$ million)
FY 11 12 13 14 15 16
Annual 1.20 2.70 3.00 3.45 3.74 .91
Cumulative 1.20 3.90 6.90 10.36 14.10 15.01
98
Annex 6: Implementation Arrangements
AFRICA: East Africa Public Health Laboratory Networking Project
1. Overview: The institutional framework for project implementation will vary from
country to country but will: (i) conform with both current international obligations and existing
national laboratory policies and TB strategies; (ii) be consistent with implementation
arrangements adopted by on-going Bank-funded health projects or those under preparation; and
(iii) be fully integrated into the appropriate operating structures.
2. Within each ministry, a lead office will coordinate project implementation; this lead
office will rely on technical focal points and report to the appropriate national program structures
responsible for the results of the project. Additional support will be provided to sections and
units responsible for implementing their respective activities under the project to improve
coordination, ensure fiduciary compliance, and strengthen supervision of project activities.
3. At the country level the implementation arrangements are as follows: (i) annual work
plans will be prepared by satellite laboratories and by the central public health laboratories,
working closely with other key stakeholders responsible for curative and public health services;
(ii) national project coordination teams will review the plans and prepare consolidated annual
work plans of all project activities; (iii) national steering committees under the overall guidance
of the Permanent Secretaries of the Ministries of Health will review and approve the
consolidated plans; (iv) project management units and other structures of Ministries of Health
will be responsible for fiduciary aspects and preparing quarterly and annual consolidated
technical and financial reports.
National Level
4. In Kenya, the project will use the existing government structures as far as possible and no
new implementation structures will be created. The overall responsibility for project
implementation will be with the Ministry of Public Health and Sanitation (MoPHS) assisted by
MoMs. Effective coordination between the two Ministries will be ensured at the national,
project, and district levels. At the national level the Director, Public Health and the Director,
Medical Services will jointly provide leadership and ensure effective inter-ministerial
coordination. They will be responsible for strategic oversight for the project and recommend
annual work plans to their respective Permanent Secretaries.
5. A project coordination committee will be constituted for providing oversight for project
implementation and this committee will be led by the Head, Disease Prevention and Control,
MoPHS who will be assisted by the Head, Department of Diagnostics, MoMS. The other
members of this committee will include heads of the Division of Leprosy TB and Lung Diseases,
National Public Health Laboratory Services, Division of Disease Surveillance and Response, and
Division of Malaria Control. The committee will have representation from non government
organizations that are engaged in project activities for example the Kenyan Society for
Prevention and Treatment of TB, representatives of facility management committees on a
rotation basis, and private sector. This committee will be provided strategic advice and technical
guidance from the Laboratory Technical Advisory Group proposed to be constituted by the
99
Ministries of Health which will include technical agencies and DPs such as CDC, JICA. USAID,
Kenya Medical Research Institute (KEMRI) and laboratory heads from respective program
divisions.
6. A dedicated Project Coordination Team will support the Head Disease Prevention and
Control who is assisted by the Head, Department of Diagnostics and Forensic Sciences in the
implementation of the project. The team will include a project officer, epidemiologist, IT expert,
operations officer and designated accountant for the project. Out of these positions the posts of
IT expert and operations officer will be contractual.
7. In each of the five districts where the project is supporting the development of a satellite
laboratory a coordination mechanism will be established which will have hospital and district
health management teams including the officer in charge of laboratory services. This committee
will provide oversight for the project activities at the district level, including disease
surveillance.
8. In Rwanda the overall implementation responsibility for the project will rest with the
MoH. The PS will have overall oversight. The project activities will be coordinated by the
ministry‘s Project Management Unit (PMU) which successfully managed the recently closed
Bank-funded HIV/AIDS project and numerous Global Fund grants. The PMU will handle day to
day management of the project and will be reinforced with an additional accountant and project
officer. The project will strengthen the NRL and TRAC+ through the recruitment of an
epidemiologist and a microbiologist. The project team, comprising of the project officer,
accountant, epidemiologist, and microbiologist, will ensure effective coordination of project
activities. The team will consist of a project officer, an epidemiologist, a microbiologist, an
information technology expert, an accountant, and an operations officer. The team will work
under the overall guidance of the PS, as well as the head of the TRAC + (Center for Treatment
and Research on AIDS, Malaria, TB, and Other Epidemics, MoH) and the National Reference
Laboratory (NRL) in their technical position as the main sub recipients of the grant. The NRL
will take leadership in laboratory networking and systems development while the TRAC+ will
focus on improving laboratory linkages with integrated disease surveillance. Both the NRL and
TRAC Plus will report directly to the PS and share the technical updates with the PMU which
will be responsible for preparation of consolidated quarterly and annual technical and financial
reports.
9. The Directors General of the NRL and TRAC Plus and Directors of the central teaching
hospitals (CHUK & CHUB) will provide technical oversight for the project and will be
responsible for reviewing and approving the consolidated annual work plan of participating
laboratories as well as the training and procurement plans. At the peripheral level, coordination
in the 5 districts where the satellite labs are located will be achieved by the heads of the subunits
of TRAC Plus working in conjunction with the directors of district hospitals and heads of the
referral and district laboratories. Members of the district coordination teams will include the
hospital director, clinical officer/nurse-in-charge of health centers, environmental health officer
and biotechnologist-in-charge of district laboratory. The risk of having weak core accounting,
reporting at decentralized levels will be addressed by maintaining the fiduciary functions of
100
procurement and FM at the Ministry‘s Project Management Unit which has worked in the recent
past with the district hospitals where the satellite laboratories are located.
10. In Tanzania, no new structures will be established for the proposed project. As is the
case for other Bank funding outside the pooled funds, the project will be fully embedded within
the ongoing coordinated support for the health sector under existing implementation structures of
the MOHSW. The PS will provide overall leadership with day to day management provided by
the Health Sector Reform Secretariat (HSRS) under the Directorate of Policy and Planning
(DPP). An SC, including the Program Manager (NTLP), Assistant Director (Diagnostic
Services), and Assistant Director (Epidemiology and Disease Control), will be established within
the MoH&SW to provide technical direction and oversight and approve the satellite laboratory
annual work plans. The Health Sector Reform Secretariat (HSRS) will be responsible for day to
day project management, FM, procurement, M&E, and preparation of consolidated quarterly and
annual technical and financial reports. A full time project coordinator/public health specialist, an
accountant, and an operations officer/training coordinator, will be appointed and other short-term
consultants would be recruited, as needed.
11. In Uganda, the proposed project will be fully embedded within the MoH, to respect the
Long-Term Institutional Arrangements (LTIA) which aim to strengthen ministry structures and
ensure broad based ownership. The PS, MOH, will have the overall responsibility for the
project. The Assistant Commissioner, National Disease Control, has been designated as the
Project Coordinator and the Head, National TB Program as the Deputy Project Coordinator. A
small Project Coordination Team, comprising of the Head, CPHL; Head, NTRL, and Assistant
Commissioner, Health Services, Epidemiological Surveillance Division, will be established to
lead implementation of their respective components/sub-components under the project. In
addition, it was agreed that a M&E Specialist, and Project Officer would be recruited and would
be accountable to the Project Coordination Team.
12. The MOH Technical Working Group on Communicable Disease Control represented by
the clinical, disease control and planning departments of MoH will provide overall direction for
strengthening health laboratory services, and will review and approve the consolidated annual
work plan for the project. A national technical advisory committee, including DPs, will provide
technical support to the technical working group, and will ensure harmonization of donor inputs
for laboratory services.
Regional Level
13. Institutional framework The East, Central and Southern African Health Community
(ECSA-HC), which has been selected to coordinate project activities at the regional level, aims
to foster regional cooperation in health and to strengthen capacity to address the health needs of
its member states. The institution‘s core mandate is to promote efficiency and relevance in the
provision of health services in the region. To this end, ECSA-HC aims to: (i) offer a regional
platform for governments, professional organizations and the scientific community to promote
cooperation, networking, and joint/cross border actions in health; (ii) establish a regional forum
for learning and information brokerage by promoting the exchange of ideas, and documenting
101
experiences and best practices; and (iii) advocate for greater attention and resources for health
related activities in the region.
14. An assessment of ECSA-HC‘s technical and fiduciary capacities was conducted during
the appraisal mission. The assessment found that the organization is relatively strong, and has
expertise and a good track record in areas of relevance to the proposed project. The details of the
FM and procurement assessments are included in Annex 7 and Annex 8, respectively. The
summary of the technical assessment is provided below.
15. Governance Structure: Established in 1974, ECSA-HC is a regional inter-governmental
organization consisting of 10 member states.49
The ECSA-HC Secretariat is based in Arusha,
Tanzania. The organization was established by the Convention of the Commonwealth Regional
Health Community for East, Central and Southern Africa. ECSA-HC is accorded a similar status
to that granted by the Convention on Privileges and Immunities of the United Nations.
16. The highest governing body is the ECSA-HC Conference of Health Ministers, as well as
the Advisory Committee of Permanent Secretaries of Health of the member states. The technical
advisory structures include: Directors‘ Joint Consultative Committee (committee of Permanent
Secretaries of Health, Directors of Health Services, Deans of Medical Schools, and heads of
research institutions), and Program Experts‘ Committees (technical advisory committees to the
ECSA-HC programs with expertise from member states, program managers, external advisors,
professional associations). The organizational structure is reflective of its function as a
secretariat. It is headed by a Director-General, has 4 directors,50
10 managers51
and 11 officers.
ECSA-HC‘s annual work program is approved by the annual Conference of Health Ministers.
The activities that ECSA-HC will perform in the context of the proposed project have been
discussed and fall within ECSA-HC‘s mandate and governance structure.
17. Institutional Capacity: ECSA-HC combines the skills of a wide range of professionals
in public health, health systems, M&E, and knowledge sharing. The rationale for using
ECSA-HC is based on the availability of this multi-disciplinary and cross cutting set of skills and
particularly on the organization‘s capacities to facilitate knowledge sharing regionally. While
the specific expertise in the area of laboratory strengthening is not housed in ECSA-HC, the
organization will make provisions for recruiting a highly knowledgeable laboratory expert to
support project activities at the regional level. Below are brief summaries of the various areas of
expertise with examples of recent activities relevant to the proposed project.
Monitoring and Evaluation
Mandate: The M&E Program has a dual mandate of supporting Secretariat interventions
through assessing the progress and impact of interventions as enumerated in the Business
49 The member states are: Kenya, Lesotho, Malawi, Mauritius, Seychelles, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. 50 The directors are for: (i) Operations and institutional development; (ii) Finance; (iii) Program management; and (iv) Technical support, research
and training. 51 The managers are for: (i) Monitoring and evaluation; (ii) Business development; (iii) HIV/AIDS, TB and infectious diseases; (iv) Family and
reproductive health; (v) Food security and nutrition; (vi) Non-communicable diseases and health promotion; (vii) Health systems and services
development; (viii) Human resources for health and capacity building; (ix) Pharmaceuticals, equipment and medical supplies; and (x) Research, information and advocacy.
102
and Strategic Plan as well as to assist Member States in implementation of the overall
ECSA-HC Mandate.
Capacity: The M&E Program is headed by a manager who is supported by a program
officer. The manager is an economist with experience in health policy and planning,
health financing, budgeting, project management, and M&E.
Recent Activities: Development of a tool for monitoring the resolutions of the Health
Ministers Conference (HMC). In the recent HMC, member states reported on
implementation of the resolutions and this will be done on an annual basis. In executing
the tool the M&E Framework will be harmonized with other regional frameworks and
also develop a core set of regional indicators for member states to report on. The tool
will form the basis of Regional M&E Expert Core Group meeting in August 2010. The
program has also developed a results-based framework for the implementation of the
ECSA-HC business Plan. ECSA-HC technical programs have also been assisted to
develop and refine the M&E component within their sphere.
Implications for the project: The M&E office is less than 1 year old and has focused
mainly on M&E tool development and implementation of internal M&E. Despite having
well skilled staff, the potential appears underutilized. This offers great opportunity for
the M&E in the project, as well as a potential area of comparative advantage that
ECSA-HC needs to nurture. Because of the multi-country nature of the project,
coordination of M&E implementation and reporting of results is critical.
Human Resources for Health and Capacity Building
Mandate: The mandate of the program is to contribute to capacity development of
Human Resources for Health (HRH) and support countries in strengthening HRH
systems and processes. The mains areas of focus are: curriculum development, training
& capacity building, policy analysis, development, harmonization and standardization of
nursing/midwifery education; and operation research on HRH issues.
Capacity: The program is headed by a Director that oversees a manager, a senior
program officer and several officers. The Director has a doctorate degree, with extensive
experience in HR policy and planning.
Recent Activities: (i) Curriculum development: examples include: midwifery and
women‘s health (in collaboration with the Commonwealth Secretariat and other
universities); fistula care curriculum (with EngenderHealth); family planning update
curriculum (in collaboration with the Capacity Project); (ii) Policy analysis, development
and implementation: examples include: infection control policy guidelines and training
manual. The process involved an initial multi country assessment of existing practices,
followed by a dissemination meeting, prototype policy development, and adaptation at
country level; (iii) Operations research on HRH: examples include: studies on human
resource migration and retention of health workers in the region (in collaboration with the
Regional Network for Equity in Health in East and Southern Africa(EQUINET); task
shifting case studies (Uganda & Swaziland) to inform countries on policy implications (in
collaboration with Health Policy Initiative); human resources for health situation analysis
to identify gaps in HRH to inform planning and management processes; workforce
studies and facility assessment for safe deliveries in Kenya and Tanzania (on-going);
desk review on HRH protocols, approaches and strategies (in collaboration with
103
EQUINET), and documentation of best practices in FP & RH retention policies for HRH
in Tanzania, Uganda and Rwanda; and (iv) Other activities on HRH: within the
coalition of South African Human Capacity Development (SAHCD) design of HIV/AIDS
workplace strategic plan, policy and programs for health sectors in Lesotho and
Swaziland and development and dissemination of the Facilitators Guide for skills transfer
in development of operational policy for Swaziland.
Implications for the project: The experience with HRH and capacity building can be
applied to the area of HRH for laboratories, diagnostics and surveillance. This includes:
developing the framework for a cross country study on HR for laboratory services;
facilitating country-level consultations and studies on curricula, policy analysis,
development of guidelines for implementation and training manuals, prototype policy
development, and adaptation at country level and dissemination meetings.
Health Systems Development
Mandate: The Health Systems and Services Development Program seeks to support and
facilitate activities and initiatives that add value to and positively advance the on-going
process of reforming and strengthening the health sector in member states. The program
operates with the recognition of health care financing constraints, compounded by the
human resource crisis in the health care workforce, and other health system challenges.
Capacity: The program is headed by a manager and assisted by a program officer. The
manager is an economist, with experience in health policy and planning, health financing,
and project management.
Recent Activities: (i) supported the institutionalization of National Health Accounts
(NHA) in the region, through training workshops for health planners (in concepts,
methodology and application of NHA results to health systems performance assessment).
TA to Tanzania and Mauritius to design the various expenditure surveys and analysis of
NHA data; (ii) convened and facilitated (with WHO/Geneva and OECD) a consultation
workshop for the Africa Region, to review and make inputs to the proposed System of
Health Accounts (SHA), which will replace the current NHA Guidelines; (iii) organized
(with WHO/Afro) a regional training on the analysis of efficiency in health care,
introducing a methodology that is currently being used in countries to assess efficiency in
health services; and (iv) Supported the development of an Operational Manual for the
Management of Community-based Health Insurance schemes in the region.
Implications for the project: Some possibilities could be explored for operations
research, notably systematic assessment of expenditure on laboratory services, technical
efficiency of laboratory spending including a comparative analysis of different models of
laboratory services across the participating countries.
18. Institutional Arrangements ECSA-HC will set up a small team to provide oversight at
the regional level. The team will consist of a Senior Laboratory Specialist with a background in
public health, an M&E Specialist who would support ECSA-HC‘s M & E section, and short term
consultants in key areas (e.g. website development, ICT). In addition, the Administrative Officer
being recruited by ECSA-HC will provide administrative support and handle procurement. The
Senior Laboratory Specialist would report directly to the Director General and would coordinate
closely with other sections of the ECSA-HC Secretariat, particularly the M&E, Research,
104
Information and Advocacy, as well as Human Resources for Health, Health Systems, and
HIV/AIDS and TB. The M&E Manager at ECSA-HC will serve as the key focal point for these
activities at the regional level, and will be assisted by an M&E Specialist to be recruited under
the proposed project. The ECSA-HC Secretariat will prepare consolidated semi-annual and
annual project status reports based on inputs from countries and organize annual meetings of
participating countries to discuss key achievements, main issues, and lessons learned, and
facilitate governmental and inter-governmental actions that may be required under the project.
ECSA-HC will establish a Regional Advisory Panel (RAP) to take stock of progress, discuss
challenges, share experiences, and draw lessons, as discussed below.
19. The financing of the activities at the regional level will come from the four participating
countries (Kenya, Rwanda, Tanzania, and Uganda). Each country will sign a Subsidiary
Agreement with ECSA-HC, under terms and conditions approved by the Association, as detailed
in Schedule 2 of the FAs, and Rwanda will also sign a Memorandum of Understanding with
ECSA-HC. The Subsidiary Agreements will stipulate the activities to be carried out and the
financial arrangements between each country and ECSA-HC, namely providing on a grant basis
to ECSA-HC US$125,000 annually or a total of US$625,000 over five years from the proceeds
of each financing agreement. The regional institutional arrangements will be reviewed and
amended, as may be necessary, during the Mid Term Review. The project management structure
is presented below along with the roles and responsibilities of different officers.
105
Project Management Structure
Responsible Officer Roles
Director General Providing overall oversight of the project and maintaining
linkages with countries for effective coordination of the project.
Giving final authorization on utilization of project funds.
Director of Operations and Institutional
Development
Maintaining linkages with collaborating partners and the
Secretariat. Supervising the Administrative Officer
Director of Finance Authorizing and monitoring financial expenditure under the
project, including preparation of IFRs.
Manager, Health Systems and Services
Development
Liaising with country project coordination teams on health system
issues.
Manager, Monitoring and Evaluation
Ensuring overall management of the M&E component of the
project, supporting the network of country M&E officers, and
supervising the M&E program and project officers.
Manager, Research, Information and Advocacy
Coordinating the documentation of case studies and best practices
and disseminating information.
Laboratory Specialist Providing advice and guidance to countries and the Secretariat on
implementation of the project.
Program Officer, M&E
Assisting the M&E Manager and working with project officer on
the implementation of the M&E activities.
Project Officer M&E Tracking and facilitating timely reporting of data monthly,
quarterly and annually.
Procurement Specialist
Executing the procurement function within the project and
assisting with preparation of management reports.
DIRECTOR OF
INSTITUTIONAL
DEVELOPMENT
MANAGER,
M&E
LABORATORY
EXPERT
MANAGER,
HEALTH
SYSTEMS &
SERVICES DEV.
M&E
PROJECT
OFFICER
MANAGER –
RESEARCH,
INFORMATION
&ADVOCACY
ADMINISTRATION
OFFICER/PROCUREMENT
OFFICER
M&E
PROGRAMME
OFFICER
DIRECTOR OF
FINANCE
DIRECTOR - GENERAL
106
20. ECSA-HC will relate with countries at the administrative and technical levels. For all
administrative matters, the Director General will communicate with the Permanent Secretaries in
from each country. At the technical level, ECSA-HC will liaise with the Country Project
Coordination Teams and with each of the Technical Working Groups, especially to ensure that
lessons are properly documented. The laboratory expert will be responsible for all formal
communication with the project teams and working groups. The working groups on Training
and Capacity building, ICT, PBF and Operations Research will relate directly to
ECSA-HC whilst the one Disease Surveillance and Response will relate to the EAC. The
diagram below illustrates the relationship between ECSA-HC, EAC and the countries.
Implementation Plan
21. The ECSA-HC Secretariat has put together an implementation plan for the first year of
the project which was discussed and approved during the appraisal mission. As spelled out in
the plan at project inception, the focus will be on putting in place mechanisms which are pre-
requisites to effective implementation of the project. This will include: recruiting of the
Laboratory Specialist and M&E Officer and procurement of office equipment; establishing a
network of M&E Specialists (a register of the country M&E specialists will be developed,
maintaining and updating on a regular basis by the Secretariat); opening a register of members of
the working groups as well as country focal points; establishing a database for managing and
analyzing information received from countries; creating a web portal to ensure information
related to the project is available immediately to end users and policy makers; developing
TWG -Training
& Capacity
Building
TWG –
ICT/PBF
&MDR-TB
TWG – Lab
Networking
TWG – OR and
Surveillance
Permanent Secretary-
MOH
Kenya, Uganda, Tanzania
and Rwanda
Project Coordination
Team – Kenya, Uganda,
Tanzania and Rwanda
ECSA-HC
SECRETARIAT EAC
SECRETARIAT
WHO
CDC
SADC
Network
of M&E
Specialists
107
standardized tools for collection and reporting of data; and sensitizing the health journalists
network on the existence of the project.
Monitoring and Evaluation (M&E)
22. The M&E component of the project comprises two main functions which are
Coordination (focusing on common reporting requirements and preparation for Joint Annual
Reviews and Medium Term Reviews) and Quality Assurance. The roles and responsibilities of
the ECSA-HC Secretariat with respect to these functions are described in Annex 3.
Regional Advisory Panel (RAP)
23. Mandate: ECSA-HC will establish, within three months after the effectiveness date, a
Regional Advisory Panel to serve as a vehicle for multi-country and multi-stakeholder expert
engagement and dialogue. The RAP will build on the partnerships developed during project
preparation. The Regional Advisory Panel will provide a forum for countries (including those
not participating in the regional project), and their implementing partners to report on overall
program progress and to share scale-up experiences and lessons. The RAP will review periodic
reports from technical partners (including WHO, TB Union, CDC, USAID/TB-CAP) on ongoing
technical support, program coordination and regional learning. The RAP will provide oversight
to inter-country learning and facilitate lesson drawing to enhance the design of the program and
draw policy implications. The multi-disciplinary panel will play an advisory and consultative
role. The RAP will offer countries a scientifically sound consultative and advisory mechanism
to meet the challenge of responding to rising demands for expanded diagnostic tools and
enhanced surveillance capabilities.
24. Composition: RAP participants will include, inter alia, officials from each participating
country (2 to 3 per country depending on the agenda topics); EAC (chair), WHO/Geneva and
WHO/AFRO, USAID/Regional, CDC, and all implementing partners. Membership would be
multi-disciplinary and include African clinicians and experts currently involved in issues related
to: (i) laboratory management; and (ii) diagnostic techniques, quality assurance, disease
surveillance, and M&E, including lab information systems development. Others would be
invited to attend meetings as observers, including officials representing other African countries,
implementing partners, African universities, and international experts.
25. Key Functions: The RAP will be responsible for reviewing: (i) annual reports from
participating countries; (ii) diagnostic and surveillance experiences from non participating
countries; and (iii) quarterly outbreak reports of diseases that have the potential for regional and
global spread. The RAP will provide advice on lessons and experiences and make
recommendations on relevant action for improvement. The advisory panel will focus on the
institutional and policy aspects and technical working groups will address the technical aspects
affecting the quality and effectiveness of laboratory networking. The specific roles and
responsibilities of the RAP will include:
108
Review policy, strategy, and institutional issues, and the organization of public health
laboratory and surveillance services in participating countries, as they relate to the project,
and, in consultation with the WHO, recommend necessary modifications.
Recommend ways of reinforcing partnerships between the respective ministries of health and
the implementing partners, for further scaling up of comprehensive laboratory networking
and integrated disease surveillance.
Provide advice on supporting country efforts to strengthen the technical skills of laboratory
personnel and facilitate networking with regional and international training institutions.
Review and recommend, as needed, relevant technical specifications for equipment and
diagnostics, including other essential laboratory commodities.
Recommend relevant topics for operational research for the East Africa region, review the
designs and results of commissioned studies, field surveillance, and follow-up activities in
participating countries.
109
Annex 7: Financial Management and Disbursement Arrangements
AFRICA: East Africa Public Health Laboratory Networking Project
1. This annex reflects the general aspects of financial and disbursement management
arrangements applicable to the participating countries.
BACKGROUND
2. The World Bank conducted a Financial Management (FM) Assessment of the four
implementing ministries in Kenya, Uganda, Tanzania and Rwanda as well as the East, Central
and Southern Africa Health Community (ECSA-HC). The four implementing ministries are as
follows: Ministry of Public Health and Sanitation (MoPHS) in Kenya that will coordinate project
activities with Ministry of Medical Services (MoMS), Ministry of Health (MoH) & Social
Welfare (MoH&SW) in Tanzania, MoH in Uganda, and the MoH in Rwanda. The assessment
also covered sub-implementing entities (mainly district hospitals) where the satellite laboratories
are located and other institutions involved in the implementation of the project (e.g. KEMSA,
KEMRI) which will receive funds from the implementing agencies.
3. The objective of the assessment was to determine whether: (a) entities have adequate FM
arrangements to ensure project funds will be used for purposes intended in an efficient and
economical way; (b) project financial reports will be prepared in an accurate, reliable, and timely
manner; and (c) entities‘ assets will be safely guarded. The FM assessment was carried out in
accordance with the FM Practices Manual issued by the FM Sector Board on November 3, 2005.
The assessment also complies with the FM Manual for World Bank-Financed Investment
Operations that became effective on March 1, 2010.
COUNTRY ISSUES
4. Public Expenditure and Financial Accountability (PEFA) assessments have been done in
Kenya, Tanzania, Rwanda and Uganda. Notable progress has been achieved in all four countries
related to the adoption of International Public Sector Accounting Standards, Supreme Audit
Institutions being strengthened, and ensuring that there are adequate public financial
management legislation and regulations in place. However, challenges remain to be tackled,
including the need to: (i) strengthen internal audit functions; (ii) ensure there is legislative
scrutiny of external audit reports; (iii) introduce robust integrated financial management
information systems (IFMIS) that can be used for the project to produce accurate and complete
accounts, particularly in Uganda, Tanzania and Kenya; and (iv) strengthen the staffing capacity
of the Supreme Audit Institutions, particularly in Rwanda. All four countries have public
financial management reform programs that are focusing on addressing these challenges.
110
RISK AND MITIGATION TABLE
5. The key risks and mitigation measures stemming from the FM risk assessment are as follows:
Risk Risk Rating Risk Mitigating Measures Residual Risk
Rating
Condition for
Effectiveness
or Negotiation
(Yes/No)?
Inherent Risk
Country Level
Risk arising out of CPIA ratings on Question 13
(Quality of Budgetary and Financial
Management) and Question 16 (Transparency,
Accountability and Corruption in the Public
Sector)
M for Uganda
and Rwanda
S for Tanzania &
Kenya
All countries have Public Financial
Management/Governance Reform Programs under
which these issues are being addressed.
M for Uganda and
Rwanda
S for Tanzania &
Kenya
No
Entity Level
Ministry in Uganda has had difficulties in
implementing donor-funded projects due to
corruption and capacity constraints while in
Tanzania and Rwanda, there are capacity
constraints at the ministries to implement
projects. ECSA-HC has a good track record of
accountability as evidenced from their audit
reports but limited experience in implementing
Bank-funded projects.
In the case of Uganda, one of the hospitals were
the laboratories will be built (i.e., Lacor Hospital)
is a nongovernmental organization that will not be
bound by Government Financial Management
procedures, hence requiring an agreement
between MoH and the hospital to have adequate
financial management arrangements in place.
S for Tanzania,
Rwanda, Uganda
& Kenya
M for ECSA-HC
Uganda to conduct six month internal audit reports
and furnish them to the Association not later than 45
days after the end of such period. In additionn, a
value for money audit will be conducted after the
construction of the laboratories.
Rwanda will use a Project Management Unit to
address the capacity challenges of the ministry while
Uganda will contract a Technical Support Unit to
address the capacity constraints. Tanzania will use
the Health Sector Reform Secretariat within the
ministry to address capacity constraints.
ECSA-HC staff to be trained in Bank Financial
Management and Disbursement Procedures to
strengthen their capacity.
MoH to sign an agreement/MoU with Lacor Hospital
to ensure there are adequate financial management
arrangements in place before funds are disbursed to
the hospital.
S for Tanzania,
Rwanda, Uganda &
Kenya
M for ECSA-HC
No
111
Risk Risk Rating Risk Mitigating Measures Residual Risk
Rating
Condition for
Effectiveness
or Negotiation
(Yes/No)?
Project Level
The project faces potential challenges of
coordinating activities at facilities which are
spread across the countries, and ensuring that the
funds are used for the purposes intended.
S for all
implementing
entities
Adequate Financial Management arrangements have
been put in place to ensure funds are utilized for
purposes intended and ECSA-HC has a good track
record of managing funds.
S for Tanzania &
Kenya, Rwanda &
Uganda
M for ECSA-HC
No
Overall Inherent Risk S for all
implementing
entities
S for Tanzania &
Kenya, Rwanda &
Uganda
M for ECSA-HC
Control Risk
Budgeting: Delays in the preparation and
approval of the budget.
Not monitoring the budget to ensure that only
approved budgeted funds are spent.
M for all
implementing
entities
Budget guidelines have been put in place to ensure
that budgets are prepared and approved on a timely
basis.
The Interim Financial Reports (IFRs) will be used by
both the project management teams and the Bank to
monitor budget compliance.
L for all
implementing entities
No
112
Risk Risk Rating Risk Mitigating Measures Residual Risk
Rating
Condition for
Effectiveness
or Negotiation
(Yes/No)?
Accounting
Kenya: No proper guidelines to account for
project funds, especially those sent to the district
hospitals where the satellite laboratories are
located.
Uganda: Inadequate number of staff in the
ministry to account for project funds.
Rwanda: Heavy work load of the PMU (MOH).
ECSA-HC: Staff does not have experience in
World Bank Financial Management and
Disbursement Guidelines.
Tanzania: The accounting software that will be
used for this project is yet to be fully installed.
S for Kenya &
Uganda
M for Rwanda,
ECSA-HC and
Tanzania
Kenya: Financial Management Manual (FMM)
prepared and will be updated incorporating
suggestions from the Bank.
Uganda to designate a qualified and experienced
accountant to manage the project funds by credit
effectiveness.
Rwanda to recruit a qualified and experienced
project accountant within one month after
effectiveness to further strengthen capacity of the
PMU.
ECSA-HC: Staff will be trained in World Bank
Financial Management and Disbursement
Guidelines.
Tanzania: Installation of the accounting software
should be completed within 6 months after credit
effectiveness.
L for ECSA-HC &
Rwanda
M for Kenya,
Tanzania & Uganda
Yes, Condition
of Effectiveness
only in regard
to Uganda
assigning an
accountant.
113
Risk Risk Rating Risk Mitigating Measures Residual Risk
Rating
Condition for
Effectiveness
or Negotiation
(Yes/No)?
Internal Control and Internal Auditing
Kenya and Tanzania audit committees suffer
from weaknesses and do not take timely effective
action to address audit issues.
The external audit reports of all the ministries
revealed internal control issues (see external audit
arrangements under annex 7).
Kenya: Internal control systems to ensure project
funds are accounted for at the district hospitals
are weak and need to be strengthened to ensure
funds are utilized for purposes intended.
ECSA-HC: Internal control systems (e.g. delays
in retiring staff imprests) identified by external
auditors.
S for Kenya,
Uganda,
Rwanda, and
Tanzania
M for ECSA-HC
Kenya and Tanzania audit committees to be
strengthened through ongoing Public Financial
Management programs. The Bank will also liaise
with the ministries to work with the audit committees
to strengthen their capacity.
Internal audit units will regularly conduct audits to
review the internal control systems. Issues arising
will be monitored by the Bank to ensure they are
addressed.
Kenya: Financial Management Manual (FMM)
prepared and will be updated incorporating
suggestions from the Bank.
ECSA-HC: The Interim Financial Reports (IFRs)
will be designed to include an ageing analysis
schedule that will facilitate the monitoring of the
accountability of advances.
S for Kenya, Uganda,
Rwanda, and
Tanzania
M for ECSA-HC
No
Funds Flow
Slow disbursements to the project beneficiary
institutions.
S for all
implementing
entities
Bottlenecks leading to slow disbursements will be
identified and addressed through training on
Procurement, Financial Management and
Disbursement Guidelines. There will also be regular
meetings with the Disbursement Center team through
video conferences to address long outstanding issues.
M for all
implementing entities
No
Financial Reporting
Delays in the submission of IFRs due to delays in
getting financial reports at sub-national level
(where the laboratories are) which are required
for consolidation of the IFRs sent to the Bank.
S for Kenya,
Uganda,
Rwanda, and
Tanzania
M for ECSA-HC
Staff at national and sub-national levels will be
trained in financial reporting and the format of the
IFRs was agreed prior to negotiations.
M Kenya, Uganda,
Rwanda, and
Tanzania
L for ECSA-HC
No
114
Risk Risk Rating Risk Mitigating Measures Residual Risk
Rating
Condition for
Effectiveness
or Negotiation
(Yes/No)?
Auditing
Quality of the audits may not be acceptable to the
Bank and audit reports may be received after the
due date.
Capacity constraints of the Supreme Audit
Institutions to conduct audits (e.g. in Rwanda).
S for all
implementing
entities
Audit ToRs were agreed with the Bank by
negotiations, defining the quality of the audit
expected by the Bank.
Recipients to use private external audit firms
acceptable to the Bank determined through a quality
review process, in cases where a firm has been sub-
contracted by the Supreme Audit Institution.
The capacity of the Supreme Audit Institutions is to
be strengthened under the respective countries Public
Reform Program. In the interim, acceptable private
audit firms can be hired to conduct the audits.
M for all
implementing entities
No
Overall Control Risk S for all
implementing
entities
S for Tanzania &
Kenya,
Rwanda & Uganda
M for ECSA-HC
Overall Risk Rating
S for all
implementing
entities
S for Tanzania &
Kenya,
Rwanda & Uganda
M for ECSA-HC
H – High S – Substantial M – Modest L – Low
115
6. The action plan below indicates the actions to be taken by the participating countries to strengthen financial management
systems and the dates that they are due to be completed by.
Action Date due by Responsible
1 Financial Management Manual for the project
was shared and it will be further updated
incorporating feedback from the Bank team.
This will include the FM arrangements for the
district hospitals where the satellite
laboratories are based.
FM manual submitted to the Bank
and being finalized based on
comments received from the Bank.
Kenya (MoPHS)
2 Rwanda to recruit and Uganda to designate a
qualified and experienced accountant for the
project.
Effectiveness (Uganda)
Within one month after effectiveness
(Rwanda)
Uganda (MoH) & Rwanda (MoH)
3 Prepare and submit to the Association six-
month internal audit reports.
During implementation: 45 days after
the end of each 6-month period.
Uganda (MoH) and Inspectorate & Internal
Audit department of MOFPED
4 Finalize the installation of the ACPACK
accounting information system in Tanzania
Within 6 months after effectiveness. Tanzania (MoHSW)
5 Strengthen the capacities of the audit
committees in the MoHSW in Tanzania and
the MoPHS in Kenya to take timely and
effective action in addressing audit issues.
During project implementation. Tanzania (MoHSW) & Kenya (MoPHS) &
6 Train ECSA accounting staff in World Bank
Financial Management & Disbursement
Guidelines to strengthen their capacity.
During implementation. ECSA
7 Open Designated and Project Accounts and
communicate the account details to IDA,
including the signatories.
During implementation. Kenya (MoPHS), Tanzania (MoHSW),
Uganda (MoH), Rwanda (MoH) & ECSA-
HC
8 Conduct one value for money audit after the
construction of laboratories in Uganda.
During implementation. Uganda (MoH)
9 Sign an agreement/MoU between Uganda
(MoH) and Lacor Hospital to ensure adequate
financial management arrangements are in
place before funds are disbursed to the
hospital.
During implementation. Uganda (MoH) and Lacor Hospital
116
INSTITUTIONAL AND IMPLEMENTATION ARRANGEMENTS
7. The implementing ministries in Uganda, Kenya, Tanzania and Rwanda and ECSA-HC
will coordinate project activities and handle:
Procurement, including purchase of goods, works, and consulting services;
Project monitoring, reporting and evaluation;
Contractual relationships with IDA and other co-financiers; and
FM and record keeping, accounts, and disbursements.
8. The PS of these four ministries and ECSA-HC Director General will be the ―Accounting
Officers‖ for their respective parts of the project, assuming the overall responsibility for
accounting of project funds. Each of the four participating countries will contribute US$125,000
annually or a total of $625,000 over the life of the project to ECSA-HC.
FINANCIAL MANAGEMENT ARRANGEMENTS
Budgeting Arrangements
9. Budget preparation and management will be conducted by the respective implementing
ministries at the national level, and by ECSA-HC at the regional level. All implementing
ministries and ECSA-HC have adequate staff to prepare budgets and well defined budgeting
procedures/guidelines. Annual work plans and budgets will be prepared by the satellite
laboratories and other key beneficiary institutions. The budgeting arrangements in the
implementing entities are deemed adequate but there are potential risks stemming from delays in
the preparation and approval of budgets and in budget monitoring.
Accounting Arrangements
Kenya
10. Financial Management Manual: In addition to the Government Financial Regulations
and Procedures used by MoPHS, the project will update the FM Procedures Manual, in form and
content satisfactory to IDA, to incorporate the Bank‘s financial management arrangements for
the district hospitals. The manual will also include requirements for opening a project account in
a commercial bank acceptable to IDA for the funds received by the district hospitals, allowing
both the internal and external auditors to conduct audits of the project funds. The manual will
provide guidelines on maintaining proper accounting records, and preparing and submitting
quarterly IFRs to the Ministry within 30 days after the end of every calendar quarter. The manual
will describe the implementing, institutional, and financial management arrangements (e.g.
budgeting, funds flow, accounting, internal control, financial reporting and audit arrangements),
transparency, social accountability and corruption prevention and risk management mechanisms,
as per Treasury Circular No. 3/2009 on development and implementation of IRMPF. A capacity
building training workshop will be conducted for project teams from all the implementing
agencies on the FM Procedures Manual and the World Bank‘s FM and disbursement procedures.
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11. Staffing: The MoPHS has designated a Project Accountant to handle all FM
arrangements for the project, including maintaining proper books of accounts, preparing the
financial reports, and ensuring that these are submitted to IDA within the stipulated deadlines, in
content and form satisfactory to IDA. The project accountant will consolidate the IFRs based on
IFR returns received from the district hospitals and other implementing institutions. The
accountant will work under the supervision of MoPHS‘s Principal Accounts Controller (PAC)
and the Director, of the Department of Disease Prevention and Control, who will be responsible
for quality assurance review of all financial reports before these are submitted to IDA within the
stipulated deadlines. The designated accountant will give priority to discharging the project
accounting duties but would be available to perform any other accounting duties within the
Ministry under the direction of the PAC. The duties and responsibilities of the project accountant
will be clearly defined in the FM Manual. District hospitals, KEMRI and KEMSA have adequate
accounting capacities to handle the project funds. Funds disbursed to the district hospitals,
KEMRI and KEMSA will be based on the government budgetary imprest system where
advanced funds have to be accounted for, before the next advance is sent.
12. Information System: MoPHS is using the Integrated Financial Management
Information System (IFMIS) to produce its accounts but the Controller and Auditor General have
raised issues about the quality of accounts produced by the IFMIS, which will be mitigated by
MoPHS producing accounts for this project using Microsoft Excel which is adequate until such a
time when the IFMIS issues will have been addressed.
13. Fixed Asset Register: Fixed assets of the MoPHS are monitored by the Ministry of
Public Works that maintains a register. A Board of Surveys does annual reviews to update the
register. The fixed (non-current) assets of this project will have to be monitored by a fixed asset
register that MoPHS will maintain for the project.
Uganda
14. Financial Management Manual: The Government‘s Treasury Accounting Instructions
issued under the 2003 Public Finance and Accountability Act will be used by the MoH to
account for the project funds. Under Section 230 of the Treasury Accounting Instructions, the
regional hospitals where the laboratories are situated will be mandated to account for the project
funds. In the case of the Lacor Hospital an agreement will be signed as the NGO-managed
facility is not subject to government accounting procedures.
15. Staffing: The Ministry is staffed with qualified and experienced accounting personnel
(i.e. 4 accountants and 5 accounts assistants), but due to excess work load, the project‘s accounts
will be prepared by a designated qualified and experienced accountant who will report to the
Assistant Commissioner who in turn reports to the Under Secretary and ultimately to the PS.
The designated accountant will be assisted by an accounts assistant. The regional hospitals
supported under the project have accountants to account for the project funds. These accountants
report to the Medical Superintendants who are the accounting officers of the hospitals. Small
amounts of funds (less than US$50,000 per year) will be disbursed to the satellite laboratories
based on tranche payments using an imprest system where advanced funds have to be accounted
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for first before the next advance is sent to the laboratory based on agreed work plans and
budgets.
16. Information System: The ministry is connected to the IFMS but the project module is
still being developed and will not be used to account for the project funds. The MoH will
therefore prepare the accounts for the project using its Navision Accounting software. Staff in
MoH is conversant in preparing the accounts using this accounting software.
17. Fixed Asset Register: A fixed asset register for the project will be maintained to record
and monitor the fixed assets of this project.
Rwanda
18. Financial Management Manual: MoH Project Management Unit (PMU) has a
Financial Management Manual (FMM) that it uses for its projects that is adequate for this
project. The FMM will be complemented by the Government‘s Financial Instructions Manual
which under Para. 1.2.1,Volume I includes arrangements for handling funds at district hospitals
in the public sector.
19. Staffing: The capacity of the FM team of the PMU was weakened due to reduction of
personnel following the closing of the Bank-funded HIV/AIDS Multi-Sectoral Project. The
PMU will be strengthened through the recruitment, within one month after effectiveness, of a
project accountant who will work under the Finance Manager of the PMU who will have the
overall oversight for the project funding. The Finance Manager will account for project funds
until the accountant is recruited. They will be assisted by the finance teams at the National
Reference Laboratory and at the district hospitals to account for project funds. Small amounts of
funds (less than US$50,000 per year) will be disbursed to the satellite laboratories based on
tranche payments using an imprest system where advanced funds have to be accounted for before
the next advance is sent to the laboratory based on agreed work plans and budgets.
20. Information System: The PMU currently uses the TOMPRO accounting software
which will be used to maintain the project books of accounts.
21. Fixed Asset Register: The PMU maintains a fixed asset register that will be used to
monitor the fixed assets of the project.
Tanzania
22. Financial Management Manual: The Health Sector Reform Secretariat (HSRS) uses
accounting policies and procedures which are spelled out in the Government Accounting Manual
developed by the Accountant General of Tanzania. The laboratories that are based in
national/regional hospitals will receive and account for their funds at the regional level (sub
Treasury) which also follow the same policies and procedures. For faith-based hospitals (i.e.
Ndanda Hospital), the current government financial mechanisms related to faith based hospitals
will apply. The beneficiary hospitals will open a sub-account at their appropriate level.
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23. Staffing: The PS of the ministry takes full fiduciary responsibility as the accounting
officer while the day-to-day financial operations are overseen by the Chief Accountant and the
Director of Policy Planning. A Project Coordinator and a Project Accountant will be responsible
for the operations and accountability for the project funds. The existing accountant has
previously worked on Bank funded projects for seven years and is considered adequate. The
regional hospitals to have adequate accounting staff. Funds disbursed to the regional hospitals
under the project will be based on the government budgetary imprest system where advanced
funds have to be accounted for before the next advance is sent.
24. Information System: The HSRS uses mainly the government IFMS accounting system
for consolidated fund transactions. The Ministry is in the process of installing the customized
ACPACK software that can interface with the IFMS system, in order to reduce transaction costs
and facilitate reporting for projects. The ACPACK should be live and running within 6 months
after credit effectiveness.
25. Fixed Asset Register: A fixed asset register will be maintained to record and monitor
the fixed assets of this project.
ECSA-HC
26. Financial Management Manual: ECSA-HC‘s accounting policies and procedures are
documented in the Accounting Policies and Procedures Manual. This manual was reviewed and
found to be adequate.
27. Staffing: The Director of Finance will take full fiduciary responsibility as the accounting
officer. The existing finance function has well qualified and experienced staff. However, they
have limited prior experience with World Bank Financed Projects. Accounting staff will be
trained in the Bank‘s financial reporting and disbursement procedures early during
implementation phase.
28. Information System: ECSA-HC operates the Advanced Accounting V6.1 software
which will be used for this project. This accounting package is capable of producing separate
ledgers for each project that ECSA-HC undertakes. It is also capable of handling budget and
computing variances. The accounting software may not be configured to produce IFRs for the
project. As a mitigation measure, ECSA-HC will export project accounts to Microsoft excel to
prepare IFRs in the format agreed with the Bank.
29. Fixed Asset Register: A fixed asset register will be maintained to record and monitor
the fixed assets of this project.
Internal Controls and Internal Audit Arrangements
Kenya
30. Internal Control Systems: The internal control arrangements in the MOPHS and
KEMRI are deemed satisfactory, as seen in the Government Financial Regulations and
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Procedures and Financial & Accounting Procedures Manual respectively. The approval and
authorization controls over payments are deemed sufficient. Fixed asset registers are maintained
and regularly updated. The fixed assets are adequately insured. There is adequate segregation of
duties in the accounts sections. The FM Manual will include internal control procedures for
district hospitals to ensure accountability of project funds.
31. Internal Auditing: The Ministry of Finance (Treasury) will ensure semi-annual internal
audits on the project are done using a risk based approach in conducting their audits. The
laboratories in the districts and at the national level have adequate internal controls and are
subject to regular internal audit checks by the respective ministries‘ internal audit units. The
internal auditors will make periodic visits to the district hospitals to review project records and
documents including payment vouchers, IFRs, cashbook, ledgers, withdrawal applications, and
procurement contracts.
32. Ministerial Audit Committee and Health Facilities Management Committees
(HFMC): The Audit Committee is properly constituted in the MoPHS in line with Treasury
Circular No.16 of 2005 (on setting up of oversight Committees). However, the audit
committee‘s capacity needs to be strengthened to be able to effectively review and take
appropriate follow up action on audit reports related to the project. In addition, the district
hospitals receiving project funds will be required to set up functioning HFMC‘s in line with the
HSSF Regulations.
33. Institutional Risk Management Policy Framework (IRMPF): Government has issued
Treasury Circular No. 3/2009, which makes it mandatory for all public institutions in Kenya to
develop and implement a risk management framework. The exercise is spearheaded by the
Internal Audit Department of Treasury. The procedures for implementation of the IRMPF will
be contained in the updated FM Procedures Manual. It will include transparency, corruption
prevention and social accountability arrangements such as:
a) Public disclosure of information regarding: (i) activities funded under the project; (ii)
periodic resource appropriation and accountability; (iii) project implementation progress
and operational results; and (iv) sharing of best practice experiences amongst beneficiary
entities. These are expected to be prominently disclosed, including through the media.
b) Complaint handling mechanisms: Anti-corruption hotlines including toll free
communication lines and other complaint handling mechanisms are expected to be
established/strengthened with explicit arrangements for collation of information,
follow-up action, and public reporting. The Internal Auditors will have follow up
responsibilities and the work will be overseen by the Ministry Audit Committee.
Uganda
34. Internal Controls: The Government‘s Treasury Accounting Instructions 2003 fall short
on external auditing and financial reporting requirements spelled out in the Financing
Agreement. A section in the Project Implementation Manual (PIM) on Financial Management
will describe the accounting system used especially for accounting for the funds disbursed to
district hospitals. This section will also contain major transaction cycles of the project; funds
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flow mechanisms; accounting records, supporting documents and specific accounts in the
financial statements involved in the processing of transactions; the list of accounting codes used
to group transactions (chart of accounts); the accounting processes from the initiation of a
transaction to its inclusion in the financial statements; authorization procedures for transactions;
the financial reporting process used to prepare the financial statements, including significant
accounting estimates and disclosures; financial and accounting policies for the project; budgeting
procedures; financial forecasting procedures; procurement and contract administration
monitoring procedures; procedures undertaken for the replenishment of the Designated Account;
and auditing arrangements.
35. Internal Audit: The Ministry has qualified and experienced internal auditors ( i.e., a
Senior Internal Auditor and an Internal Auditor). The Senior Internal Auditor in the ministry
reports to the Accounting Officer who is the PS although reforms are underway to ensure
internal auditors report to a sector Audit Committee. The internal audit unit issues reports on a
quarterly basis based on their review of the internal control system of the ministry and the
management at the ministry takes action on the report. The commissioner Internal Audit and
Inspectorate in the Ministry of Finance, Planning and Economic Development (MoFPED) also
receives copies of the audit reports for monitoring purposes. The Ministry agreed to incorporate
the project into their internal audit work plan. The qualification and experience of the staff in the
unit is adequate and their quality assurance is monitored by the MoFPED under the
Commissioner Internal Audit. In this regard, the internal audit arrangements at the ministry are
adequate. For the purposes of this project, the internal audit unit will conduct six month internal
audits and provide reports within 45 days after the reporting period, as stipulated in the
Financing Agreement.
Rwanda
36. Internal Controls: The PMUt internal controls are documented in the existing Financial
Management Manual. The accounting systems, policies and procedures employed by the PMU
will be complemented with financial instructions alongside the Organic Budget Law that was
issued under the PFM reforms and will document specific procedures for budgeting, accounting
systems, internal controls, funds flow, reporting and auditing, depicting document and
transaction flows, the appropriate filing of project documents, management approvals and
organizational duties and responsibilities. The accounting system will consist of methods and
records established to identify, analyze, classify, record and report the transactions of a project,
and to maintain accountability for the related assets and liabilities. The aspects to be covered in
the Financial Management manual will include: (i) flow of funds; (ii) financial and accounting
policies; (iii) accounting system (including centers for maintenance of accounting records, Chart
of Accounts, formats of books and records, accounting and financial procedures); (iv) procedures
for authorization of transactions, budgeting, and financial forecasting; (v) financial reporting
(including formats of reports, linkages with Chart of Accounts and procedures for reviewing
financial information); (vi) auditing arrangements; and (vii) aspects of human resources.
37. Internal Audit: The internal audit function is currently established in the PMU. The unit
will include in its plan at least once a year and depending on the risk level an audit of this
project. The audit will be carried out in accordance with internationally accepted auditing
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standards using a risk based approach. The internal auditors will conduct reviews which will
include ex post verification of expenditure eligibility, as well as physical inspection of works and
goods acquired during its implementation. The findings and recommendations of the Internal
Auditors will be used by this project to improve its implementation in areas related to financial
management and procurement.
Tanzania
38. Internal Controls: The financial accounting policies and procedures in place are
sufficient to ensure that the project complies with the relevant Bank policies (OP/BP 10.02).
These include the establishment of internal controls and proper accounting procedures which are
documented in the Government Accounting Manual. In line with government accounting, the
project accounts and transactions will be prepared on a cash basis.
39. Internal Audit: It is noted that each ministry has its own internal audit function.
Currently, MoH&SW has increased its internal audit staffing from seven to about 25 due to
increased activities. They are mandated to carry out quarterly internal audits. Formal
arrangements need to be made by the Project Coordinator to ensure the Internal Audit
department of the Ministry includes the project in their annual work plans. According to the
internal audit regulation, the audit committee should ensure that audit queries‘ are being
implemented in a timely manner but this has not been the case during the implementation of the
Health Sector Reform Project.
ECSA-HC
40. Internal Controls: The Accounting Policies and Procedures Manual was reviewed and
covers the following items: accounting policies, budgetary process, financial accounting, control
over accountable and security documents, operations of bank accounts, petty cash, procurement
of goods and services, payroll, travel imprests, salary advances, car and household loans,
operating assets control, award and monitoring of sub-grants, accounting for stores, controls over
telephone, faxes, motor vehicles and postage costs, month and year end procedures, the list of
accounting codes used to group transactions (chart of accounts); the accounting processes from
the initiation of a transaction to its inclusion in the financial statements; authorization procedures
for transactions; the financial reporting process used to prepare the annual financial statements
and the monthly management accounts, significant accounting estimates and disclosures;
financial and accounting policies and auditing arrangements.
41. Internal Audit: ECSA-HC has a financial advisor who is their internal auditor. The
advisor is required to undertake two audit visits each year and submit his reports to the Advisory
Committee (Effectively the board of directors). The latest audit report for the period ended June
2009 was found to be generally satisfactory except for the delay in retiring advances (imprest)
that will be addressed through having an ageing analysis of advances to monitor the retirements
in the IFRs. Ernst & Young, the auditors issued a clean (unqualified) opinion.
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Flow of Funds and Disbursement Arrangements
42. The project shall adopt the report-based method of disbursement by use of quarterly IFRs
for Kenya, Tanzania and Uganda and use of the traditional transaction method using Statement
of Expenditure (SOE) for Rwanda. ECSA-HC will receive funds for the project from the four
countries. Each of the implementing ministries will open a Designated and Project account
which are to be communicated to the IDA within one month after effectiveness. Counterpart
funds for the project received from government can be deposited into the project account.
IDA Disbursement methods
43. Report-based Disbursements: IDA disbursements will be made into the respective
Designated Accounts for Uganda, Kenya and Tanzania based on quarterly IFRs which would
provide actual expenditure for the preceding quarter and cash flow projections for the next 2
quarters (i.e. 6 months). Initial cash flow forecasts upon which the advance disbursement will be
made from the IDA Credit should be prepared within one month after the date of effectiveness.
A duly authorized Withdrawal Application for the additional cash replenishment required into
the Designated Account will be provided along with the IFRs. The IFRs together with the
Withdrawal Applications (WAs) will be reviewed by the Bank‘s Financial Management
Specialist (FMS) and approved by the Task Team Leader (TTL) before the request for
disbursement is processed by the Bank‘s Loan Department. These withdrawal requests and IFRs
need to be submitted to the Bank within 45 days after the end of the quarterly period (3 months).
The report based method will always allow the project to have buffer funds for a 3-month period
given that it is made every 3 months and the cash flow projections are for 6 months. The cash
flow projections will be supported by work plans as well as the procurement plan.
44. Statement of Expenditures (SOEs): Upon grant effectiveness, the MoH of Rwanda
will be required to submit a withdrawal application for an initial advance to the Designated
Account, drawn from IDA, up to the ceiling of the Designated Account. Replenishment of funds
from IDA to the Designated Account will be made upon evidence of satisfactory utilization of
the advance, reflected in SOEs and/or on full documentation for payments above SOE
thresholds. Replenishment applications would be required to be submitted regularly on a
monthly basis.
45. Other Methods: In addition, whenever needed, the direct payment method of
disbursement, involving direct payments to suppliers for works, goods and services upon the
borrower‘s request, may also be used. Payments may also be made to a commercial bank/central
bank for expenditures against pre-agreed special commitments. These payments will also be
reported in quarterly IFRs. The IDA Disbursement Letter will stipulate the minimum application
value for direct payment and special commitment procedures as well as detailed procedures to be
complied with under these disbursement arrangements including those in regard to
reimbursements.
46. Remedies for non-compliance: If ineligible expenditures are found to have been made
from the Designated and Project Account, the borrower will be obligated to refund the same. If
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the Designated Account remains inactive for more than six months, IDA may reduce the amount
advanced. IDA will have the right, as reflected in the terms of the Financing Agreement, to
suspend disbursement of the funds if significant conditions, including reporting requirements, are
not complied with.
Funds Flow Arrangements
Kenya
47. Funds Flow Arrangements: The IDA funds will be deposited in a dollar denominated
Designated Account (DA) opened by Treasury in a commercial bank, acceptable to IDA.
Treasury will transfer some of the funds in the DA to ECSA-HC to support regional coordination
of the project. MOPHS will open a separate Project Account in Kenya shillings into which
Treasury will transfer funds based on their respective 6 month cash forecasts and their budgets
prepared for specific project activities in consultation with the MOMS, and approved by the
Project Coordination Committee. MOPHS will transfer funds for laboratories to the Centers of
Excellence (5 district hospitals & Nairobi based National Public Health Laboratories) and bank
accounts specific to the project should be opened for this purpose. MOPHS will also transfer
funds to KEMRI and KEMSA into a project account opened for the purpose of this project.
48. Bank Signatories: The DA will be operated as per the existing GoK Financial
Procedures and Regulations. The Ministry Project Accounts will have the following two
mandatory signatories. The categories of signatories are as follows:
Category 1: Accounting Officer The PS MOPHS as the Accounting Officer, in consultation with PS, MOMS, shall
delegate this responsibility to his designated representative who shall be the Director
DDC and the Project Manager; and
Category 2: Accounts Department Staff:
o The Principal Accounts Controller (PAC), or
o Any of the 3 designated Ministry accountants as per existing Government Financial
Regulations.
49. Any 2 signatories one from each category, will sign a cheque for making payments for
the Project.
50. The signatories for KEMRI‘s and KEMSA‘s project accounts should also be
communicated to the MoPHS and copied to the Bank when the project account is opened. These
signatories should be in accordance with their Financial & Accounting Procedures Manual.
Uganda
51. The following bank accounts will be authorized by the MoFPED and maintained by the
MoH for purposes of implementing the project:
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Designated Account (DA): Denominated in US dollars where disbursements from the
IDA will be deposited. ECSA-HC funds will be paid from this account.
Project Account: This will be denominated in local currency. Transfers from the
Designated Account (for payment of transactions in local currency) will be deposited on
this account in accordance with project objectives.
52. These bank accounts shall be opened at Bank of Uganda in accordance with the
Financing Agreement. The signatories for the Designated and Project Accounts will be in
accordance with the Treasury Accounting Instructions/Public Finance and Accountability Act,
2003. Payments will be approved and signed by the Accounting Officer (Permanent Secretary)
as the principal signatory and the person designated by the Accountant General who in this case
is the Principal Accountant. Disbursements to the regional hospitals will have to be made into a
project account opened in a commercial bank acceptable to IDA and signatories should be
communicated to the MoH and copied to the Bank (IDA). An MOU will be signed between
MOH and Lacor Hospital, before disbursing funds to them, with similar treasury instructions on
advances/accountability as it is a non-government independent hospital.
Rwanda
53. The following bank accounts will be opened by the MoH at the National Bank of Rwanda
for purposes of implementing the project:
Designated Account (DA): Denominated in US dollars where disbursements from the
IDA will be deposited. ECSA-HC funds will be paid from this account. The ceiling of
the DA is US$ 1 million equivalent to four months of forecasted project expenditures.
Project Account: This will be denominated in local currency. Transfers from the
Designated Account (for payment of transactions in local currency) will be deposited on
this account in accordance with project objectives.
54. Disbursements to the district hospitals will be made to project accounts opened in
commercial banks acceptable to IDA. The signatories to these accounts should be
communicated to the MoH copied to the Bank. Each hospital should have an accountant to
account for the project‘s funds in order to receive project funds.
Tanzania
55. MoH&SW will open a designated bank account denominated in United State Dollars
authorized by the Ministry of Finance at the Bank of Tanzania. The MoHSW will open an
operations account in local currency at a commercial bank acceptable to the Bank of Tanzania
and to IDA. ECSA-HC funds will be paid from the Designated Account. An operations account
denominated in local currency will also be opened in the same bank to handle payments made in
local currency. Most of the payments made under the project will be made centrally from the
MoH&SW, except for minimal amounts of funds advanced/transferred to the Centers of
Excellence or regional offices that contain the sub-project accounts for the hospitals with
laboratories engaged with this project. Existing channels will be used by the ministry to transfer
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funds to these entities. These regional offices will make their payments and submit monthly
accountabilities to the ministry head office.
56. Bank Signatories to the Designated Account will be operated under the existing
Government Financial Procedures and Regulations issued by Treasury. The Project Account
will have the following two mandatory signatories:
Category A: 1 -Chief Accountant Officer 2 -Director Policy Planning
Category B: 1 –Program Manager 2 –Head of Budget Section
ECSA-HC
57. ECSA-HC will open a project bank account denominated in United States Dollars at a
commercial bank acceptable to the Bank. An operations account denominated in local currency
may be opened in the same bank to handle payments made in local currency. Bank Signatories to
the Project Account will be operated under the existing ECSA-HC Accounting Policies and
Procedures Manual.
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Kenya Funds Flow Diagram
IDA
Designated Account - Treasury
ECSA Transfer MOPHS Project account
(PA)
Laboratories
5 Districts/Nairobi Public
Health Laboratories
KEMRI and KEMSA
(PA)
PAYMENTS FOR GOODS, SERVICES AND
CONSULTANCIES
Project Coordination
Committee Approval
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Uganda, Rwanda and Tanzania Funds Flow Diagram
ECSA-HC Funds Flow Diagram
Designated Accounts for
Uganda, Tanzania, Kenya and
Rwanda
Project Account (United
States Dollars)
Project Account (Local
Currency)
Project transactions paid in either United States Dollars or Local
Currency
Acco
untab
ility
IDA Government
Counterpart
Funds
Designated Account
(United States Dollars)
Project Account (Local
Currency)
Funds sent to Centers of Excellence and payments from the ministries for project
transactions paid in either United States Dollars or Local Currency. Transfers to
ECSA will be paid from the Designated Account of the respective countries.
Acco
untab
ility
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Financial Reporting Arrangements
58. Quarterly unaudited IFRs will be produced for all the 4 implementing ministries and
ECSA-HC. The IFRs are to be produced and submitted to the Bank within 45 days after the end
of the calendar quarterly period. The IFRs are to be produced in a form and content satisfactory
to IDA. All the IFRs formats for all the primary implementing entities have been agreed with the
Bank during negotiations.
59. The IFRs submitted to the Bank will have a section on Financial Reporting and
Disbursement containing the following:
Reporting Section includes:
Statement of Sources and Uses of Funds; and
Statement of Uses of Funds by Project Activity/Component.
Disbursement Section which is only for implementing entities using the report based method of
disbursement includes:
Designated Account (DA) Activity Statement;
Bank Statements for both the Designated and Project Account;
Summary Statement of DA Expenditures for Contracts subject to Prior Review; and
Summary Statement of DA Expenditures not subject to Prior Review.
60. Each of the primary implementing entities will also prepare the project‘s annual
accounts/financial statements within 3 months after the end of the accounting/fiscal year in
accordance with accounting standards acceptable to the Bank. All primary implementing entities
are preparing their accounts in accordance with International Public Sector Accounting
Standards.
61. The accounts/ financial statements will comprise of:
A Statement of Sources and Uses of Funds / Cash Receipts and Payments which
recognizes all cash receipts, cash payments and cash balances controlled by the entity;
and separately identifies payments by third parties on behalf of the entity.
The Accounting Policies Adopted and Explanatory Notes. The explanatory notes
should be presented in a systematic manner with items on the Statement of Cash
Receipts and Payments being cross referenced to any related information in the notes.
Examples of this information include a summary of fixed assets by category of assets,
and a summary of SOE Withdrawal Schedule, listing individual withdrawal
applications; and
A Management Assertion that Bank funds have been expended in accordance with
the intended purposes as specified in the relevant World Bank legal agreement.
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62. Indicative formats of these statements will be developed in accordance with IDA
requirements and agreed with the Country Financial Management Specialist.
External Auditing Arrangements
63. The Supreme Audit Institutions of Kenya, Tanzania, Rwanda and Uganda are primarily
responsible for the auditing of all their respective ministries implementing this project. Usually,
the audit is subcontracted to a firm of private auditors, with the final report being issued by the
Supreme Audit Institution, based on the tests carried out by the subcontracted firm. In case the
audit is subcontracted to a firm of private auditors, IDA funding may be used to pay the cost of
the audit. In the case of ECSA-HC, the Board will have to appoint a private external audit firm
while in the case of Rwanda an independent external auditor will have to be appointed for the
project not later than three months after effectiveness. The private external auditors have to be
acceptable to the IDA. The audits are done in accordance with International Standards on
Auditing.
64. The audit reports along with management letters are to be submitted to IDA within six
months after the end of each financial year. The audit reports for the project may be
consolidated into the entity accounts provided there are adequate notes disclosing the sources
and uses of IDA funds and reconciliation of the Designated Account. The terms of reference for
the audit have been communicated by all the four implementing ministries and ECSA-HC and
agreed with IDA during negotiations. The Bank encourages the project‘s audit reports to be
disclosed to the public in the spirit of being transparent.
65. A review of the external audit reports for the ministries for the year ended 30 June 2008
in Tanzania (unqualified opinion with emphasis of the matter), Kenya (opinion not disclosed),
Rwanda (qualified opinion) and Uganda (except for qualified opinion) revealed a number of
internal control issues that will need to be addressed in order to strengthen the internal control
systems. These ranged from: Uganda (accountability of advances & unexplained disposals of
public assets); Rwanda (weaknesses in management of bank accounts with long outstanding
unreconciled differences and lack of segregation of duties leading to misappropriation of funds);
Tanzania (significant amounts of unsupported payment vouchers –T.Shs 1,780 million); and
Kenya (unreconciled differences between the appropriation account and the accounts ledger).
Mitigation measures that will be put in place to address these issues include having a strong
internal audit function to regularly audit the system and flag the issues arising to management to
follow up and address. In Uganda at least one Value for Money audit will be carried out on
Laboratories after construction to ensure that project funds are utilized for purposes intended.
The review of the ECSA-HC audit reports did not flag any significant internal control issues
except for the delays in the accountability of staff advances which will be addressed through
monitoring the accountability of advances using an ageing analysis table that will be included in
the IFRs.
66. The audit reports and due dates that will be required by Kenya (MoPHS and MOMS),
Uganda (MoH), Rwanda (MoH), Tanzania (MoH&SW) and ECSA-HC are as follows:
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Audit Report Due Date
Project audited annual financial statements (that include
a note on the Designated Account‘s reconciliation and
other accounting policies disclosure) and Management
Letter.
Submitted within six months after the end of each
fiscal/financial year.
CONDITIONALITY
Negotiation Conditions
67. For all implementing entities, there were two negotiation conditions that were complied
with, namely to: (i) prepare and agree the IFR format with the Bank;
(ii) prepare and agree the audit Terms of Reference for the project with the Bank. Both
documents were attached to the minutes of negotiations.
Effectiveness Conditions
68. Uganda: The Recipient has assigned to the MoH an accountant, with qualifications, experience
and terms of reference satisfactory to the Association, to manage the project accounts.
69. Dated Covenants
Uganda
The Recipient shall prepare and submit to the Association six-month internal audit reports not
later than 45 days after the end of such period.
Tanzania
The Recipient shall not later than six months after credit effectiveness, computerize the
accounting functions of the project.
Rwanda
The Recipient shall: (a) appoint independent auditors not later than three months after the
effectiveness date; and (b) recruit an accountant to the Project Management Unit not later than
one month after the effectiveness date.
FINANCIAL COVENANTS
70. Financial covenants are the standard ones as stated in the Financing Agreement Schedule
2, Section II (B) on Financial Management, Financial Reports and Audits and Section 4.09 of the
General Conditions.
IMPLEMENTATION SUPPORT PLAN
71. Based on the outcome of the financial management risk assessment, the following
implementation support plan is proposed:
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FM Activity Frequency
Desk reviews
Interim Financial Reports review. Quarterly
Audit report review of the program. Annually
Review of other relevant information such as interim
internal control systems reports.
Continuous as they become
available.
On site visits
Review of overall operation of the FM system. Twice a year for the country
projects in Tanzania, Rwanda,
Kenya and Uganda and once a year
for ECSA-HC (Implementation
Support Mission).
Monitoring of actions taken on issues highlighted in
audit reports, auditors‘ management letters, internal
audit and other reports.
As needed.
Transaction reviews (if needed). As needed.
Capacity building support
FM training sessions. Before project start and thereafter
as needed.
72. The objectives will include that of ensuring that satisfactory financial management
systems are maintained for the project throughout its life.
CONCLUSION
73. The conclusion of the assessment is that the financial management arrangements for all
the implementing entities meet the Bank‘s minimum requirements under OP/BP10.02. The
residual risk rating for ECSA-HC is moderate and substantial for all the four ministries
implementing the project in Kenya, Rwanda, Tanzania and Uganda. With the action plan being
implemented, financial management arrangements for all the implementing entities will be
further enhanced.
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Annex 8: Procurement Arrangements
AFRICA: East Africa Public Health Laboratory Networking Project
A. Background:
1. Procurement Environment: National Procurement Procedures are normally acceptable
for National Competitive Bidding (NCB), subject to some exceptions as listed for each country
in paragraphs 17, 18, and 19 below.
2. The East, Central and Southern Africa Health Community (ECSA-HC), based in Arusha
Tanzania, will be responsible for coordinating activities at regional level and conducting
procurement of consultant services and goods. Procurement capacity of ECSA-HC was carried
out during the Appraisal Mission.
B. Applicable Procurement Guidelines:
3. General: Procurement for the proposed project would be carried in the three (3)
countries in accordance with the World Bank‘s "Guidelines: Procurement under IBRD Loans
and IDA Credits" dated May 2004, revised October 2006; and "Guidelines: Selection and
Employment of Consultants by World Bank Borrowers" dated May 2004, revised October 2006,
and the provisions stipulated in the Legal Agreement. The various items under different
expenditure categories are described below. For each contract to be financed by the Credit, the
different procurement methods or consultant selection methods, the need for pre-qualification,
estimated costs, prior review requirements, and time frame are agreed between the Borrower and
the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually, or as
required to reflect the actual project implementation needs and improvements in institutional
capacity. The borrowers as well as contractors, suppliers, and consultants will observe the
highest standards of ethics during procurement and execution of contracts financed under this
project. The project will carry out implementation in accordance with the ―Guidelines on
Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA
and Grants‖ dated October 15, 2006 (the Anti-Corruption Guidelines).‖
4. Bidding Documents Applicable under the Project: Bank‘s Standard Bidding Documents
(SCBs) will be used for procurement of works and goods under International Competitive
Bidding (ICB); and the Standard Request for Proposals (SRFP) will be used for consultants‘
contracts estimated to cost US$200,000 and above equivalent per contract. In addition, the
implementing agencies will use Standard Bid Evaluation Form for procurement of goods and
works for ICB contracts, and Sample Form of Evaluation Report for Selection of Consultants
selected using the Bank‘s SRFP for consultants‘ contracts estimated to cost US$200,000 and
above equivalent. However National Bidding Documents acceptable to the Bank may be used
for: (i) procurement of works and goods under National Competitive Bidding (NCB)
procedures, and (ii) consultants contracts estimated to cost less than US$200,000 equivalent per
contract subject to the exceptions indicated below under each country. Alternatively, Bank‘s
SBDs will be used with appropriate modifications. Furthermore, in accordance with para.1.14
(e) of the Procurement Guidelines each bidding document and contract financed out of the
proceeds of the Financing shall provide that: (i) the bidders, suppliers, contractors and
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subcontractors shall permit the Association, at its request, to inspect their accounts and records
relating to the bid submission and performance of the contract, and to have said accounts and
records audited by auditors appointed by the Association; and (ii) the deliberate and material
violation by the bidder, supplier, contractor or subcontractor, of such provision may amount to
an obstructive practice as defined in paragraphs 1.14(a)(v) of the Procurement Guidelines.
C. Applicable Procurement Methods
5. Scope of Procurement: The implementation of the project entails procurement of
various types that vary from country to country, but it generally comprise: (a) works
(construction and/or rehabilitation of laboratories, incinerators etc); (b) goods (computers,
computer software, bio-safety equipment, protective gear, etc); (c) consulting services (i.e.
technical assistance (TA), research studies, M&E, etc.); and (d) training and workshops.
6. Procurement of Works and Goods: Contract packages estimated to cost US$5,000,000
(for Uganda, Tanzania, and Kenya); and US$3,000,000 (for Rwanda) equivalent per contract and
above for works and US$500,000 (for Uganda, Tanzania, and Kenya); and US$300,000 (for
Rwanda) equivalent per contract and above for goods will be procured through ICB procedures.
Works estimated to cost less than US$5,000,000 and US$3,000,000 equivalent per contract
respectively, and US$500,000 and US$300,000 equivalent per contract for goods respectively
would be procured through NCB procedures, except for small contracts estimated to cost less
than US$100,000 for works, and US$50,000 for goods equivalent per contract that may be
procured through Shopping procedures by comparing prices for quotations received from at least
three (3) reliable contractors or suppliers. In such cases, request for quotations shall be made in
writing and shall indicate the description, scope of the works, the time required for completion of
the works and the payment terms. All quotations received shall be opened at the same time. As
a general rule, a qualified supplier who offers goods or materials that meet the specifications at
the lowest price shall be recommended for award of the contract. Limited International Bidding
for goods may exceptionally be used when there are only a limited number of known suppliers
worldwide. Direct contracting for works or goods may exceptionally be an appropriate method
in emergency situation, provided the Bank is satisfied in such cases that no advantage could be
obtained from competition and that prices are reasonable.
7. Procurement of non-consulting services: Non-consulting services which are services
that are not of intellectual or advisory in nature will include for instance the distribution of
supplies from central-level procurement to the districts. The procurement of non-consulting
services shall follow the existing Bank‘s SBDs for ICB, or national SCBs for NCB, with
appropriate modifications.
8. Selection of Consultants: Contracts with firms estimated to cost US$200,000 and above
will be selected using Quality and Cost Based Selection Method (QCBS). Quality Based
Selection (QBS) and/or Fixed Budget Selection (FBS) may be used for assignments which meet
the requirements of paragraph 3.2 and 3.5 of the Consultants Guidelines respectively. However,
consultants used for assignments of a standard and routine nature such as audits and other
repetitive services would be selected through Least-Cost Selection (LCS) method in accordance
with paragraph 3.6 of the Consultants Guidelines. Contracts for consulting services, using firms,
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estimated to cost less than US$ 200,000 equivalent and for which the cost of a full-fledged
selection process would not be justified may be selected on the basis of Consultant Qualifications
(CQS) in accordance with paragraphs 3.7 and 3.8 of the Consultants Guidelines. Short List of
consultants for services estimated to cost less than US$200,000 equivalent per contract may be
comprised entirely of national consultants in accordance with the provisions of paragraph 2.7 of
the Consultant Guidelines.
9. Single-Source Selection (SSS) of consulting firms or individuals would be applied only
in exceptional cases if it presents a clear advantage over competition when selection through a
competitive process is not practicable or appropriate and would be made on the basis of strong
justifications and upon Bank‘s concurrence to the grounds supporting such justification.
10. Individual Consultants (IC) will be selected on the basis of their qualifications by
comparison of CVs of at least three candidates from those expressing interest in the assignment
or those approached directly by the Implementing Agency in accordance with the provision of
Section V of the Consultants Guidelines.
11. The Bank‘s Standard Request for Proposal will be used in the selection of consulting
firms. National standard documents for consulting services, where existing, shall not apply for
selection of Consultants for this project.
12. Training and Workshops: The project will fund the activities included in the country
training plans which were approved by the Association during appraisal. The training plans
include details on: (i) type of training to be provided, including: attendance at training courses at
national and regional institutes; laboratory attachments, fellowships, and regional exchanges at
recognized centers of laboratory excellence; and selective graduate training required to support
specialized services; (ii) number of beneficiaries to be trained, duration of training, and estimated
cost; (iii) institutions selected based on their expertise; and (iv) expected learning outcomes. The
training plans will be updated annually and be submitted for IDA review. For Uganda, the
Project Implementation Manual for the Health Systems Strengthening Project shall specify how
candidates eligible for graduate training shall be selected. Workshops shall be prior reviewed as
a part of the annual work-plans of the participating countries.
13. Operating Costs: Incremental operating costs include expenditures for maintaining
equipment and vehicles; fuel; office supplies; utilities; consumables; workshop venues and
materials; and per diems, travel costs, and accommodation for staff when travelling on duty
during implementation of this project, but excluding salaries of civil/public servants. These will
be procured using the Borrower's administrative procedures, acceptable to the Bank.
14. Bank’s Review Thresholds: The Borrower shall seek World Bank prior review in
accordance with Appendix 1 of both Procurement and Consultant Guidelines for contracts above
the thresholds as agreed in the Procurement Plan. For purposes of the initial Procurement Plan,
the Borrower shall seek Bank prior review for: (i) works contracts estimated to cost
US$5,000,000 (for Uganda, Tanzania, and Kenya); and US$3,000,000 (for Rwanda) equivalent
and above per contract; (ii) goods contracts valued at US$500,000 (for Uganda, Tanzania, and
Kenya), and US$300,000 (for Rwanda) equivalent and above per contract ;(iii) all consultancy
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contracts for services to be provided by consulting firms of US$200,000 equivalent and above;
(iv) for individual consultants contracts estimated to cost the equivalent of US$100,000 or more;
(iv) all direct contracting and single source selection contracts regardless of their value; and
(v) annual training plan. In addition, a specified number of contracts to be identified in the
procurement plan for the procurement of goods and works below the ICB threshold will also be
subject to prior review. These prior review thresholds may be re-visited annually and any
revisions based on the assessment of the implementing agencies capacity will be agreed with the
Borrower and included in an updated Procurement Plan.
15. Record Keeping: Each implementing agency in a respective country will be responsible
for record keeping and filing of procurement records for ease retrieval of procurement
information. In this respect, each contract shall have its own file and should contain all
documents on the procurement process in accordance with the requirements and as described in
the national procurement Law.
16. Monitoring: M&E of procurement performance will be carried out through Bank
supervision and post procurement review missions.
D. Use of National Procurement Procedures for Goods and Works
17. National Procurement Procedures are normally acceptable for NCB, subject to some
exceptions as listed below for each country:
18. Uganda: Procurement in Uganda is governed by the Public Procurement and Disposal of
Public Assets Act of 2003. The procedures in the PPDA act have been reviewed by the Bank
and found to be acceptable subject to the following exceptions which will not be applicable
under this project:
Negotiations with the best evaluated bidder: This practice is not appropriate, except
for consulting service contracts and for goods and works under exceptional
circumstances, and for contracts procured through direct contracting.
The merit point system for bid evaluation: This shall not be applied for goods and
works contracts procured on basis of competition (ICB, NCB or restricted tender).
Pre-qualifying bidders and then inviting only a few on a rotational basis: For
shopping procedures, the Procuring and Disposal Entity (PDE) will not be allowed to pre-
qualify suppliers on an annual basis and invite only a few on a rotational basis. Where
pre-qualification is conducted, all pre-qualified providers will be invited to submit bids.
Common supplies like stationery and consumables will be aggregated and procured
annually through framework contracts to enable implementing agencies to place orders
for urgently needed supplies at short notice, at a competitive price.
Application of Domestic Preference under NCB: Domestic Preference shall only be
applied under ICB.
Micro-procurement: Micro-procurement as defined in the PPDA Act will only apply
for contracts estimated to cost the equivalent of $150 or less.
The following documentation or their equivalent shall not be treated as eligibility
requirements: (i) tax clearance certificates; (ii) VAT registration certificates; and
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(iii) trading licenses. These may however be included as post qualification requirements,
on which clarification/additional information can be sought during the evaluation.
Where the PPDA documents are used, ONLY the ―Technical Compliance‖ Selection
methodology as defined in the Act shall be adopted for Evaluation. The rest of the
methodologies shall not be used for the procurement of goods, works and non-consulting
services.
19. Tanzania: The Government has already prepared SCBs for National Competitive
Bidding (NCB) procedures for procurement of works which have been found acceptable to the
Bank, except for the provision of Domestic Preference given to domestic suppliers/contractors,
which is not as per Bank‘s Guidelines. The Government may use these documents when
carrying out procurement of works through NCB procedures with the exception of the provision
of Domestic Preference.
20. Kenya: All contracts other than those to be procured on the basis of International
Competitive Bidding (ICB) and consulting services shall follow the procedures set out in the
Public Procurement and Disposal Act of 2005. The Act has been reviewed by the Bank and
found to be acceptable except for the following provisions that would not be applied under this
project: (i) bidding period for National Competitive Bidding (NCB) shall not be less than 30
days as opposed to 21/14 days provided in the law; (ii) government parastatal institutions shall
be allowed to participate in procurement only if they are legally and financially autonomous,
operate under commercial law, and are independent from the borrower and its
purchasing/contracting authority; (iii) preference system shall not be allowed under NCB
procedures; (iv) merit point system shall not be used for bid evaluation; (v) price negotiations
under NCB shall be allowed only where the bid price is substantially above market or budget
levels and only then if negotiations are carried out to try to reach a satisfactory contract through
reduction in scope and/or reallocation of risk and responsibility, which can be reflected in a
reduction in Contract price; (vi) shopping procedures shall be used instead of direct procurement
for low value contracts; (vii) the ―two envelope‖ bid opening procedure for procurement of
goods shall not be permitted; and (viii) the Bank‘s SCBs for goods and works with appropriate
modifications shall be used.
21. Rwanda: Rwanda has recently accomplished preparation of SCBs for NCB in close
collaboration with the Bank. Apparently, there are exceptions for NCB procedures. Rwanda is
one of the candidate countries for piloting the use country procurement systems in the Bank
supported operations (UCS). The assessments in line with the Board approved UCS paper are
currently underway.
E. Implementation Arrangements and Risk Assessment
22. The overall responsibility for procurement of works and goods and selection of
consultants will be carried out by streamlined agencies or entities at national level in each
country. The description of implementation arrangements and assessments of the
agencies/entities‘ capacity to handle and manage procurement in each country is provided below.
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23. Uganda: The project will be mainstreamed into the MoH under the direct oversight of
the PS (the Accounting Officer). The MoH has a Procurement and Disposal Unit and Contracts
that will be solely responsible for procurement function of this project. However, its capacity is
inadequate because of heavy workload and inadequate experience of procurement staff in World
Bank procurement procedures. Filing and record keeping system is also inadequate partly due to
insufficient office space. The MoH has a Contract Committee (CC) in place as per procurement
law. The CC meets at least weekly or as need arises. Due to inadequate quality of procurement
documents, the CC has been returning procurement documents to PDU for improvements. To
improve the quality of procurement documents prepared by PDU, it is recommended that the
MoH recruits a Procurement Specialist, with ToR acceptable to IDA for at least the first two
years to handle procurement of contracts related to this project, establish filing and record
keeping system, and provide hands-on coaching to PDU staff.
24. An assessment of the capacity of the Implementing Agency to implement procurement
actions for the project has been carried out in July 2009. The capacity assessment reviewed
some of the MoH‘s contract records and observed that the procedures followed in the preparation
of documents, management of bidding process, bid evaluation, and contract award, although
carried out in compliance to the PPDA Act were not always fully satisfactory. However, the
MoH has adequate capacity to prepare technical specifications for medical equipment. Besides
having qualified staff with sufficient experience in preparation of specifications for TB
Laboratory equipment, there is also a specialized committee, the National Advisory Committee
on Medical Equipment (NACME). This Committee has prepared Medical Equipment Policy
together with detailed technical specifications for the different medical equipment for each level
of health facilities. The MoH would however, require TA in designing and supervision of the
TB laboratories as civil works for TB laboratories is more sophisticated and more specialized
than that of conventional health facilities. Therefore, the MoH would need to engage a
Laboratory Infrastructure Consultant with experience in TB and microbiology to design and
supervise the construction/expansion of these relevant laboratories.
25. The key issues and risks concerning procurement for implementation of the project have
been identified and include: (i) staff capacity gaps in the PDU, particularly inadequate
experience in IDA procurement procedures; (ii) inadequate capacity to design and supervise TB
laboratories; (iii) inadequate filing and record keeping system and office space; and (iv) heavy
workload for the PDU that supports Government and other partner‘s procurement as well.
26. The corrective measures which have been agreed to mitigate the overall risk are:
(i) MoH will prepare a Procurement Manual to clearly indicate the roles and responsibilities of
user departments and the procedures to be followed in executing procurement under the
proposed project; (ii) hiring of a Procurement Specialist to carry out procurement transactions,
establish filing and record keeping system, and hands-on coaching and mentoring of PDU staff;
(iii) development of performance targets for the PDU staff to meet specific targets,
(iv) appraisal of the PDU staff from time to time on the basis of the agreed performance targets;
(v) improvement in management oversight – quarterly meetings to review procurement progress;
and (vi) recruit Laboratory Infrastructure Consultant to design and supervise TB Laboratories
civil works.
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27. The overall project risk for procurement is ―Substantial‖. The proposed actions to
mitigate the risk are summarized in the following table:
Risk Action Completion Date Responsible
Entity
Inadequate
capacity and
procurement
skills of PDU
staff to handle
IDA financed
procurement
management.
Recruit a Procurement Specialist to carry
out procurement transaction, establish
filing and record keeping system, provide
hands-on coaching and mentoring of PDU
staff and User Departments.
To be handled under
the IDA financed
UHSSP.
MoH
PDU staff to attend ESAMI or GIMPA
courses in:
(i) procurement of works and
goods,
(ii) selection of consultants.
To be handled under
the IDA financed
UHSSP.
MoH
Delegate to user departments micro-
procurement function or use framework
contracts for common items.
Immediately MoH
Inadequate
procurement
filing and record
keeping system.
MoH to establish an acceptable MIS for
procurement tracking as well as an
acceptable procurement filing and record
keeping system.
To be handled under
the IDA financed
UHSSP.
MoH
Inadequate office
space for PDU
staff and
procurement
files.
MOH to make available an office space
for the procurement specialist.
To be handled under
the IDA financed
UHSSP.
MoH
Inadequate skills
to design and
supervise civil
works for TB
laboratories.
Recruit a Laboratory Infrastructure
Consultant with experience in TB and
microbiology laboratory design.
Within three months
of effectiveness.
MoH
Inadequate
procurement
planning.
PDU to prepare a procurement plan for
the first 18 months in coordination with
the user departments.
(i) By project
negotiations.
MoH
Lack of
understanding of
roles and
responsibilities
between user
departments and
PDU.
(i) Prepare Procurement Manual to clarify
roles and responsibilities of staff.
(ii) Train user departments in
procurement and contract management.
To be handled under
the IDA financed
UHSSP.
MoH
MOH
28. Tanzania: The overall responsibility for procurement of works and goods (with the
exception of pharmaceuticals and medical supplies) and selection of consultants will be with the
Ministry of Health and Social Welfare (MoHSW) through its Procurement Management Unit
(PMU). Procurement of pharmaceuticals and medical supplies is performed by Medical Stores
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Department (MSD), which is a semi-autonomous body under the MOHSW. Planning of the
various activities will be coordinated by the Director of Policy and Planning Division under the
HSRS which has also been responsible for the day to day activities of other Bank financed
projects.
29. Procurement activities will be carried out by PMU of the MOHSW. According to the
PPA 2004, every Procuring Entity is required to establish a PMU to manage all procurement and
disposal activities except adjudication and award of contracts. The PMU has been established in
accordance with the PPA 2004 and is headed by a Principal Supplies Officer (PSO), assisted by
one Principal Supplies Officer, two Senior Supplies Officers and eighteen Supplies Officers of
different grades, most of whom have limited experience in procurement and support staff
including Assistant Supplies Officers, Supplies Assistants and secretaries. The PMU is also
responsible for the procurement activities for the ongoing HSDP II financed by the Government
and IDA. Procurement activities for this operation will also be undertaken by the same team.
30. An assessment of the capacity of the MOHSW to implement procurement actions for this
project was carried out on August 10, 2009. The assessment reviewed the organizational
structure, functions, staff skills and experiences, and adequacy for implementation of the project.
31. The key issues and risks concerning procurement for implementation of the project have
been identified and mitigation measures proposed. The assessment found out that the MOHSW
has some experience in the procurement of goods through ICB procedures. The ministry has
however limited experience in the procurement of works as well as in selection of large value
consultancy contracts. It was also noted that some projects implemented by the ministry have
dedicated procurement staff which has helped to ensure full attention to the procurement
activities of the projects. This has resulted into a limited capacity of the PMU for handling
procurement activities of the other programmes of the ministry. This project will need to have a
dedicated procurement staff and the ministry finds it difficult to identify a qualified and
experienced Procurement Specialist to be dedicated for the project. There will be a need to
recruit a Procurement Specialist for the project.
32. The overall project risk for procurement is ―High‖. The proposed actions to mitigate the
risk are summarized in the following table.
Risk Action Timeframe Responsibility
Procurement staff
overwhelmed with ongoing
procurements under HSDP II
and procurements under GOT
own financing.
Recruit a procurement
specialist for duration of at
least two years.
Six months after
effectiveness.
Borrower
Inadequate experience in
procurement of works as well
as in selection of large value
consultancy contracts.
Key procurement staff to
be trained in procurement
of works as well as in
selection of large value
consultancy contracts.
During
implementation of
the project.
Borrower and
IDA
Inadequate procurement Prepare a draft By negotiations. Borrower
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Risk Action Timeframe Responsibility
planning. procurement plan for the
first 18 months.
Inadequate procurement filing
and record keeping.
Train staff in data
management and establish
acceptable procurement
filing and record keeping
system.
Within six months
of implementation
of the project.
Borrower
Revised thresholds for ICB/
NCB and for prior review.
Identify NCB contracts
each year in the
procurement plan to be
subject to prior review.
During project
preparation
(annually).
Borrower and
IDA
33. Kenya: The implementation of the project will be carried out by the Department of
Disease Prevention & Control (DDP&C) in the MoPHS (MOPHS) guided by the Project
Coordination Committee. The MOPHS will have the overall responsibility for procurement of
works, goods and consultants services, with the exception of medical commodities, which will be
carried out by the Kenya Medical Supplies Agency a state corporation established under an act
of parliament. However, KEMSA is still depending on the MOMS for budgetary support. This
may affect effectiveness of procurement processes in the event of delayed release of
administrative budgets.
34. Procurement activities will be carried out by the DDP&C. The department has a
procurement unit which in accordance with the Public Procurement and Disposal Act 2005, is
responsible for the procurement of small value contracts not exceeding US$6,500 equivalent per
contract, while large value contracts are carried by MOPHS (with the exception of medical
commodities) that is done by KEMSA. The DDP&C is staffed by a procurement officer I who is
assisted by two procurement officers II and a stores officer, all of whom have little or no
experience in Bank-funded procurement. The MOPHS is staffed by a chief procurement officer
assisted by two procurement officers I and a stores officer with limited experience in Bank
procurement processes.
35. KEMSA is a state corporation with the mandate to procure, warehouse, and distribute
medical commodities to public health facilities in the country under the MoH, currently split into
the Ministries of Medical Services (MOMS), and Public Health and Sanitation (MOPHS).
KEMSA gets its funding from the MOMS, which in turn receives an annual budget from the
Exchequer for medical commodities based on an estimate of the national public health delivery
requirements. KEMSA has a procurement unit and all the other necessary Committees stipulated
under the Act. The procurement unit is staffed by a procurement manager, who is assisted by an
assistant procurement manager, two procurement officers and two assistant procurement officers
who are all experienced in procurement. Starting this financial year, KEMSA has been
mandated by the two ministries of health to procure medical commodities and essential supplies
on their behalf.
36. An assessment of the capacity of the Implementing Agencies to implement procurement
actions for the project was carried out on August 10, and 17, 2009, for the MOPHS and KEMSA,
respectively. The assessment reviewed the organizational structures, institutional strengths and
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weaknesses, staff skills and experiences, and the operating procurement environment under
which the project will be implemented.
37. The key issues and risks concerning procurement for implementation of the project have
been identified and mitigation measures proposed. It was observed that the Ministry of Health
(MoH), before it was split into two Ministries, MOPHS and MOMS was involved in the
implementation of Bank funded programs in the health sector and as such the two ministries
although limited, have experience in procurement of goods and consultant services under Bank
funded programs. However, MOPHS which has the overall responsibility for procurement under
the project does not have experience in the procurement of works, large value goods contracts
and consultancy assignments. KEMSA, on the other hand, is experienced in the procurement of
medical commodities and other essential supplies. However, since its establishment in early
2000, its operations have been greatly hampered by inadequate funding and limited
administrative control on procurement related matters. Although the ministries have mandated
KEMSA to handle procurement of all medical commodities beginning this financial year, it will
take some time before this responsibility is institutionalized and materially supported.
38. The overall project risk for procurement is ―High‖. The proposed risk mitigation
measures are summarized below:
Risk Action Timeframe Responsibility
Inadequate
Procurement Capacity.
-Conduct training in procurement of
goods, works, and selection of
consultants for the MOPHS
procurement staff.
During
implementation of
the project.
IDA
Sustainability of
Existing Capacity.
MoF to ensure that procurement
officers seconded to the ministry
are retained for the duration of the
project.
During
implementation of
the project.
Borrower
National Procurement
Procedures.
Exception provisions to the
National Law included in the
Financing Agreement.
During
negotiations.
Borrower
SBD for NCB
Contracts.
Bank‘s SBD to be used for NCB
contracts.
During
implementation of
the project.
Borrower
RFP documents for
selection of consultants.
Bank‘s RFP documents to be used. During
implementation of
the project.
Borrower
Sporadic and
inadequate budgetary
support to KEMSA.
MoMS to ensure consistent and
timely budgetary support to allow
KEMSA to carry out its activities
under the project.
During
implementation of
the project.
Borrower
Revised thresholds for
ICB/NCB and prior
review.
Determine NCB contracts each year
in the procurement plan to be
subject to prior reviewed.
During project
preparation.
Borrower / IDA
39. Rwanda: The overall implementation responsibility for the project will rest with the
MoH. The Permanent Secretary (PS) will have overall oversight. The fiduciary arrangements in
143
Rwanda will be broadly similar to those used for the recently completed HIV/AIDS Project
(MAP) that was managed by a central Project Management Unit that manages other large grants.
The PMU has a solid procurement structure, including four procurement officers familiar with
both national and donors‘ procedures. The unit will be responsible for procurement of all items
except drugs, which will be procured by CAMERWA (Centrale d’achat des medicaments du
Rwanda). One of the procurement officers has worked on the Bank-funded project and is
familiar with the Bank‘s procurement procedures. With additional training to update their skills
on Bank procurement procedures this team will be able to handle procurement of project
activities satisfactorily.
40. The procurement team will work closely with the TRAC + (Center for Treatment and
Research on AIDS, Malaria, TB, and Other Epidemics, MoH), and the National Reference
Laboratory (NRL) in their technical position as the main sub recipients of the grant. The NRL
will take leadership in laboratory networking and systems development while the TRAC+ will
focus on improving laboratory linkages with integrated disease surveillance. In line with the
decentralization efforts, district health Steering Committee (SC)s will have a key role in project
implementation at district level and will have oversight responsibilities for the satellite labs.
41. An assessment of the capacity of the Implementing Agencies to implement procurement
actions for the project was carried out on September 25, 2009, and December 15, 2009. The
assessment reviewed the organizational structures, institutional strengths and weaknesses, staff
skills and experiences, and the operating procurement environment under which the project will
be implemented.
42. The key issues and risks concerning procurement for implementation of the project have
been identified and mitigation measures proposed. It was observed that the procurement officers
from the Project Management Unit, apart from dealing with day-today procurement, are also
responsible for contract management. This adds to the workload of the procurement officers,
and as a result contracts have not always been adequately managed. It is therefore recommended
that the technical departments be asked to be much involved in contract management. The
existing internal manual would be updated to outline clear roles of the technical departments in
management of contracts. Another weakness noticed relates to difficulties in preparing cost
estimates. This will be mitigated by using price data of the previous or already awarded
contracts to come up with unit costs of major procurement activities.
43. The proposed actions to mitigate the risks noted above are summarized in the following
table.
Risk Action Timeframe Responsibility
Heavily involvement of
procurement officers in
contract management.
-Update the existing internal
procurement manual to
outline clear roles of the
technical departments in
contract management
function.
Three months after
effectiveness.
Borrower
-Train technical staff in
contract management.
Six months after
effectiveness.
Borrower and
IDA
144
Risk Action Timeframe Responsibility
Inadequate skills of technical
and procurement staff in
preparation of cost
estimates.
Use price data of previous or
already awarded contracts to
come up with unit costs to
enable preparation of realistic
cost estimates.
Three months after
effectiveness
Borrower
Insufficient experience in
Bank procurement
procedures for three out of
four procurement officers in
the PMU.
Procurement staff to attend
ESAMI or GIMPA courses.
During
implementation of
the project
Borrower and
IDA
44. ECSA-HC: The procurement function is under the Director of Operations and
Institutional Development, headed by an Administration Officer and supported by an
Administrative Assistant (Procurement).
45. ECSA-HC has a Tender Board chaired by the Director of Operations and Institutional
Development. It has eight members appointed by positions with the Administration Officer as
the Secretary. All contracts above US$15,000 equivalent require the approval of the Advisory
Committee, after the approval of the award recommendations by the Tender Board before the
Director General can sign the contracts. This arrangement may delay implementation of the
project since the Advisory Committee meets only twice a year, and it is not in line with PPA,
2004.
46. The procurement capacity assessment of ECSA-HC focused on the following aspects:
overall institutional set up as well as organizational set up of the procurement function; staffing
in terms of numbers and qualifications; procurement cycle management; record keeping; and
presence of controls in the procurement processes. ECSA-HC establishment has two
procurement staff positions (i.e., Administration Officer and Administrative Assistant,
Procurement). However, only the Administrative Assistant (Procurement) is on board. The staff
member has a Bachelor‘s degree in Public Administration, but has no training in procurement.
The position of the Administration Officer is vacant after the previous staff member left for
another job. Based on the volume of procurement currently being handled by ECSA-HC (mainly
procurement of fuel, stationery, insurance services and individual consultants for conference
facilitation) and that anticipated under the project (e.g. office furniture, office equipment, a
vehicle, and individual consultants for conference facilitation), which is mainly through
Shopping and Individual Consultants methods, one administrative officer with a background in
procurement and the Administrative Assistant will be sufficient, particularly with additional
training. ECSA-HC is in the process of recruiting a replacement staff for the position of
Administrative Officer. Since the main responsibilities of the Administrative Officer are related
to procurement, ECSA-HC was advised to change the job description of this position and recruit
a staff with procurement knowledge for the position who after reorganization should become the
Head of the Procurement Management Unit.
47. The only staff currently handling procurement in ECSA-HC would need training in basic
procurement as well as World Bank procurement procedures. The staff member to be recruited
as Procurement Specialist should have sufficient procurement skills and experience in Public
145
Procurement Act, 2004 and its Regulations. S/he should be familiar and have a good
understanding of procurement under World Bank procedures. In addition, ECSA-HC will need
to prepare a Procurement Manual to provide guidance in the procurement processes in line with
the Public Procurement Act, 2004 and its Regulations.
48. ECSA-HC has been conducting most of its procurement through the shopping method.
Thus, it has limited skills in procurement planning, preparation of bidding documents, and
processing of procurement through methods other than shopping and selection of individual
consultants. There is no system for record keeping.
49. Risk Rating: Considering the organizational set up of the procurement function within
the organization and the level of training with regard to procurement for the only staff currently
in ECSA-HC to handle procurement activities, the procurement is considered HIGH.
Action Plan to Mitigate Procurement Risks
50. A summary of actions to mitigate the above risks is presented in the table below.
Risk Action Timeframe Responsibility
PMU not established. Establish a PMU, reporting
directly to the Director General
and recruit an Administrative
Officer with procurement
knowledge to head the Unit.
During Project
Implementation.
ECSA-HC
Appointment of members of
the Tender Board by titles.
Appoint members of the Tender
Board based on names and number
of members
During Project
Implementation.
ECSA-HC
Lack of adequate procurement
staff in terms of numbers and
skill/s.
Provide basic procurement training
in goods and consultancy services
to procurement staff.
During Project
Implementation.
ECSA-HC
Lack of appropriate record
keeping and filing system.
Design and establish a
procurement record keeping and
filing system.
During Project
Implementation.
ECSA-HC
Lack of Procurement Manual. Prepare a Procurement Manual. During Project
Implementation.
ECSA-HC
Involvement of Advisory
Committee in procurement
approvals after Tender Board
award.
Relieve Advisory Committee from
procurement processing approvals.
During Project
Implementation.
ECSA_HC
F. Frequency of Procurement Supervision
51. In addition to the prior review supervision to be carried out from Bank offices, the
capacity assessments of the Implementing Agencies has recommended semi-annual supervision
missions to conduct field visits, of which at least one mission will involve post review of
procurement actions.
146
52. Prior Review Threshold:
I. Procurement of Goods and Works
Expenditure
Category
Contract Value (Threshold)
USD
Procurement
Method
Contracts Subject to
Prior Review
1. Works >=5,000,000 (for Uganda,
Tanzania, and Kenya)
>=3,000,000 (for Rwanda)
< 5,000,000 (for Uganda,
Tanzania, and Kenya)
< 3,000,000 (for Rwanda)
<100,000
ICB
NCB
Shopping
All Contracts
Selected Contracts as indicated
on Procurement Plan
None
2. Goods >=500,000 (for Uganda,
Tanzania, and Kenya)
>=300,000 (for Rwanda)
<500,000 (for Uganda,
Tanzania, and Kenya)
< 300,000 (for Rwanda)
<50,000
ICB
NCB
Shopping
All Contracts
Selected Contracts as indicated
on Procurement Plan
None
II. Selection of Consultants
Expenditure
Category
Contract Value (Threshold)
USD
Selection Method Contracts Subject to
Prior Review
(a) Firms
>=200,000
<200,000
All values
QCBS,
QBS,LCS,FBS
CQS, LCS, QBS,
FBS
SSS
All contracts
Selected Contracts as
indicated on
Procurement Plan
All contracts
(b) Individual >=100,000
All values
IC
SSS
All contracts
All contracts
G. Readiness for Implementation and Procurement Plan
53. Procurement Plans were prepared and discussed during project appraisal in each country.
The Plans were prepared in a format acceptable to IDA. The plans have been agreed between the
Borrower and the Project Teams and will be available in each MoH. They will also be available
in the project databases and on the Bank‘s external website. The Procurement Plans will be
updated in agreement with the Project Teams annually or as required to reflect the actual project
implementation needs and improvements in institutional capacity. Details of the Procurement
Arrangements are provided below for each country.
147
54. Goods, Works, and Non Consulting Services
(a) List of contract packages to be procured following ICB direct contracting, and selected NCB
contracts:
148
Goods, Works, and Non Consulting Services
A. Uganda
List of contract packages, which will be procured following ICB and Direct Contracting procedures:
1 2 3 4 5 6 7 8 9
Ref. No.
Contract
(Description)
Estimated
Cost ($ mill)
–
Procurement
Method
Pre-
qualificatio
n (yes/no)
Domestic
Preference
(yes/no)
Review
by Bank
(Prior / Post)
Expected
Bid-Opening
Date
Comments
GOODS
1 Provision of critical
equipment and other
supportive infrastructure
for the National TB
Reference Laboratory
(different items e.g.
microscopes, BSC II
cabinets, autoclaves,
laboratory refrigerators,
pippets, laboratory
freezers, etc..) 560,000 ICB
No No Prior
Jan 4th, 2011
2 Procurement of critical
equipment for satellite
laboratories (different
items e.g. microscopes,
BSC II cabinets,
autoclaves, laboratory
refrigerators, pippets,
laboratory freezers,
generator, etc..) 399,000 ICB
No No Prior
Jan, 2011
3 Procurement of
Mycobacteria Growth
Indicator Tube machines
(MGIT) 80,000
Direct
contracting
No No Post
Jan, 2011
149
B. Tanzania
1 2 3
4 5 6 7 8 9
S/N Description Total
amount
(USD)
Method of
Procurement
Prequalification
(yes/no)
Domestic
Preference
(yes/no)
Review
by Bank
(Prior/Post)
Expected
Bid-
Opening
Date
Comments
1. Goods
1.1 Procurement of laboratory equipment and
instruments with motor and heating
elements
482,926 NCB No No Selected for
Prior
Review
Sept 30,
2010
1.2 Procurement of laboratory equipment and
stabilizers
250,070 NCB No No Post Sept 30,
2010
1.3 Procurement of laboratory cold
generating equipment
192,600 NCB No No Post Oct 31,
2010
1.4 Procurement of laboratory cabinets,
containers and instruments
234,736 NCB No No Post Oct 31,
2010
2. Works
2.1 Construction of the National Public
Health Laboratories (Dar es Salaam)
1,600,000 NCB No No Selected for
Prior
Review
May 15,
2011
2.2 Expansion of the existing Mtwara
Regional Laboratory to accommodate TB
and Molecular Biology Functions and
installation of an incinerator.
250,000
NCB
No
No
Post
Jan 31,
2011
2.3 Expansion of the existing Mnazi mmoja
Regional Laboratory to accommodate TB
and Molecular Biology Functions and
installation of an incinerator.
100,000
NCB
No
No
Post
Jan 31,
2011
2.4 Expansion of the existing Kibong‘oto TB
Laboratory to accommodate Reference
and Molecular Biology Functions.
100,000
NCB
No
No
Post
Jan 31,
2011
3. Non – Consultant Services
3.1 Provision of Internet and Telephone
Services
156,000 NCB No No Selected for
Prior
Review
Mar 31,
2011
150
C. Kenya
List of contract packages to be procured following ICB, LIB and NCB procedures:
1 2 3 4 5 6 7 8 9
Ref No. Contract (Description) Estimated Cost Procurement
Method
P-Q Domestic
Preference
Review by the
Bank (Prior /
Post)
Expected
Bid-Opening
Date
Comment
s
1 MGIT & Molecular TB Tests
Consumables
5,787,331 LIB N/A N/A Prior December
2010
2 Lab Equipment and Consumables 1,901,532 ICB N/A N/A Prior December
2010
3 ICT Equipment 765,750 ICB N/A N/A Prior December
2010
4 Renovations to National Public
Health Laboratories
492,975 NCB N/A N/A Prior April 2011
5 Construction of Satellite Laboratory
at Wajir District Hospital
741,225 NCB N/A N/A Prior April 2011
6 Bio-Safety Equipment 158,706 NCB N/A N/A Post December
2010
7 Construction of Satellite Laboratory
at Malindi District Hospital
666,225 NCB N/A N/A Post April 2011
8 Construction of Satellite Laboratory
at Kitale District Hospital
666,225 NCB N/A N/A Post April 2011
9 Construction of a Satellite
Laboratory at Busia District
Hospital
666,225 NCB N/A N/A Post April 2011
10 Construction of a Satellite
Laboratory at Machakos District
Hospital
424,237 NCB N/A N/A Post April 2011
151
D. Rwanda
List of contract packages, which will be procured following ICB and Direct contracting procedures:
1 2 3 4 5 6 7 8 9
Ref. No.
Contract
(Description)
Estimated
Cost
US$
Procurement
Method
Prequalification
(yes/no)
Domestic
Preference
(yes/no)
Review
by Bank
(Prior/Post)
Expected
Bid-Opening
Date
Comments
1.1 I. Renovation / Extension
of a Satellite lab in:
Lot 1: Byumba, District Hospital
Lot 2: Nyagatare District Hospital
Lot 3: Gisenyi District Hospital
Lot 4: Kibungo District Hospital
Lot 5: Gihundwe District Hospital
II. Renovation /Extension
of NRL as a Center of
Excellence
1, 510 000
350 000
270 000
270 000
350 000
270 000
1,600,000
NCB
NCB
NO
NO
NO
NO
Prior
Prior
Feb 2011
Feb 2011
1.2 5 satellites labs total equipment 992, 392,40 ICB NO NO Prior Dec 2010
1.3 5 satellite labs reagents and
consumables for the first 18
months
792, 655,40 ICB NO NO Prior Dec 2010
1.4 NRL Equipment and consumables 1,200,000 ICB NO NO Prior Dec 2010
1.5 Procure the software and hardware
(x laptops, x desktops, x internet
modems, x antivirus, x printers and
x software databases)
1,475,000 ICB NO NO Prior Feb 2011
1.6 Procurement of 3 vehicles for
sample transportation and
supervision
150, 000 NCB NO NO Post Feb 2011
1.7 Installation, equipments and
consumables for the 5 lab related to
HCWM
680,255 ICB NO NO Prior Feb 2011
152
E. ECSA-HC
A contract package that will be procured following NCB procedures:
1 2 3
4 5 6 7 8 9
S/N Description Total amount
(USD)
Method of
Procurement
Prequalification
(yes/no)
Domestic
Preference
(yes/no)
Review
by Bank
(Prior/Post)
Expected
Bid-Opening
Date
Comments
Goods
1.1 Purchase of Video
Conferencing
Equipment
100,000 NCB No No Post Sept 30, 2010
CONSULTING SERVICES
LIST OF CONSULTING ASSIGNMENTS WITH SHORT-LIST OF INTERNATIONAL FIRMS
A. Uganda
List of consulting assignments with short-list of international firms:
1 2 3 4 5 6 7
Ref. No.
Description of
Assignment
Estimated Cost in
US $) Selection
Method
Review
by Bank
(Prior / Post)
Expected
Proposals Submission
Date
Comments
1 Consultant services to
design, and construction
supervision for NTRL and
satellite labs 272,300 QCBS Prior review July, 2010
2 Consultant services to
provide TA for lab
accreditation 350,000 QCBS Prior review May, 2011
3 Recruit a Laboratory
Infrastructure Consultant
with experience in TB and
microbiology laboratory
design. 200,0000 QCBS Prior review August , 2010
153
B. Tanzania
List of consulting assignments with short-list of international firms:
1 2
3 4 5 6 7
SN Description of Assignments Estimated Costs
(USD)
Selection
Method
Review
by Bank
(Prior/
Post)
Expected
Proposals Submission
Date
Comments
1
Provision of Consultancy Services for Pre and
Post Contract Services for Designing and
Supervision for the Proposed Construction of the
National Public Health Laboratory (Dar es
Salaam)
300,000
CQBS
Prior
December 31, 2010
2 Provision of Consultancy Services for Pre and
Post Contract Services for Designing and
Supervision for the Proposed Rehabilitation and
Extension of Zonal Laboratories in Musoma,
Mtwara, Dodoma, Sumbawanga and Kigoma
Regional Hospitals and Kibong‘oto TB Hospital
140,000 CQS Post Jul 31, 2010
3 Provision of Consultancy Services for Supply,
Installation and Training on the use of
Laboratory Information Systems Software
200,000 CQBS Prior December 31, 2010
4 Provision of Consultancy Services for Technical
Assistance (TA) in the accreditation process of
the Seven Laboratories under the East Africa
Public Health Laboratory Project
240,000 CQBS Prior Nov. 30, 2010
5 Provision of Consultancy Services for
Preparation of Business Plan and E- learning
modules for National Health Laboratory –
Quality Assurance and Training Centres
150,000 CQS Post Sept 30, 2010
154
C. Kenya
List of consulting assignments with short-list of international firms:
1 2 3 4 5 6 7
Ref. No.
Description of Assignment
Estimated
Cost
Selection
Method
Review
by Bank
(Prior / Post)
Expected
Proposals Submission
Date
Comments
1 Design and Supervision of Civil Works 697,973 QCBS Prior August 2010
Other consultancy services:
1 2
3 4 5 6 7
SN Description of Assignments Estimated
Costs (USD)
Selection
Method
Review
by Bank
(Prior/
Post)
Expected
Proposals
Submission
Date
Comments
2.1 Laboratory Specialist/Project
Coordinator
293,045 IC Prior Jul 31,
2010
2.2 M&E Consultant (Long term) 122,102 IC Prior Jul 31,
2010
155
D. Rwanda
List of consulting assignments with short-list of international firms:
1 2 3 4 5 6 7
Ref. No.
Description of
Assignment
Estimated (a) Cost
Selection
Method
Review
by Bank
(Prior / Post)
Expected
Proposals
Submission
Date
Comments
2.1 Selection of a
consultant for
Supervision of
constructions
107,500 QCBS Post Oct 2010
2.2 Provision of Quality
standards
certification by an
international
recognized ISO
institution for the
five labs
116,025 SSS Prior Sept 2011
E. ECSA-HC
Other consultancy services:
1 2
3 4 5 6 7
SN Description of Assignments Estimated
Costs (USD)
Selection
Method
Review
by Bank
(Prior/
Post)
Expected
Proposals
Submission
Date
Comments
2.1 Laboratory Specialist/Project Coordinator 293,045 IC Prior Jul 31,
2010
2.2 M&E Consultant (Long term) 122,102 IC Prior Jul 31,
2010
156
Annex 9: Economic and Financial Analysis
AFRICA: East Africa Public Health Laboratory Networking Project
1. In light of inherent market failures there is a strong economic justification for a
regional approach to control of communicable diseases. As noted in the 2002 “Global Public
Goods for Health‖ report by the Commission on the Macroeconomics of Health, acting
independently each country may have limited motivation to invest in communicable disease
control efforts, as benefits accrue to neighboring countries. Priority should thus be placed on the
provision of key public goods, namely: (i) control and prevention of cross border spread of
communicable diseases; (ii) standardized data collection efforts; and (iii) research, which are all
areas of support under this regional project.
Research and
Development Activities supporting basic and applied research are the engine of knowledge
generation, which has been widely recognized as one of the most valuable global
public goods for development (Stiglitz). Control and
prevention of cross
border spread of
communicable
disease
In health, ―three areas in which countries have organized collectively to respond
to health risks that emanate beyond their borders are: (1) disease control,
elimination and eradication programs; (2) global surveillance activities; and (3)
containment of antimicrobial resistance (AMR). The global architecture to
address the first two is in place but chronically underfunded. A global Strategy in
the third area is just beginning to emerge.‖ Standardized data
collection efforts The collection of standardized data is a mutually beneficial goal that requires
international coordination and collaboration to achieve. Source: Regional Framework for Communicable Disease Control and Preparedness (Draft, October 2009).
2. There is also a strong economic rationale for investing in TB control and in
strengthening lab and diagnostic services. It is well recognized that investments in tuberculosis
prevention and control have a significant economic impact on individuals, households, and
economies. As noted in a recent World Bank research report the economic cost of TB-related
deaths (including HIV co-infection) in sub-Saharan Africa would be about US$52 billion
annually through 2015 in the absence of effective TB treatment, as prescribed by WHO's Stop
TB Strategy.52
If these countries were to offer such treatment to TB patients, in keeping with the
global plan to halve the prevalence and death rates by 2015 (relative to 1990 figures), the
economic benefits would exceed costs by up to 9 times in the most afflicted countries. Mean
household spending on TB can be catastrophic and premature death has a devastating impact on
African households. 53
Children in households with adults suffering from TB are vulnerable, as
the disease may force them out of school, ultimately limiting their job prospects. The effects of
inadequate diagnostic services can be severe as poor patients spend a disproportionate share of
household income to be cured and often resort to sub-standard care which increases risks of drug
resistance. Although the Project is not financing TB treatment, it is addressing an important
weakness in TB control efforts, namely weak diagnostic infrastructure, human resources and
diagnostic services.
52
Laxminarayan, R., Klein, E., Dye, C., Floyd, K., Darley, S., Adeyi, S., Economic Benefit of Tuberculosis Control,
Policy Research Working Paper 4295, The World Bank, August 2007. 53
For example, in Zambia, adult deaths among cotton farmers caused crop yields to fall by roughly 15 percent
(Laxminarayan, et. al.).
157
3. The management of drug resistance through the use of a standardized regimen that
includes second-line drugs costs roughly US$70 to US$450 per DALY averted. Individualized
treatment regimens for multidrug-resistant TB—that is, with drug combinations adjusted to the
resistance pattern of each patient—are more costly but usually yield higher cure rates.
4. There are important efficiency gains to be reaped from introducing modern diagnostics
for treating HIV related tuberculosis and promoting an integrated health care model for co-
infected individuals. The state of diagnostics in the participating countries implies that many
patients go undiagnosed for long periods, continuing to infect others, and ultimately leading to
premature death. With the introduction of culture techniques and expansion in drug
susceptibility testing, the turnaround time for getting results will be reduced from months to
days, and individuals can be placed on treatment more promptly. Strong laboratory networks
with well trained and well protected staff will be able to respond quickly and reliably to drug-
resistant TB and other public health threats, reducing the risk of transmission, and assisting
health facilities to deal more efficiently with patients, ultimately reducing morbidity and
mortality. Expected benefits are as follows:
Enhanced accuracy: One of the main benefits of the project will be boosting country
capacity for liquid culture and other advanced diagnostic techniques which not only
increase the accuracy (i.e. fewer false positive and false negative results) and reduce the
time between test and result, but in some cases will represent the introduction of an entirely
new level of capability (i.e. capacity to diagnose drug-resistance in-country rather than
shipping the sample to another country). It is worthy of note that the current diagnostic
technology is sputum-smear microscopy – a technology that has changed little in the past
100 years and catches roughly only 50 percent of the TB cases it tests. The TB patients
that microscopy fails to diagnose continue spreading TB, get sick, and for the most part –
without access to treatment, die.
Reduction in diagnostic delay: In many African countries (including Kenya, Tanzania,
Uganda, Rwanda), the appropriate technology for rapidly diagnosing TB among HIV+
people, children, or MDR and XDR-TB doesn‘t exist. If there is capacity at all, it is often
very limited, solid culture-based (i.e. taking several weeks to generate a result), and unable
to cope with the volume of tests that would be required to make a meaningful impact.
Some countries are compelled to send their samples overseas (i.e. to Europe or South
Africa) to diagnose drug-resistant cases with a turnaround time of 6-7 weeks. For many
people with HIV and drug-resistant TB, the delay is too long and they die while waiting for
test results. By introducing liquid culture and other advanced diagnostic tests, this project
would drastically cut the time between test and result from weeks to days. Ensuring that
the linkages between lab and programmatic functions are strong will further reduce the
delay in transmitting the patient‘s test result to the closest treatment center.
Interruption of transmission: The reduction in diagnostic delay and time to initiation of
treatment means that infectious cases will be detected and rendered non-infectious earlier.
By finding and curing infectious TB patients earlier, their ‗transmission time‘ is reduced as
are the number of additional people they infect. In this way, transmission is interrupted and
the incidence and prevalence of the disease begins to fall.
158
Increased Case Detection (CD) and treatment success rates54
: Many African countries
struggle to reach the targets of 70 percent CD and 85 percent treatment success due to poor
diagnostic and program capacity underscored by weak health systems and high rates of
HIV/AIDS. The current average in Africa is 46 percent CD and 74 percent treatment
success. In other words, for every 100 infectious TB patients in Africa, only 35 are
currently being found and cured under the current system. Improved diagnostic capacity
will increase treatment success rates by, for example, preventing situations where a person
with drug-resistant TB is placed on a first-line anti-TB drug regimen as a result of an
inability of the system to differentiate between drug-resistant and drug-susceptible TB.
The availability of rapid, accurate diagnostic technology will increase the number of cases
of TB detected by the system by improving the accuracy of the diagnosis. At present, the
principle diagnostic tool is sputum-smear microscopy which is an inadequate tool for the
current epidemiologic environment in many African countries.
Control the spread of drug-resistant TB: The project aims to increase the availability of
drug susceptibility testing (DST) and advanced diagnostics that are essential to diagnosing
drug-resistance. This means that more cases of drug-resistant TB will be detected and,
with proper attention to programmatic linkages, treated by the system, blocking
transmission, and reducing the country and regional burden of TB.
Protection of lab and health workers through improved biosafety: Health and lab workers
are at a much higher risk of being infected due to their proximity to infectious patients and
samples. By improving lab conditions, including protective gear, biosafety equipment,
procedures, and training – lab and health workers will be protected from nosocomial
infection. This is an important safeguarding element with clear benefits.
Reduction in morbidity and mortality: For people infected with TB, particularly people
living with HIV/AIDS, rapid, accurate diagnosis is literally the difference between life and
death. In addition to reducing the overall burden of the disease, increasing country
capacity for rapid diagnosis will ultimately reduce morbidity and mortality associated with
the disease, particularly among the most vulnerable groups (e.g. HIV+ people, children,
and those infected with MDR/XDR-TB).
Modeling the impact of cross-border flow and treatment failure as sources of infections
5. Many economic and epidemiologic models used to project the returns to improved TB
control do not consider two main issues which this project addresses, namely: (i) cross-border
flow and (ii) treatment failure as sources of new infections.55
The two issues are inter-related
54 In 1991, the 44th World Health Assembly (WHA) recognized the importance and previous neglect of tuberculosis (TB), and set two key global
targets to be reached by 2000: 70% Case Detection of acid-fast bacilli smear-positive TB patients under the then-new DOTS strategy recommended by WHO, and 85% treatment success for those detected. Achieving these targets would significantly decrease TB prevalence and
reduce TB incidence by approximately 5%-10% per year in the absence of any major change in TB epidemiology. 55 A special analysis and projection of these benefits was commissioned during project preparation and underpins this part of the
economic analysis. The paper, Transboundary Benefits of Controlling Multi-drug resistant Tuberculosis by Klein and
Laxminarayanan, 2010 is available upon request. The bioeconomic model with progressive evolution of multi-drug resistance
was developed and applied to assess the benefits of MDR-TB control in one participating country on prevalence in a neighboring
country. The methodology for this analysis draws on mathematical models of tuberculosis (Blower, McLean et al. 1995; Dye and
Williams 2000; Dye and Espinal 2001; Blower and Chou 2004) and on other modeling approaches. The burden of disease
159
because MDR-TB infections take a while to develop de novo, have longer clearance times and
less successful treatment rates. Consequently, the percentage of infections that are MDR-TB
increases significantly when external infections enter the country. Because MDR-TB is 2 to 10
times more expensive to treat than drug-susceptible disease, the exclusion of drug-resistant cases
in the modeling severely underestimates the returns to investments that specifically aim to
address cross border flows and drug resistant cases.
6. The scenarios that were modeled depend on the assumption of the extent to which
transboundary infections will be reduced. The estimates presented for the four participating
countries over a 20 year period in Figures 1 to 3. The example of Kenya provides some
indicative estimates. The estimated number of averted TB infections range between a low of
14,000 (95% CI, 16,275–11,722), assuming 10% of transboundary infections were prevented to a
high of 173,392 (95% CI,144,718–202,065), assuming no transboundary infections enter the four
countries. As mentioned, the percentage of infections that is MDR-TB increases significantly
when external infections enter the country. Thus, while only modest levels of TB infections
were prevented, much higher levels of MDR-TB are averted. It is estimated that the number of
MDR-TB cases averted in Kenya over the projection period range between 45,253 (95% CI,
43,076–47,492), assuming 10% of transboundary infections were prevented and 543,123 (95%
CI, 522,303–563,943), assuming no transboundary infections enter the four countries. Assuming
a $17,000 cost of treating MDR-TB, the projected benefit of about US$769 million over the
projection period assuming a 10% reduction in transboundary infections.56
7. Consistent with other studies that found it important to tackle the problem before a
reservoir of MDR-TB is built up (Dye, Williams et al. 2002), this analysis showed that
transboundary movement of MDR-TB cases can significantly increase the future number of
MDR-TB infections, even if overall TB infections are only modestly impacted—this is because
they allow a reservoir of infections to build up much faster. Mobility between the East African
Community countries is expected to have many economic benefits, but, this analysis has shown
there are also important risks that need to be mitigated and this project goes a long way toward
addressing one aspect of this risk. Models of TB control programs have neglected the
importance of incoming cases, and in particular MDR-TB infections.
coming from TB control is quantified, and in particular the control of multidrug-resistant tuberculosis (in terms of the potential
impact of adult morbidity and mortality and the associated impact on loss of productivity), as well as the benefits of MDR-TB
control in one country on the prevalence in a neighboring country. The modeling parameters were strongly informed by the TB
epidemiology in Kenya, and these were then used to construct the model and then apply the model to demographic and other
epidemiologic information from the respective countries. 56 Note, these costs have not been discounted.
160
Figure 1. Total TB Infections by country
Figure 2. MDR-TB Infections by Country
Figure 3. Percentage of Infections that are MDR-TB by Country
-
200,000
400,000
600,000
800,000
1,000,000
1,200,000
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l TB
Infe
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Rwanda
Kenya
Tanzania
Uganda
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100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
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R-T
B In
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Kenya
Tanzania
Uganda
0
0.05
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0.15
0.2
0.25
0.3
0.35
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s M
DR
-TB
Rwanda
Kenya
Tanzania
Uganda
161
Critical role of functioning laboratory services in the production function for effective disease
control
8. The dependence of disease control programs on functioning laboratory and diagnostic
services is well understood by health practitioners. In recent years here has been a much greater
appreciation of the health systems underpinnings of disease control programs. In microeconomic
theory this can be described as a more complete appreciation of the production function for
effective disease control.57
By appreciating the critical role of functioning laboratory services in
the production function for effective disease control this project links the benefits from
communicable disease control with the project‘s systems investments in diagnostic
infrastructure, human resources, and diagnostic services. Analytical frameworks that make this
link highlight the vulnerability of the returns to the investment in communicable disease control
to poorly functioning diagnostic services, making explicit the benefits of enhanced diagnostic
accuracy, reduced delays in diagnosis (and associated loss to follow-up), which are some of the
key benefits of the project.58
Pro-poor effects of project impacts
9. While communicable diseases account for only a third (36 percent) of the global disease
burden,59
the burden of communicable disease is considerably higher among the poor. Given
that morbidity and mortality from communicable diseases fall disproportionately on the poor and
investment in these diseases can yield pro-poor benefits. The link between socio-economic
status and TB is particularly strong, and given its cross-boundary focus, the returns to
investments proposed under this project will be strongly pro-poor.
Figure 4. Sources of mortality among the poor, 2000
Source: Martin 2010, IEG Background Paper, Portfolio Review of World Bank lending for Communicable Disease Control (based on evidence from Ergo
and Gwatkin, Personal Communication, March 2009).
57 A production function is a specification of the input requirements needed to produce designated quantities of output, with given technology.
Where technology advances are introduced the production function changes because larger outputs can be generated from given levels of inputs. 58 The empirical quantification of these returns would be an important topic for the operational research that is to be funded under the project. 59 Disease Control Priorities Project, 2006.
0
20
40
60
80
100
Poorest 20% of world
population
Richest 20% of world
population
% o
f to
tal m
ort
ality
Communicable diseases Non-communicable diseases Injuries
162
10. TB places an extraordinary burden on affected households. The greatest burden of TB
falls on productive adults who, once infected, are weakened and often unable to work. Mean
household spending on TB can account for as much as 8–20 percent of annual household
income, varying by region (Russell 2004). In addition to being at greater risk of infection, family
members also bear the burden of taking care of a sick family member, which in turns lowers their
productivity. Children also are affected. Each year, a significant proportion of children from
families in India in which the primary breadwinner has TB are forced to drop out of school or
seek employment (Rajeswari, Balasubramanian et al. 1999). The most devastating impact of TB
is death; without treatment, two-thirds of smear-positive cases die within five to eight years, with
most dying within 18 months of being infected (Styblo and Rouillon 1991). Moreover, premature
death, rather than morbidity, is responsible for more than 80 percent of the disability-adjusted
life years lost to TB (Dye 2006). Finally, a significant proportion of the TB-afflicted population
may be unemployed (Rajeswari, Balasubramanian et al. 1999) (and labor supply may be fairly
elastic); therefore, morbidity-related productivity costs may be quite small relative to the costs of
TB-related deaths.
Positive-externalities at the country level
11. Externalities related to communicable diseases work not just at the level of individuals
but also of countries. Individual countries may fail to fully account for the impact they have on
disease control efforts in neighboring efforts through their lack of sufficient investment in areas
like lab capacity or treatment. In fact, the earliest international conventions that called for global
cooperation were for reporting of diseases like cholera, plague and yellow fever. Furthermore,
disease spillovers across countries are the main reason why programs to control malaria, TB or
Onchocerciasis have aspired to work at a regional scale. Laboratory capacity is a central element
of these control programs, especially for MDR-TB and the benefits of regional coordination can
be quite significant.
163
Annex 10: Safeguard Policy Issues
AFRICA: East Africa Public Health Laboratory Networking Project
1. The regional project has triggered OP 4.01 due to the planned construction/rehabilitation
of laboratories as well as the generation of medical waste at laboratories and has been assigned
the environmental category B. To ensure proper assessment and mitigation of potential adverse
environmental and social impacts an Environmental and Social Management Framework
(ESMF) for laboratories has been elaborated. Countries have also updated their Health Care
Waste Management Plans.
2. The ESMF was prepared to ensure proper assessment and mitigation of potential adverse
environmental and social impacts under the project in conformity with the policy requirements of
the participating countries as well as the World Bank. The ESMF outlines the steps in the
environmental and social screening process, and includes Environmental Guidelines for
Contractors, a summary of the Bank‘s safeguard policies, an Environmental and Social
Checklist, and generic EA and social terms of reference to be applied in the event that the
screening results indicate the need for a separate EA report, and a separate Environmental and
Social Management Plan (ESMP) for the regional project. The Waste Management Plans focus
on existing laboratory waste generation as well as segregation, storage, collection, transport, and
final disposal practices; technologies for waste disposal; public awareness programs; and
relevant national legislation.
3. Based on field work in assessing the potential project sites, the project does not involve
land acquisition because rehabilitation of current laboratories is within the existing footprint and
the potential sites within the footprint involve no resettlement. IDA will not finance civil works
on land for which there is involuntary resettlement and/or any claims.
4. During negotiations the delegations from the four participating countries confirmed that
proposed construction and renovations will be done on land owned by the respective
governments and that there will be no involuntary displacement of any individuals since there are
no squatters or other vendors at these sites. In cases involving construction, such as a new health
laboratory or an annex to existing structures, the ESMF contains appropriate checklists and
diagnostic procedures to assess risks and identify appropriate mitigation measures. As agreed
during negotiations and as stipulated in Schedule 2 D (Environmental and Social Safeguards) of
the four Financing Agreements the project will not fund activities that would involve involuntary
resettlement. OP 4.10 is triggered in Kenya, and a separate Indigenous Peoples Policy
Framework (IPPF) was prepared and disclosed to ensure that the development process of this
project fully respects the dignity, rights, economies, and cultures of vulnerable indigenous
communities and that the project is able to gain the broad community support of affected
indigenous peoples and other marginalized groups.
5. The ESMF recommends that for successful implementation of the project, there is need to
ensure that existing environmental regulations are adhered to in all participating countries and
that there is broad based participation of key stakeholders. Other key recommendations include:
The screening process and the screening forms need to be used for all sub-projects.
164
The Environmental and Social Units in the respective ministries of health need to be
strengthened to oversee implementation.
Environmental and social awareness activities and related training need to be conducted.
Capacities need to be strengthened at the district levels and resources provided to carry
out these activities.
Staff capacities at all levels needs to be strengthened to adequately administer the ESMF.
165
Annex 11: Project Preparation and Supervision
AFRICA: East Africa Public Health Laboratory Networking Project
1. Project preparation has been led by the participating countries, and has benefited from
close collaboration from Development Partners (DPs) and regional institutions. Key institutions
responsible for preparation have included:
Ministry of Public Health and Sanitation, and Ministry of Medical Services, Kenya
Ministry of Health and Social Welfare, Tanzania
Ministry of Health, Uganda
Ministry of Health, Rwanda
East, Central, and Southern African Health Community
2. Supervision. The project will need intensive supervision, given the inherently risky
nature of this regional operation and the challenge of coordinating activities across four
countries. Therefore, the project will require a much heavier than normal supervision effort and
supervision budget. The overall supervision strategy is as follows:
Maintain a core team, consisting of the Task Team Leader, Deputy Team Leader
(field based), and M&E Specialist; the task team leader would provide overall
oversight and continue fostering the partnerships established during the preparation
process; the deputy would be field based and would provide technical back stopping
and operational support.
Continue to rely on country office fiduciary staff that can provide close support and
ensure synergies with broader country work in procurement, financial management,
and environmental and social safeguards.
Promote synergies between the activities supported under the regional project and
those funded under health sector investment operations in the participating countries;
this would imply that task team leaders and cluster leaders participate in supervision
missions, ensure that cross cutting issues (human resources, sector financing)
affecting implementation are raised in policy and budgetary dialogues with
government officials.
Tap expertise at the HSO hubs, particularly the Nairobi one, given its strategic
location.
Maintain a strong dialogue with key partners (e.g., WHO, CDC, USAID) and ensure
that they participate in the supervision efforts to share experiences and minimize risk
of duplication.
Mobilize trust fund resources to further support the Bank‘s supervision budget;
particular priority would be given to M&E, operational research, and performance
based financing, public/private partnerships.
Continue to take advantage of video conferencing to contain supervision costs and
maintain regular contact with country implementers.
Organize periodic mini Quality Enhancement Reviews to take stock of progress
attained and seek advice on challenging issues.
166
Organize reverse supervision missions by having country representatives come to
headquarters to benefit from exchanges with other sector staff working on similar or
complementary issues.
3. The frequency of supervision missions would be higher in the initial two years until the
project is on autopilot. The core team would conduct three supervision missions (i.e. every four
months) during the first year and one would coincide with the annual meeting of the Regional
Advisory Panel at ECSA-HC headquarters in Arusha. The deputy would conduct interim
missions, with a focus on the countries which need additional support. In subsequent years, there
would be at least two main supervision missions annually. The average annual supervision
budget required over the five years would be about US$200,000.
4. The timetable for preparation, including planned and actual milestones, is summarized
below:
Planned Actual
PCN review (PCN approval) 10/07/2008 10/07/2008 (12/8/2008)
Initial PID to PIC 11/21/2008
Initial ISDS to PIC 11/25/2008
Appraisal 2/15/2010 2/15/2010
Negotiations 4/7/2010 4/6/2010
Board 5/25/2010
Planned date of effectiveness 8/24/2010
Planned date of mid-term review 6/30/2013
Planned closing date 3/30/2016
5. Project Team: Peer reviewers for this operation are Gavin Macgregor-Skinner, Senior
TB Laboratory Advisor (USAID), Thomas M. Shinnick, Associate Director for Global Laboratory
Activities (CDC), Helen Perry, Integrated Disease Surveillance and Response Systems (CDC), Emanuele
Capobianco, Health Specialist (SASHD), Patricio Marquez, Lead Health Specialist (ECSHD),
Montserrat Meiro-Lorenzo, Senior Health Specialist (HDNHE), Eduard R. Bos, Lead Population
Specialist (HDNHE), and Peter Berman, Lead Health Economist (HDNHE). Bank staff and
consultants who worked on the project include:
Name Title Unit
Aissatou Diallo Finance Officer CTRFC
Alex Kamurase Social Protection Specialist AFTSP
Aly Sy Senior Health Specialist AFTHE
Amy Ba Task Team Assistant AFTHE
Antoinette Kamanzi Procurement Assistant AFTPC
Arleen Seed Senior E-Government Specialist ISGLA
Bella Leloume Diallo Senior Financial Management Specialist AFTFM
Chantal Kajangwe Procurement Analyst AFTPC
Edith Ruguru Mwenda Senior Counsel LEGAF
Emmanuel Malangalila Senior Health Specialist, Consultant AFTHE
Evelyne Kapya Program Assistant AFCE1
167
Name Title Unit
Frode Davanger Operations Officer AFCRI
Francois Boillot Health Systems Specialist, Consultant
Gayle Martin Senior Economist (Health) AFTHE
Gladys Alupo Team Assistant AFMUG
Gisbert Kinyero Procurement Specialist AFTPC
G.N.V. Ramana Lead Health Specialist AFTHE
Grace M. Munanura Procurement Specialist AFTPC
Henry Amuguni Financial Management Specialist AFTFM
Joel Munyori Procurement Specialist AFTPC
Joel Spicer Senior Health Specialist AFTHE
Jeremiah Chakaya TB Specialist, Consultant
John Paul Clark Senior Technical Specialist AFTHE
Josiane Niyonkuru Team Assistant AFMRW
Lucy Musira Team Assistant AFCE2
Luis M. Schwarz Senior Finance Officer CTRFC
Maria Cruz Lead Social Development Specialist AFTCS
Maryse Pierre-Louis
Lead HNP Specialist, Program Leader,
Disease Control Program AFTHE
Michael Mills Lead Economist and HD Sector Leader AFTHE
Michael Okuny Senior Financial Management Specialist AFTFM
Miriam Schneidman Lead Health Specialist, TTL AFTHE
Moussou Soukoule Language Program Assistant AFTHE
Nadège Nouviale Program Assistant AFTSP
Nyambura Githagui Senior Social Development Specialist AFTCS
Otieno Ayany Financial Management Specialist AFTFM
Pascal Tegwa Procurement Hub Coordinator AFTPC
Patrick Umah-Tete Senior Financial Management Specialist AFTFM
Paul Kamuchwezi Financial Management Specialist AFTFM
Paul Mahler Junior Professional Associate AFTHD
Peter Bachrach Institutional and Implementation Specialist,
Consultant
Peter Okwero Senior Health Specialist AFTHE
Pinki Chaudhuri Senior Operations Officer AFCRI
Rogers Kayihura
Communications and External Affairs
Officer AFREX
Sylvie Ingabire Team Assistant AFMRW
Timothy Clary Infectious Disease Specialist, Consultant
Uma Lele Economist, Consultant
Victoria Gyllerup M&E Specialist AFTRL
Wacuka Ikua Senior Operations Officer AFTHE
Staff from partner organizations:
Name Title Organization
Achilles Katamba, Technical Adviser TB-CAP, Uganda
Carlyn Collins Pathologist Laboratory Advisor Division of Laboratory Systems,
CDC
Catherine Mundy Principal Program Associate for USAID/MSH
168
Name Title Organization
Laboratory Services
Devery Howerton, Lab Systems Quality Manager Infectious Disease Labs, CDC
Edward Kataika Manager, Health Systems and Services
Development
ECSA-HC
Jeroen van Gorkam Deputy-Director Project Management
Unit
USAID (TB-CAP), KNCV
Tuberculosis Foundation
Kimberly McCarthy Microbiologist, Division of TB
Elimination
National Center for HIV, Hepatitis,
Sexually-Transmitted Infections, and
Tuberculosis Prevention, CDC
Linda M. Parsons Team Lead, Clinical and Opportunistic
Infection Team,
International Laboratory Branch,
Global AIDS Program, CDC
Maarten Bosman Public Health and TB Specialist USAID (TB-CAP)
Mark Rayfield Chief, Lab Systems Branch, CDC
Max Meis Public Health Specialist USAID (TB-CAP)
Robert Martin Laboratory Science Officer,
Coordinating Office for Global Health
CDC
Souleymane
Sawadogo
Lab Technical Adviser CDC
Stella Van Beers Laboratory Systems Specialist KIT
Thomas M. Shinnick Associate Director for Global Laboratory
Activities
Division of Tuberculosis
Elimination, CDC
Victor Ombeka TB Specialist TB-CAP, Kenya
6. Bank funds expended to date on project preparation are as follows:
Bank resources: US$446,000
Trust funds: US$34,000
Total: US$480,000
7. Estimated Approval and Supervision costs:
Remaining costs to approval: US$142,000
Estimated annual supervision cost: US$200,000
169
Annex 12: Documents in the Project File
AFRICA: East Africa Public Health Laboratory Networking Project
KENYA:
Identification Mission:
Kenya Aide Memoire, East Africa Public Health Laboratory Networking Project,
Identification Mission – April 6-17, 2009.
Consultant Report of the Scoping and Identification Mission to Kenya, April 13-17,
2009.
Back-to-Office Report, Identification Mission – April 6-17, 2009.
Preparation Mission:
Kenya Aide Memoire, East Africa Public Health Laboratory Networking Project
Preparation Mission – June 15-June 26, 2009.
Policy and Strategy Documents:
Kenya Project Technical Annex.
National Health Sector Strategic Plan II.
National Public Health Laboratory (NPHL) Plan.
Division of Leprosy, TB and Lung Disease (DLTLD) Strategic Plan.
Draft CTRL Strategic Plan.
Country Assistance Strategy (2007).
Laboratory Waste Management Plan (2009).
National Health Care Waste Management Plan (2005).
Indigenous/Marginalized Peoples Planning Framework (2009).
TANZANIA:
Identification Mission:
Tanzania Aide Memoire, East Africa Public Health Laboratory Networking Project,
Identification Mission, April 6-10, 2009.
Consultant Report of the Scoping and Identification Mission to Tanzania (Tanzania
CDC Report), April 6-11, 2009.
Back-to-Office Report, Identification Mission – April 6-10, 2009.
Preparation Mission:
Tanzania Aide Memoire, East Africa Public Health Laboratory Networking Project,
Preparation Mission – June 8 - 19, 2009.
Tanzania Technical Note, East Africa Public Health Laboratory Networking Project,
Preparation Mission – September 13, 2009.
Policy and Strategy Documents:
Tanzania Project Technical Annex.
National Health Laboratory Strategic Plan (2009-2015).
Country Assistance Strategy (2007).
National Health Care Waste Management Plan (2003).
Laboratory Waste Management Plan (2009).
170
UGANDA:
Identification Mission:
Uganda Aide Memoire, East Africa Public Health Laboratory Networking Project,
Identification Mission – March 29 to April 4, 2009.
Consultant Report of the Scoping and Identification Mission to Uganda (Uganda TMS
Report), March 29-April 4, 2009.
Back-to-Office Report, Identification Mission – March 30-April 4, 2009.
Preparation Mission:
Uganda Aide Memoire, East Africa Public Health Laboratory Networking Project,
Preparation Mission – May 25-June 5, 2009.
Uganda Technical Note, East Africa Public Health Laboratory Networking Project,
Preparation Mission – September 13, 2009.
Policy and Strategy Documents
Uganda Project Technical Annex.
Country Assistance Strategy (2005-2009).
National Health Care Waste Management Plan (2007/8- 2009-2010), prepared by the
Healthcare Waste Management Technical Working Group.
RWANDA:
Identification Mission:
Rwanda Aide Memoire, East Africa Public Health Laboratory Networking Project,
Identification Mission, October 2009.
Back-to-Office Report, Identification Mission – October 2009.
Preparation Mission:
Rwanda Aide Memoire, East Africa Public Health Laboratory Networking Project,
Preparation Mission – December 2009.
Policy and Strategy Documents:
National Environmental Health Policy (2008).
National Waste Management Plan (2008).
National Healthcare Waste Management (2009).
Rwanda Country Assistance Strategy (2002-2006).
Country Consultations
Agenda/Minutes, VC Consultation, July 22-24, 2009.
Agenda/Minutes, VC Consultation, July 31, 2009.
Agenda/Minutes, VC Consultation, August 19, 2009.
Agenda/Minutes, VC Consultation, September 9, 2009.
Other Project Documents:
Report o the Fact Finding Mission to the Regional Institutions in Arusha - February 19-
21, 2009.
Report of the Visit to the East, Central and Southern African Health Community
(ECSA-HC), April 2009.
171
Annex 13: Statement of Loans and Credits
AFRICA: East Africa Public Health Laboratory Networking Project
KENYA
CAS Annex B8 - Kenya
Operations Portfolio (IBRD/IDA and Grants)
As Of Date 3/3/2010
Closed Projects 128
IBRD/IDA *
Total Disbursed (Active) 491.46
of which has been repaid 0.00
Total Disbursed (Closed) 332.12
of which has been repaid 482.56
Total Disbursed (Active + Closed) 823.58
of which has been repaid 482.56
Total Undisbursed (Active) 1,013.52
Total Undisbursed (Closed) 0.00
Total Undisbursed (Active + Closed) 1,013.52
Difference Between
Active Projects Last PSR Expected and Actual
Supervision Rating Original Amount in US$ Millions Disbursements a/
Project ID Project Name Development Objectives
Implementation Progress
Fiscal Year IBRD IDA GRANT Cancel Undisb. Orig.
Frm Rev'd
P083250 KE-Financial & Legal Sec TA (FY05) S MS 2005 18 14.2453 13.595559 13.59556
P078058 KE-Arid Lands 2 SIL (FY03) S S 2003 120 17.1942 -52.2814 -5.96348
P111545 KE-Cash Transfer for OVC (FY09) MS MS 2009 50 50.8725 -1.83733
P078209 KE-Dev Learning Centre LIL MS S 2004 2.7 0.67438 0.3223227
P087479 KE-Edu Sec Sup Project (FY07) S MU 2007 80 26.2554 23.152798
P083131 KE-Energy Sec Recovery Prj (FY05) S S 2005 160 116.732 30.061366 -11.1045
P072981 KE-GEF W KE Int Ecosys Mgmt SIL (FY05) S S 2005 4.1 0.69985 0.6998503
P090567 KE-Inst Reform & CB TA (FY06) MS MS 2006 25 18.0291 16.521786
P095050 KE-NRM SIL (FY07) MU MU 2007 68.5 56.3788 4.019484 17.58726
P085414 KE-Natl STATCAP Dev S S 2007 20.5 17.9378 14.341158
P082615 KE-Northern Corridor Trnsprt SIL (FY04) S S 2004 460 348.418 63.585984 16.75253
P081712 KE-Tot War Against HIV/AIDS-TOWA (FY07 MS MS 2007 80 60.6489 72.841229
P074106 KE-W Kenya CDD/Flood Mitigation (FY07) MS MS 2007 86 71.4203 5.5018032
P096367 KE-Water & Sanitation Srv Impr (FY08) S S 2008 150 114.085 19.434751
P109683 Kenya Agric Productivity & Agribusiness S MU 2009 82 85.4486
P085007 MSME Competitiveness MS MS 2005 22 15.183 13.696745
Overall Result 1425 4.1 1014.22 223.65611 30.8674
172
IFC Committed and Disbursed Outstanding Investment Portfolio
Amounts in US Dollar Millions
Committed
Disbursed Outstanding
FY Commitment Company Loan Equity
**Quasi
Equity *GT/M Loan Equity
**Quasi
Equity *GT/RM
2007 ABE-Kenya 6.00 0.48 - -
- 0.48 - -
1999 AEF Deras Ltd. 1.00 - - -
1.00 - - -
2006/7/8/9/10 Barclays Bank - - - 0.28
- - - 0.28
2007 BP Kenya - 5.00 - -
- 3.10 - -
CfC Stanbic - - 10.00 -
- - 10.00 -
1982/93/2007/8/9/10 Diamond Trust 10.00 4.45 15.00 0.76
10.00 4.45 15.00 -
2009 Faulu Kenya - - - 4.75
- - - 4.75
2005/6/7/8/9/10 I & M Bank 0.90 - - 11.54
0.90 - - 11.54
1987/93 IPS(K)-Allpack - 0.36 - -
- 0.36 - -
1987 IPS(K)-Frigoken - 0.06 - -
- 0.06 - -
19987 IPS(K)-Prem food - 0.11 - -
- 0.11 - -
1997/2000/9 K-Rep Bank - 3.94 - -
- 1.51 - -
2008/9/10 KCB - - 0.16 -
- - 0.16 -
2007/8 Kenya Schools - - 0.78 -
- - 0.78 -
2006 Kingdom hotel 20.00 - - -
- - - -
2005 Kongoni 1.07 - - -
1.07 - - -
2000 Mabati 5.00 - - -
- - - -
2005 Magadi Soda Co. - - - 3.23
- - - 1.30
2007/8/9/10 Prime Kenya - - - 3.06
- - - 3.06
2007 RVR 22.00 - 10.00 -
- - 10.00 -
2008/9 Strathmore - - 1.75 -
- - 1.75 -
2009 TEL 7.00 - - -
- - - -
1990 TPS EA Ltd. - 0.04 1.98 -
- 0.04 1.98 -
2000/1 Tsavo Power 4.12 0.83 0.39 0.03
4.12 0.83 0.39 -
Total Portfolio: 77.09 15.27 37.37 26.32 17.09 10.94 37.37 21.90
* Denotes Guarantee and Risk Management Products.
** Quasi Equity includes both loan and equity types.
173
RWANDA
Closed Projects 62
IBRD/IDA *
Total Disbursed (Active) 123.81
of w hich has been repaid 0.00
Total Disbursed (Closed) 623.61
of w hich has been repaid 53.10
Total Disbursed (Active + Closed) 747.43
of w hich has been repaid 53.10
Total Undisbursed (Active) 280.70
Total Undisbursed (Closed) 1.09
Total Undisbursed (Active + Closed) 281.80
Active Projects
Project ID Project NameDevelopment
Objectives
Implementation
ProgressFiscal Year IDA GRANT Cancel. Undisb. Orig. Frm Rev'd
P097818 RW - Sustainable Energy Dev. Proj (GEF) S S 2010 7.8
P112712 RW Emergency Demob and Reintegration # # 2010 8 8.0
P057295 RW-Compet & Enterprise Dev (FY01) MS MS 2001 46.8 0.1 4.7 -7.1 -1.2
P074102 RW-Decentr & Community Dev Prj (FY04) S S 2004 20 0.9 -0.2
P070700 RW-GEF Crit Ecosystm Intgrtd Mgmt (FY05) S S 2005 4.3 1.5 1.5
P113241 RW-PRSG VI DPL # # 2010 115.8 112.4
P066386 RW-Pub Sec CB TAL (FY05) MS MU 2005 20 10.4 9.5
P105176 RW-Rural Sector Supt APL2 (FY08) S S 2008 35 23.6 10.4
P117758 RW-Second Community Living Standards Gra # # 2010 6 5.9
P079414 RW-Transport Sector Development Project MU MU 2008 11 8.6 5.8
P090194 RW-Urgent Electricity Rehab SIL (FY05) S S 2005 25 0.7 -0.5
P098926 RW-eRw anda TAL (FY07) S S 2007 10 3.7 2.4 -0.1
P114931 RW:Land Husband,Water Harvest,Hill Irrig # # 2010 34 32.7 3.2
P111567 Rw anda Electricity Access Scale-up Proj. S S 2010 70 69.1 1.7
Overall Result 401.6 12.1 0.1 282.2 26.7 -1.3
Original Amount in US$ Millions Disbursements a/
Difference Between
Expected and Actual
Supervision Rating
Rwanda
Last PSR
As Of Date 4/21/2010
CAS Annex B8 -
Operations Portfolio (IBRD/IDA and Grants)
174
Rwanda
Committed and Disbursed Outstanding Investment Portfolio
As of 3/31/2010
(In USD Millions)
Committed Disbursed Outstanding
FY Approval Company Loan Equity
**Quasi
Equity *GT/RM
Partici
pant Loan Equity
**Quasi
Equity *GT/RM
Partici
pant
0 Bakhresa rwanda 8 0 0 0 0 8 0 0 0 0
2007 Intraspeed 0 0 4.4 0 0 0 0 4.4 0 0
0 Lake kivu energy 0 0 4 0 0 0 0 0 0 0
2007 Mille collines 2.5 0 0 0 0 2.5 0 0 0 0
2008 Tps (r) 3.47 2 0 0 0 3.47 2 0 0 0
Total Portfolio: 13.97 2 8.4 0 0 13.97 2 4.4 0 0
* Denotes Guarantee and Risk Management Products.
** Quasi Equity includes both loan and equity types.
B8 (IFC) for Rwanda
175
TANZANIA
Closed Projects 127
IBRD/IDA *
Total Disbursed (Active) 1,157.19
of w hich has been repaid 0.00
Total Disbursed (Closed) 2,150.77
of w hich has been repaid 238.52
Total Disbursed (Active + Closed) 3,307.96
of w hich has been repaid 238.52
Total Undisbursed (Active) 1,014.30
Total Undisbursed (Closed) 2.36
Total Undisbursed (Active + Closed) 1,016.66
Active Projects
Project ID Project NameDevelopment
Objectives
Implementation
ProgressFiscal Year IBRD IDA GRANT Cancel. Undisb. Orig. Frm Rev'd
P099231 Financial Sector Support MS MS 2006 15 13.88111 9.7975728
P117242 TZ - Housing Finance Project # # 2010 40 38.86694 0.6833333
P114291 TZ : Accelerated Food Security Project MS MS 2009 160 135.8806 9.8885805
P103633 TZ Second Central Transport Corridor S S 2008 190 149.4847 102.12026
P070544 TZ-Accountability,Transparency&Integrity MU U 2006 40 27.24884 -3.220811
P085752 TZ-Agr Sec Dev (FY06) MS MS 2006 120 44.73299 -15.19133
P059073 TZ-Dar Water Supply & Sanitation (FY03) MS MS 2003 61.5 2.972662 -2.794392 -3.24995
P101645 TZ-Energy Development & Access Expansion S S 2008 130 103.0647 28.043582
P092154 TZ-GEF Energy Dvpt and Access Expansion S S 2008 6.5 5.9 2.6866667
P084213 TZ-GEF Marine & Coastal Env Mgmt (FY06) S S 2006 10 3.444695 1.8546953
P082335 TZ-Health Sector Development II (FY04) S S 2004 165 29.32041 -73.41803 -13.4277
P070736 TZ-Loc Govt Supt SIL (FY05) S S 2005 150 49.05594 -56.58087 5.423251
P073397 TZ-Lower Kihansi Env Mgmt TAL (FY02) S S 2002 9.8 1.553618 -2.940029 -0.12603
P082492 TZ-Marine & Coastal Env Mgmt SIL (FY06) S S 2006 51 17.37736 9.9355955
P067103 TZ-Partic Agr Dev & Empwrmnt SIL (FY03) S S 2003 56.58 3.44E-05 -6.328035
P092898 TZ-Performance Results & Accountability MS S 2008 40 21.0734 -0.869459
P085009 TZ-Private Sector/MSME Competitiveness MS MS 2006 95 32.81038 -3.94266
P098496 TZ-Sci.&Tech. High Educ. Prog-Ph.1 (FY08 S MS 2008 100 75.96822 9.3417933
P085786 TZ-Soc Action Fund 2 SIL (FY05) S S 2005 180 31.5188 -6.782803 3.217197
P002797 TZ-Songo Gas Dev & Power Gen (FY02) S S 2002 183 33.5229 2.3896948 49.85919
P096302 TZ-Sustainable Mgt of Min.Resources TAL S S 2009 50 52.85651 1.336345
P100314 TZ-Tax Modernization Project MS S 2006 12 0.971903 2E-08
P087154 TZ-Water Sector Support SIL MS MS 2007 200 110.7594 60.176586
P102262 TZ-Zanzibar Basic Educ. SIL (FY07) S S 2007 42 41.38038 7.2951538
Overall Result 2090.88 16.5 1023.646 73.481436 41.69592
Supervision Rating
Tanzania
Last PSR
As Of Date 4/21/2010
CAS Annex B8 -
Operations Portfolio (IBRD/IDA and Grants)
Original Amount in US$ Millions Disbursements a/
Difference Between
Expected and Actual
176
Tanzania
Committed and Disbursed Outstanding Investment Portfolio
As of 3/31/2010
(In USD Millions)
Committed Disbursed Outstanding
FY Approval Company Loan Equity
**Quasi
Equity *GT/RM
Partici
pant Loan Equity
**Quasi
Equity *GT/RM
Partici
pant
9/10/2007 Accesstanzania 2.05 0.88 0 0 0 1.03 0.88 0 0 0
2001 Aef boundary hil 0.2 0 0 0 0 0.2 0 0 0 0
0 Alaf 4.29 0 0 0 0 4.29 0 0 0 0
2005 Bbl 4 0 0 0 0 4 0 0 0 0
2007 Exim bank 3.25 0 0 0 0 3.25 0 0 0 0
2009 Green resources 10 0 8 0 0 5 0 0 0 0
2010 Helio resource 0 7.06 0 0 0 0 5.29 0 0 0
2007 Ifa-zanzibar 10.18 0 0 0 0 10.18 0 0 0 0
2000 Nbc 0 4 0 0 0 0 4 0 0 0
0 Stanbic tanzania 0 0 3 0 0 0 0 3 0 0
1994 Tanzania brewery 0 3.25 0 0 0 0 3.25 0 0 0
2008 Trl 44 0 0 0 0 14 0 0 0 0
Total Portfolio: 77.97 15.19 11 0 0 41.95 13.42 3 0 0
* Denotes Guarantee and Risk Management Products.
** Quasi Equity includes both loan and equity types.
B8 (IFC) for Tanzania
177
UGANDA
Closed Projects 91
IBRD/IDA *
Total Disbursed (Active) 568.65
of w hich has been repaid 0.00
Total Disbursed (Closed) 1,829.32
of w hich has been repaid 163.37
Total Disbursed (Active + Closed) 2,397.97
of w hich has been repaid 163.37
Total Undisbursed (Active) 734.26
Total Undisbursed (Closed) 0.28
Total Undisbursed (Active + Closed) 734.54
Active Projects
Project ID Project NameDevelopment
Objectives
Implementation
ProgressFiscal Year
IB
RDIDA GRANT Cancel. Undisb. Orig. Frm Rev'd
P069208 UG - Power Sector Dev. Project (FY07) S S 2007 300 83.11829 35.719968
P073089 UG-EMCBP SIL 2 (FY01) S S 2001 37 14.33456 -3.205814 7.994186
P075932 UG-GEF PAMSU SIL (FY03) S S 2003 8 0.209876 0.2098758
P078382 UG-Kampala Inst & Infrast Dev Prj (FY08) S MS 2008 33.6 30.32742 24.557265
P090867 UG-Local Govt Mgt Svc Del Pjt (FY08) S MS 2008 55 35.82896 17.538898
P086513 UG-Millennium Science Init (FY06) S S 2006 30 17.2768 1.7767426
P079925 UG-Natl Re Dev TAL (FY04) MS MS 2004 30 8.457382 1.3566064 0.997849
P065437 UG-PAMSU SIL (FY03) S S 2003 27 0.025065 -3.451826
P110803 UG-Post Primary Educ & Trg APL-1 (FY09) S S 2009 150 105.9288 -44.9323
P050439 UG-Priv & Utility Sec Reform (FY01) MS S 2001 48.5 12.13691247 8.533264 17.217963 11.71796
P083809 UG-Priv Sec Competitiveness 2 MS MS 2005 70 41.81667 38.576405
P050440 UG-Pub Serv Perform Enhance (FY06) MU MU 2006 70 51.208525 16.6723 59.788926 1.936769
P074079 UG-Road Dev APL 3 (FY05) S S 2005 107.6 10.27368 3.6779534 4.120091
P111633 UG-SEC N-Uganda SAF (NUSAF2) (FY09) S S 2009 100 87.32002
P112334 UG: Energy for Rural Transformation APL2 S S 2009 75 73.86239 8.94445
P112340 UG: GEF Energy for Rural Transf. APL2 S S 2009 9 9 1.207026
P110207 UG:Program for Control of Avian Influ U U 2008 10 9.478064 5.5
P092837 UG:Transport Sector Development Project # # 2010 190 191.0052 1.66E-06
Overall Result 1333.7 17 63.34543747 743.4688 149.18214 26.76686
Supervision Rating
Uganda
Last PSR
As Of Date 4/21/2010
CAS Annex B8 -
Operations Portfolio (IBRD/IDA and Grants)
Original Amount in US$ Millions Disbursements a/
Difference Between
Expected and Actual
178
Uganda
Committed and Disbursed Outstanding Investment Portfolio
As of 3/31/2010
(In USD Millions)
Committed Disbursed Outstanding
FY Approval Company Loan Equity
**Quasi
Equity *GT/RM
Partici
pant Loan Equity
**Quasi
Equity *GT/RM
Partici
pant
1992 Aef clovergem 0.84 0 0 0 0 0.84 0 0 0 0
2007 Bujagali energy 100 0 30 0 0 55.25 0 30 0 0
2007 Celtel uganda 16.29 0 0 0 9.36 16.29 0 0 0 9.36
0 Dfcu bank 7.86 0 3 0 0 7.86 0 0 0 0
2009 Pine 2.5 0 2.5 0 0 0 0 0 0 0
2009 Umeme 25 0 0 0 0 5 0 0 0 0
Total Portfolio: 152.49 0 35.5 0 9.36 85.24 0 30 0 9.36
* Denotes Guarantee and Risk Management Products.
** Quasi Equity includes both loan and equity types.
B8 (IFC) for Uganda
179
Annex 14: Countries at a Glance
AFRICA: East Africa Public Health Laboratory Networking Project
Kenya at a glance 2/25/10
Sub-
Key D evelo pment Indicato rs Saharan Low
Kenya Africa income
(2008)
Population, mid-year (millions) 38.5 818 973
Surface area (thousand sq. km) 580 24,242 19,310
Population growth (%) 2.7 2.5 2.1
Urban population (% of to tal population) 22 36 29
GNI (Atlas method, US$ billions) 28.4 885 510
GNI per capita (Atlas method, US$) 740 1,082 524
GNI per capita (PPP, international $) 1,580 1,991 1,407
GDP growth (%) 1.7 5.0 6.4
GDP per capita growth (%) -1.0 2.5 4.2
(mo st recent est imate, 2003–2008)
Poverty headcount ratio at $1.25 a day (PPP, %) 20 51 ..
Poverty headcount ratio at $2.00 a day (PPP, %) 40 73 ..
Life expectancy at birth (years) 54 52 59
Infant mortality (per 1,000 live births) 80 89 78
Child malnutrition (% of children under 5) 17 27 28
Adult literacy, male (% of ages 15 and o lder) .. 71 72
Adult literacy, female (% of ages 15 and o lder) .. 54 55
Gross primary enro llment, male (% of age group) 113 103 102
Gross primary enro llment, female (% of age group) 112 93 95
Access to an improved water source (% of population) 57 58 67
Access to improved sanitation facilities (% of population) 42 31 38
N et A id F lo ws 1980 1990 2000 2008 a
(US$ millions)
Net ODA and official aid 393 1,181 510 1,275
Top 3 donors (in 2007):
United States 39 95 46 325
European Commission 14 40 19 114
United Kingdom 39 67 73 111
Aid (% of GNI) 5.6 14.4 4.1 4.7
Aid per capita (US$) 24 50 16 34
Lo ng-T erm Eco no mic T rends
Consumer prices (annual % change) 13.9 17.8 10.0 25.1
GDP implicit deflator (annual % change) 9.6 10.6 6.1 13.1
Exchange rate (annual average, local per US$) 7.4 22.9 76.3 69.2
Terms of trade index (2000 = 100) 86 85 100 116
1980–90 1990–2000 2000–08
Population, mid-year (millions) 16.3 23.4 31.3 38.5 3.6 2.9 2.6
GDP (US$ millions) 7,265 8,591 12,691 30,355 4.2 2.2 4.5
Agriculture 32.6 29.5 32.4 27.0 3.3 1.9 2.7
Industry 20.8 19.0 16.9 18.8 3.9 1.2 4.9
M anufacturing 12.8 11.7 11.6 12.1 4.9 1.3 4.4
Services 46.6 51.4 50.7 54.2 4.9 3.2 4.4
Household final consumption expenditure 62.1 62.8 77.7 77.7 4.5 3.6 4.8
General gov't final consumption expenditure 19.8 18.6 15.1 17.2 2.6 6.9 2.6
Gross capital formation 24.5 24.2 17.4 19.2 0.4 6.1 8.5
Exports o f goods and services 29.5 25.7 21.6 27.3 4.4 1.0 7.0
Imports of goods and services 35.9 31.3 31.7 41.4 1.9 9.4 8.4
Gross savings 15.4 18.6 13.0 12.8
Note: Figures in italics are for years other than those specified. 2008 data are preliminary. .. indicates data are not available.
a. A id data are for 2007.
Development Economics, Development Data Group (DECDG).
(average annual growth %)
(% of GDP)
10 5 0 5 10
0-4
15-19
30-34
45-49
60-64
75-79
percent of total population
Age distribution, 2008
Male Female
0
50
100
150
200
1990 1995 2000 2007
Kenya Sub-Saharan Africa
Under-5 mortality rate (per 1,000)
-6
-3
0
3
6
9
95 05
GDP GDP per capita
Growth of GDP and GDP per capita (%)
180
Kenya
Balance of Payments and Trade 2000 2008
(US$ millions)
Total merchandise exports (fob) 1,773 4,665
Total merchandise imports (cif) 3,306 9,726
Net trade in goods and services -1,288 -4,114
Current account balance -557 -2,069 as a % of GDP -4.4 -6.8
Workers' remittances and
compensation of employees (receipts) 538 1,692
Reserves, including gold 897 2,928
Central Government Finance
(% of GDP)
Current revenue (including grants) 18.8 25.3
Tax revenue 15.8 20.6
Current expenditure 16.3 28.7
Technology and Infrastructure 2000 2008Overall surplus/deficit 0.6 -8.0
Paved roads (% of total) 12.1 14.1
Highest marginal tax rate (%) Fixed line and mobile phone
Individual 30 30 subscribers (per 100 people) 1 43
Corporate 30 30 High technology exports (% of manufactured exports) 3.9 5.4
External Debt and Resource Flows
Environment
(US$ millions)
Total debt outstanding and disbursed 6,141 7,441 Agricultural land (% of land area) 47 47
Total debt service 591 409 Forest area (% of land area) 6.3 6.2
Debt relief (HIPC, MDRI) – – Nationally protected areas (% of land area) .. 12.1
Total debt (% of GDP) 48.4 24.5 Freshwater resources per capita (cu. meters) 629 552
Total debt service (% of exports) 21.2 4.3 Freshwater withdrawal (billion cubic meters) 1.6 2.7
Foreign direct investment (net inflows) 111 96 CO2 emissions per capita (mt) 0.33 0.31
Portfolio equity (net inflows) -6 5
GDP per unit of energy use
(2005 PPP $ per kg of oil equivalent) 2.7 2.8
Energy use per capita (kg of oil equivalent) 481 491
World Bank Group portfolio 2000 2008
(US$ millions)
IBRD
Total debt outstanding and disbursed 47 0
Disbursements 0 0
Principal repayments 40 0
Interest payments 7 0
IDA
Total debt outstanding and disbursed 2,262 3,050
Disbursements 170 178
Private Sector Development 2000 2008 Total debt service 45 99
Time required to start a business (days) – 30 IFC (fiscal year)
Cost to start a business (% of GNI per capita) – 39.7 Total disbursed and outstanding portfolio 99 104
Time required to register property (days) – 64 of which IFC own account 99 94
Disbursements for IFC own account 40 11
Ranked as a major constraint to business 2000 2008 Portfolio sales, prepayments and
(% of managers surveyed who agreed) repayments for IFC own account 14 31
Access to/cost of financing .. 72.5
Corruption .. 72.5 MIGA
Gross exposure 42 102
Stock market capitalization (% of GDP) 10.1 36.0 New guarantees 37 95
Bank capital to asset ratio (%) 12.9 12.4
Note: Figures in italics are for years other than those specified. 2008 data are preliminary. 2/25/10
.. indicates data are not available. – indicates observation is not applicable.
Development Economics, Development Data Group (DECDG).
0 25 50 75 100
Control of corruption
Rule of law
Regulatory quality
Political stability
Voice and accountability
Country's percentile rank (0-100)higher values imply better ratings
2008
2000
IBRD, 0
IDA, 3,050
IMF, 252
Other multi-lateral, 638
Bilateral, 2,278
Private, 302
Short-term, 921
181
Millennium Development Goals Kenya
With selected targets to achieve between 1990 and 2015(estimate closest to date shown, +/- 2 years)
Goal 1: halve the rates for extreme poverty and malnutrition 1990 1995 2000 2008
Poverty headcount ratio at $1.25 a day (PPP, % of population) 38.4 19.6 .. 19.7
Poverty headcount ratio at national poverty line (% of population) .. 52.0 .. ..
Share of income or consumption to the poorest qunitile (%) 3.4 5.6 .. 4.7
Prevalence of malnutrition (% of children under 5) .. 20.1 17.5 16.5
Goal 2: ensure that children are able to complete primary schooling
Primary school enrollment (net, %) .. .. 66 86
Primary completion rate (% of relevant age group) .. .. .. 93
Secondary school enrollment (gross, %) 48 40 39 53
Youth literacy rate (% of people ages 15-24) .. .. 80 ..
Goal 3: eliminate gender disparity in education and empower women
Ratio of girls to boys in primary and secondary education (%) 94 .. 98 95
Women employed in the nonagricultural sector (% of nonagricultural employment) 21 27 .. ..
Proportion of seats held by women in national parliament (%) 1 3 4 9
Goal 4: reduce under-5 mortality by two-thirds
Under-5 mortality rate (per 1,000) 97 111 117 121
Infant mortality rate (per 1,000 live births) 64 72 77 80
Measles immunization (proportion of one-year olds immunized, %) 78 83 75 80
Goal 5: reduce maternal mortality by three-fourths
Maternal mortality ratio (modeled estimate, per 100,000 live births) .. .. .. 560
Births attended by skilled health staff (% of total) 50 45 44 42
Contraceptive prevalence (% of women ages 15-49) 27 33 39 39
Goal 6: halt and begin to reverse the spread of HIV/AIDS and other major diseases
Prevalence of HIV (% of population ages 15-49) .. .. .. ..
Incidence of tuberculosis (per 100,000 people) 112 224 405 353
Tuberculosis cases detected under DOTS (%) .. 58 53 72
Goal 7: halve the proportion of people without sustainable access to basic needs
Access to an improved water source (% of population) 41 46 51 57
Access to improved sanitation facilities (% of population) 39 40 41 42
Forest area (% of total land area) 6.5 6.4 6.3 6.2
Nationally protected areas (% of total land area) .. .. .. 12.1
CO2 emissions (metric tons per capita) 0.2 0.3 0.3 0.3
GDP per unit of energy use (constant 2005 PPP $ per kg of oil equivalent) 3.0 2.8 2.7 2.8
Goal 8: develop a global partnership for development
Telephone mainlines (per 100 people) 0.7 0.9 0.9 0.7
Mobile phone subscribers (per 100 people) 0.0 0.0 0.4 42.1
Internet users (per 100 people) 0.0 0.0 0.3 8.7
Personal computers (per 100 people) 0.0 0.1 0.5 1.4
Note: Figures in italics are for years other than those specified. .. indicates data are not available. 2/25/10
Development Economics, Development Data Group (DECDG).
Kenya
0
25
50
75
100
125
2000 2002 2004 2006 2008
Primary net enrollment ratio
Ratio of girls to boys in primary & secondary education
0
10
20
30
40
50
2000 2002 2004 2006 2008
Fixed + mobile subscribers Internet users
0
25
50
75
100
1990 1995 2000 2007
Kenya Sub-Saharan Africa
182
Rwanda at a glance 2/25/10
Sub-
Key D evelo pment Indicato rs Saharan Low
Rwanda Africa income
(2008)
Population, mid-year (millions) 9.7 818 973
Surface area (thousand sq. km) 26 24,242 19,310
Population growth (%) 2.8 2.5 2.1
Urban population (% of to tal population) 18 36 29
GNI (Atlas method, US$ billions) 4.3 885 510
GNI per capita (Atlas method, US$) 440 1,082 524
GNI per capita (PPP, international $) 1,010 1,991 1,407
GDP growth (%) 11.2 5.0 6.4
GDP per capita growth (%) 8.2 2.5 4.2
(mo st recent est imate, 2003–2008)
Poverty headcount ratio at $1.25 a day (PPP, %) 77 51 ..
Poverty headcount ratio at $2.00 a day (PPP, %) 90 73 ..
Life expectancy at birth (years) 50 52 59
Infant mortality (per 1,000 live births) 109 89 78
Child malnutrition (% of children under 5) 18 27 28
Adult literacy, male (% of ages 15 and o lder) .. 71 72
Adult literacy, female (% of ages 15 and o lder) .. 54 55
Gross primary enro llment, male (% of age group) 146 103 102
Gross primary enro llment, female (% of age group) 149 93 95
Access to an improved water source (% of population) 65 58 67
Access to improved sanitation facilities (% of population) 23 31 38
N et A id F lo ws 1980 1990 2000 2008 a
(US$ millions)
Net ODA and official aid 154 288 321 713
Top 3 donors (in 2007):
United Kingdom 0 1 53 95
United States 7 13 23 91
European Commission 21 36 49 79
Aid (% of GNI) 13.2 11.2 18.7 21.0
Aid per capita (US$) 30 40 40 75
Lo ng-T erm Eco no mic T rends
Consumer prices (annual % change) 7.2 4.2 3.9 15.4
GDP implicit deflator (annual % change) 3.1 13.5 -3.0 17.4
Exchange rate (annual average, local per US$) 92.8 82.6 389.7 546.9
Terms of trade index (2000 = 100) .. 78 100 69
1980–90 1990–2000 2000–08
Population, mid-year (millions) 5.2 7.2 8.0 9.7 3.2 1.1 2.5
GDP (US$ millions) 1,163 2,584 1,735 4,457 2.2 -0.2 6.7
Agriculture 45.8 32.5 37.2 37.4 0.5 2.5 3.5
Industry 21.5 24.6 13.6 14.1 2.5 -3.8 8.7
M anufacturing 15.3 18.3 7.0 4.5 2.6 -5.8 5.4
Services 32.6 42.8 49.2 48.5 3.6 -0.9 8.9
Household final consumption expenditure 83.3 83.7 87.7 82.1 1.2 0.4 ..
General gov't final consumption expenditure 12.5 10.1 11.0 10.2 5.2 -2.6 ..
Gross capital formation 16.1 14.6 18.3 24.1 4.3 0.4 ..
Exports o f goods and services 14.4 5.6 8.7 14.9 3.4 -6.4 ..
Imports o f goods and services 26.4 14.1 25.7 31.2 2.6 6.1 ..
Gross savings 13.3 11.3 12.9 28.3
Note: Figures in italics are for years other than those specified. 2008 data are preliminary. .. indicates data are not available.
a. A id data are for 2007.
Development Economics, Development Data Group (DECDG).
(average annual growth %)
(% of GDP)
10 5 0 5 10
0-4
15-19
30-34
45-49
60-64
75-79
percent of total population
Age distribution, 2008
Male Female
0
50
100
150
200
250
1990 1995 2000 2007
Rwanda Sub-Saharan Africa
Under-5 mortality rate (per 1,000)
-60
-40
-20
0
20
40
95 05
GDP GDP per capita
Growth of GDP and GDP per capita (%)
183
Rwanda
B alance o f P ayments and T rade 2000 2008
(US$ millions)
Total merchandise exports (fob) 90 257
Total merchandise imports (cif) 328 881
Net trade in goods and services -291 -727
Current account balance -90 -244
as a % of GDP -5.2 -5.5
Workers' remittances and
compensation of employees (receipts) 7 51
Reserves, including gold 191 536
C entral Go vernment F inance
(% of GDP)
Current revenue (including grants) 20.2 27.1
Tax revenue 9.7 13.5
Current expenditure 13.2 15.1
T echno lo gy and Infrastructure 2000 2008
Overall surplus/deficit 0.8 0.5
Paved roads (% of to tal) 8.3 19.0
Highest marginal tax rate (%) Fixed line and mobile phone
Individual .. .. subscribers (per 100 people) 1 14
Corporate .. .. High technology exports
(% of manufactured exports) 0.6 16.3
External D ebt and R eso urce F lo ws
Enviro nment
(US$ millions)
Total debt outstanding and disbursed 1,272 679 Agricultural land (% of land area) 68 79
Total debt service 35 19 Forest area (% of land area) 13.9 19.5
Debt relief (HIPC, M DRI) 908 225 Nationally protected areas (% of land area) .. 8.1
Total debt (% of GDP) 73.3 15.2 Freshwater resources per capita (cu. meters) 1,113 1,005
Total debt service (% of exports) 21.4 4.9 Freshwater withdrawal (billion cubic meters) 0.2 ..
Foreign direct investment (net inflows) 8 103 CO2 emissions per capita (mt) 0.07 0.07
Portfo lio equity (net inflows) 0 0
GDP per unit o f energy use
(2005 PPP $ per kg of o il equivalent) .. ..
Energy use per capita (kg of o il equivalent) .. ..
Wo rld B ank Gro up po rtfo lio 2000 2008
(US$ millions)
IBRD
Total debt outstanding and disbursed 0 0
Disbursements 0 0
Principal repayments 0 0
Interest payments 0 0
IDA
Total debt outstanding and disbursed 692 242
Disbursements 37 41
P rivate Secto r D evelo pment 2000 2008 Total debt service 11 2
Time required to start a business (days) – 14 IFC (fiscal year)
Cost to start a business (% of GNI per capita) – 108.9 Total disbursed and outstanding portfo lio 2 6
Time required to register property (days) – 315 o f which IFC own account 2 6
Disbursements for IFC own account 0 3
Ranked as a major constraint to business 2000 2008 Portfo lio sales, prepayments and
(% of managers surveyed who agreed) repayments for IFC own account 0 0
Electricity .. 31.8
Tax rates .. 26.9 M IGA
Gross exposure – 17
Stock market capitalization (% of GDP) .. .. New guarantees – 17
Bank capital to asset ratio (%) 8.1 9.2
Note: Figures in italics are for years other than those specified. 2008 data are preliminary. 2/25/10
.. indicates data are not available. – indicates observation is not applicable.
Development Economics, Development Data Group (DECDG).
0 25 50 75 100
Control of corruption
Rule of law
Regulatory quality
Political stability
Voice and accountability
Country's percentile rank (0-100)higher values imply better ratings
2008
2000
Governance indicators, 2000 and 2008
Source: Kaufmann-Kraay-Mastruzzi, World Bank
IBRD, 0
IDA, 242
IMF, 11Other multi-lateral, 313
Bilateral, 90
Private, 0 Short-term, 23
Composition of total external debt, 2008
US$ millions
184
Millennium Development Goals Rwanda
With selected targets to achieve between 1990 and 2015(estimate closest to date shown, +/- 2 years)
Go al 1: halve the rates fo r extreme po verty and malnutrit io n 1990 1995 2000 2008
Poverty headcount ratio at $1.25 a day (PPP, % of population) .. .. 76.6 ..
Poverty headcount ratio at national poverty line (% of population) .. 51.2 60.3 ..
Share of income or consumption to the poorest qunitile (%) .. .. 5.3 ..
Prevalence of malnutrition (% of children under 5) 24.3 .. 20.3 18.0
Go al 2: ensure that children are able to co mplete primary scho o ling
Primary school enro llment (net, %) 67 .. 68 94
Primary completion rate (% of relevant age group) 37 .. 21 35
Secondary school enro llment (gross, %) 8 .. 10 18
Youth literacy rate (% of people ages 15-24) 75 .. 78 ..
Go al 3: e liminate gender disparity in educat io n and empo wer wo men
Ratio of girls to boys in primary and secondary education (%) 92 .. 96 100
Women employed in the nonagricultural sector (% of nonagricultural employment) .. 32 33 ..
Proportion of seats held by women in national parliament (%) 17 17 17 56
Go al 4: reduce under-5 mo rtality by two -thirds
Under-5 mortality rate (per 1,000) 195 193 189 181
Infant mortality rate (per 1,000 live births) 117 115 113 109
M easles immunization (proportion of one-year o lds immunized, %) 83 84 74 99
Go al 5: reduce maternal mo rtality by three-fo urths
M aternal mortality ratio (modeled estimate, per 100,000 live births) .. .. .. 1,300
B irths attended by skilled health staff (% of to tal) 26 .. 31 39
Contraceptive prevalence (% of women ages 15-49) 21 14 13 17
Go al 6: halt and begin to reverse the spread o f H IV/ A ID S and o ther majo r diseases
Prevalence of HIV (% of population ages 15-49) 9.2 7.0 4.7 2.8
Incidence of tuberculosis (per 100,000 people) 167 241 348 397
Tuberculosis cases detected under DOTS (%) .. 34 32 25
Go al 7: halve the pro po rt io n o f peo ple witho ut sustainable access to basic needs
Access to an improved water source (% of population) 65 64 65 65
Access to improved sanitation facilities (% of population) 29 26 25 23
Forest area (% of to tal land area) 12.9 13.4 13.9 19.5
Nationally protected areas (% of to tal land area) .. .. .. 8.1
CO2 emissions (metric tons per capita) 0.1 0.1 0.1 0.1
GDP per unit o f energy use (constant 2005 PPP $ per kg of o il equivalent) .. .. .. ..
Go al 8: develo p a glo bal partnership fo r develo pment
Telephone mainlines (per 100 people) 0.1 0.1 0.2 0.2
M obile phone subscribers (per 100 people) 0.0 0.0 0.5 13.6
Internet users (per 100 people) 0.0 0.0 0.1 3.1
Personal computers (per 100 people) .. .. 0.1 0.3
Note: Figures in italics are for years other than those specified. .. indicates data are not available. 2/25/10
Development Economics, Development Data Group (DECDG).
R wanda
0
25
50
75
100
125
2000 2002 2004 2006 2008
Primary net enrollment ratio
Ratio of girls to boys in primary & secondary education
Education indicators (%)
0
5
10
15
2000 2002 2004 2006 2008
Fixed + mobile subscribers
Internet users
ICT indicators (per 100 people)
0
25
50
75
100
1990 1995 2000 2007
Rwanda Sub-Saharan Africa
Measles immunization (% of 1-year olds)
185
Tanzania at a glance 2/25/10
Sub-Key Development Indicators Saharan Low
Tanzania Africa income(2008)
Population, mid-year (millions) 42.5 818 973
Surface area (thousand sq. km) 947 24,242 19,310Population grow th (%) 2.9 2.5 2.1Urban population (% of total population) 26 36 29
GNI (Atlas method, US$ billions) 18.3 885 510GNI per capita (Atlas method, US$) 440 1,082 524GNI per capita (PPP, international $) 1,230 1,991 1,407
GDP grow th (%) 7.5 5.0 6.4GDP per capita grow th (%) 4.4 2.5 4.2
(most recent estimate, 2003–2008)
Poverty headcount ratio at $1.25 a day (PPP, %) 89 51 ..Poverty headcount ratio at $2.00 a day (PPP, %) 97 73 ..Life expectancy at birth (years) 56 52 59Infant mortality (per 1,000 live births) 73 89 78Child malnutrition (% of children under 5) 17 27 28
Adult literacy, male (% of ages 15 and older) 79 71 72Adult literacy, female (% of ages 15 and older) 66 54 55Gross primary enrollment, male (% of age group) 112 103 102Gross primary enrollment, female (% of age group) 113 93 95
Access to an improved w ater source (% of population) 55 58 67Access to improved sanitation facilities (% of population) 33 31 38
Net Aid Flows 1980 1990 2000 2008 a
(US$ millions)Net ODA and off icial aid 676 1,163 1,035 2,811Top 3 donors (in 2007): Japan 39 41 217 722 United Kingdom 73 27 153 232 European Commission 25 42 32 187
Aid (% of GNI) .. 28.6 11.6 17.4
Aid per capita (US$) 36 46 30 68
Long-Term Economic Trends
Consumer prices (annual % change) 30.2 35.8 6.2 5.4GDP implicit deflator (annual % change) .. 22.4 7.5 8.9
Exchange rate (annual average, local per US$) 8.2 195.1 800.4 1,196.3Terms of trade index (2000 = 100) 83 61 100 77
1980–901990–2000 2000–08
Population, mid-year (millions) 18.7 25.5 34.1 42.5 3.1 2.9 2.7GDP (US$ millions) .. 4,259 9,079 20,490 .. 2.9 6.8
Agriculture .. 46.0 45.0 45.3 .. 3.2 4.9Industry .. 17.7 15.7 17.4 .. 3.1 9.6 Manufacturing .. 9.3 7.5 6.9 .. 2.7 8.0Services .. 36.4 39.2 37.3 .. 2.7 6.2
Household f inal consumption expenditure .. 80.9 79.2 73.1 .. 5.1 3.0General gov't f inal consumption expenditure .. 17.8 10.6 16.2 .. -7.0 16.9Gross capital formation .. 26.1 17.6 16.6 .. -1.6 7.3
Exports of goods and services .. 12.6 16.8 21.7 .. 9.3 12.0Imports of goods and services .. 37.5 24.2 27.5 .. 3.9 5.7Gross savings .. 7.7 8.5 9.5
Note: Figures in italics are for years other than those specif ied. 2008 data are preliminary. .. indicates data are not available.a. Aid data are for 2007.
Development Economics, Development Data Group (DECDG).
(average annual growth %)
(% of GDP)
10 5 0 5 10
0-4
15-19
30-34
45-49
60-64
75-79
percent of total population
Age distribution, 2008
Male Female
0
50
100
150
200
1990 1995 2000 2007
Tanzania Sub-Saharan Africa
Under-5 mortality rate (per 1,000)
-4
0
4
8
95 05
GDP GDP per capita
Growth of GDP and GDP per capita (%)
186
Tanzania
B alance o f P ayments and T rade 2000 2008
(US$ millions)
Total merchandise exports (fob) 663 2,141
Total merchandise imports (cif) 1,534 4,598
Net trade in goods and services -757 -1,431
Current account balance -916 -1,556
as a % of GDP -10.1 -10.9
Workers' remittances and
compensation of employees (receipts) 8 15
Reserves, including gold .. ..
C entral Go vernment F inance
(% of GDP)
Current revenue (including grants) 10.6 12.4
Tax revenue 9.5 11.5
Current expenditure 11.1 17.2
T echno lo gy and Infrastructure 2000 2008
Overall surplus/deficit -5.4 -11.6
Paved roads (% of to tal) 4.2 8.6
Highest marginal tax rate (%) Fixed line and mobile phone
Individual 30 30 subscribers (per 100 people) 1 31
Corporate 30 30 High technology exports
(% of manufactured exports) 1.2 1.5
External D ebt and R eso urce F lo ws
Enviro nment
(US$ millions)
Total debt outstanding and disbursed 7,136 5,938 Agricultural land (% of land area) 38 39
Total debt service 166 65 Forest area (% of land area) 42.1 39.8
Debt relief (HIPC, M DRI) 2,828 2,038 Nationally protected areas (% of land area) .. 38.7
Total debt (% of GDP) 78.6 29.0 Freshwater resources per capita (cu. meters) 2,336 2,035
Total debt service (% of exports) 12.3 3.4 Freshwater withdrawal (billion cubic meters) 5.2 ..
Foreign direct investment (net inflows) 463 744 CO2 emissions per capita (mt) 0.08 0.12
Portfo lio equity (net inflows) 0 3
GDP per unit o f energy use
(2005 PPP $ per kg of o il equivalent) 2.2 2.1
Energy use per capita (kg of o il equivalent) 394 519
Wo rld B ank Gro up po rtfo lio 2000 2008
(US$ millions)
IBRD
Total debt outstanding and disbursed 11 0
Disbursements 0 0
Principal repayments 4 0
Interest payments 1 0
IDA
Total debt outstanding and disbursed 2,593 1,971
Disbursements 142 394
P rivate Secto r D evelo pment 2000 2008 Total debt service 23 14
Time required to start a business (days) – 29 IFC (fiscal year)
Cost to start a business (% of GNI per capita) – 41.5 Total disbursed and outstanding portfo lio 43 43
Time required to register property (days) – 73 o f which IFC own account 43 43
Disbursements for IFC own account 8 20
Ranked as a major constraint to business 2000 2008 Portfo lio sales, prepayments and
(% of managers surveyed who agreed) repayments for IFC own account 4 3
Electricity .. 72.9
Access to /cost o f financing .. 9.3 M IGA
Gross exposure 175 76
Stock market capitalization (% of GDP) 2.6 6.3 New guarantees 172 0
Bank capital to asset ratio (%) .. ..
Note: Figures in italics are for years other than those specified. 2008 data are preliminary. 2/25/10
.. indicates data are not available. – indicates observation is not applicable.
Development Economics, Development Data Group (DECDG).
0 25 50 75 100
Control of corruption
Rule of law
Regulatory quality
Political stability
Voice and accountability
Country's percentile rank (0-100)higher values imply better ratings
2008
2000
Governance indicators, 2000 and 2008
Source: Kaufmann-Kraay-Mastruzzi, World Bank
IBRD, 0
IDA, 1,971
IMF, 17
Other multi-lateral, 705
Bilateral, 945
Private, 978
Short-term, 1,322
Composition of total external debt, 2008
US$ millions
187
Millennium Development Goals Tanzania
With selected targets to achieve between 1990 and 2015(estimate closest to date shown, +/- 2 years)
Go al 1: halve the rates fo r extreme po verty and malnutrit io n 1990 1995 2000 2008
Poverty headcount ratio at $1.25 a day (PPP, % of population) 72.6 .. 88.5 ..
Poverty headcount ratio at national poverty line (% of population) 38.6 .. 35.7 ..
Share of income or consumption to the poorest qunitile (%) 7.4 .. 7.3 ..
Prevalence of malnutrition (% of children under 5) 25.1 26.9 25.3 16.7
Go al 2: ensure that children are able to co mplete primary scho o ling
Primary school enro llment (net, %) 51 .. 53 98
Primary completion rate (% of relevant age group) 62 .. 55 112
Secondary school enro llment (gross, %) 5 5 6 ..
Youth literacy rate (% of people ages 15-24) .. .. 78 78
Go al 3: e liminate gender disparity in educat io n and empo wer wo men
Ratio of girls to boys in primary and secondary education (%) 97 .. 99 ..
Women employed in the nonagricultural sector (% of nonagricultural employment) .. .. 29 ..
Proportion of seats held by women in national parliament (%) .. 18 16 30
Go al 4: reduce under-5 mo rtality by two -thirds
Under-5 mortality rate (per 1,000) 157 154 143 116
Infant mortality rate (per 1,000 live births) 96 94 89 73
M easles immunization (proportion of one-year o lds immunized, %) 80 78 78 90
Go al 5: reduce maternal mo rtality by three-fo urths
M aternal mortality ratio (modeled estimate, per 100,000 live births) .. .. .. 950
B irths attended by skilled health staff (% of to tal) 53 47 44 43
Contraceptive prevalence (% of women ages 15-49) 10 18 25 26
Go al 6: halt and begin to reverse the spread o f H IV/ A ID S and o ther majo r diseases
Prevalence of HIV (% of population ages 15-49) 4.8 7.4 7.1 6.2
Incidence of tuberculosis (per 100,000 people) 178 271 339 297
Tuberculosis cases detected under DOTS (%) .. 61 52 51
Go al 7: halve the pro po rt io n o f peo ple witho ut sustainable access to basic needs
Access to an improved water source (% of population) 49 50 53 55
Access to improved sanitation facilities (% of population) 35 35 34 33
Forest area (% of to tal land area) 46.8 44.5 42.1 39.8
Nationally protected areas (% of to tal land area) .. .. .. 38.7
CO2 emissions (metric tons per capita) 0.1 0.1 0.1 0.1
GDP per unit o f energy use (constant 2005 PPP $ per kg of o il equivalent) 2.2 2.2 2.2 2.1
Go al 8: develo p a glo bal partnership fo r develo pment
Telephone mainlines (per 100 people) 0.3 0.3 0.5 0.3
M obile phone subscribers (per 100 people) 0.0 0.0 0.3 30.6
Internet users (per 100 people) 0.0 0.0 0.1 1.2
Personal computers (per 100 people) .. 0.2 0.3 0.9
Note: Figures in italics are for years other than those specified. .. indicates data are not available. 2/25/10
Development Economics, Development Data Group (DECDG).
T anzania
0
25
50
75
100
125
2000 2002 2004 2006 2008
Primary net enrollment ratio
Ratio of girls to boys in primary & secondary education (..)
Education indicators (%)
0
10
20
30
40
2000 2002 2004 2006 2008
Fixed + mobile subscribers Internet users
ICT indicators (per 100 people)
0
25
50
75
100
1990 1995 2000 2007
Tanzania Sub-Saharan Africa
Measles immunization (% of 1-year olds)
188
Uganda at a glance 2/25/10
Sub-
Key D evelo pment Indicato rs Saharan Low
Uganda Africa income
(2008)
Population, mid-year (millions) 31.7 818 973
Surface area (thousand sq. km) 241 24,242 19,310
Population growth (%) 3.3 2.5 2.1
Urban population (% of to tal population) 13 36 29
GNI (Atlas method, US$ billions) 13.3 885 510
GNI per capita (Atlas method, US$) 420 1,082 524
GNI per capita (PPP, international $) 1,140 1,991 1,407
GDP growth (%) 9.5 5.0 6.4
GDP per capita growth (%) 6.0 2.5 4.2
(mo st recent est imate, 2003–2008)
Poverty headcount ratio at $1.25 a day (PPP, %) 52 51 ..
Poverty headcount ratio at $2.00 a day (PPP, %) 76 73 ..
Life expectancy at birth (years) 53 52 59
Infant mortality (per 1,000 live births) 82 89 78
Child malnutrition (% of children under 5) .. 27 28
Adult literacy, male (% of ages 15 and o lder) 82 71 72
Adult literacy, female (% of ages 15 and o lder) 66 54 55
Gross primary enro llment, male (% of age group) 116 103 102
Gross primary enro llment, female (% of age group) 117 93 95
Access to an improved water source (% of population) 64 58 67
Access to improved sanitation facilities (% of population) 33 31 38
N et A id F lo ws 1980 1990 2000 2008 a
(US$ millions)
Net ODA and official aid 113 663 845 1,728
Top 3 donors (in 2007):
United States 13 30 58 302
United Kingdom 7 35 217 167
European Commission 25 35 36 117
Aid (% of GNI) 9.2 15.7 13.9 14.3
Aid per capita (US$) 9 37 35 56
Lo ng-T erm Eco no mic T rends
Consumer prices (annual % change) .. 45.5 5.8 3.5
GDP implicit deflator (annual % change) 45.9 44.4 8.5 6.3
Exchange rate (annual average, local per US$) 1.0 319.6 1,512.0 1,720.4
Terms of trade index (2000 = 100) .. 85 100 102
1980–90 1990–2000 2000–08
Population, mid-year (millions) 12.7 17.7 24.4 31.7 3.4 3.2 3.2
GDP (US$ millions) 1,245 4,304 6,193 14,326 2.9 7.1 7.5
Agriculture 72.0 56.6 29.6 22.7 2.1 3.7 1.8
Industry 4.5 11.1 22.9 25.8 5.0 12.1 10.2
M anufacturing 4.3 5.7 7.8 7.6 3.9 14.1 6.7
Services 23.5 32.4 47.5 51.5 2.8 8.2 10.0
Household final consumption expenditure 88.9 91.9 77.8 82.4 2.7 6.8 7.4
General gov't final consumption expenditure 11.2 7.5 14.5 11.8 2.0 7.1 3.9
Gross capital formation 6.2 12.7 19.5 23.6 8.0 8.9 12.1
Exports o f goods and services 19.4 7.2 10.6 15.6 1.8 14.7 12.4
Imports of goods and services 26.0 19.4 22.5 33.4 4.4 10.0 11.4
Gross savings -0.9 0.6 8.6 12.1
Note: Figures in italics are for years other than those specified. 2008 data are preliminary. .. indicates data are not available.
a. A id data are for 2007.
Development Economics, Development Data Group (DECDG).
(average annual growth %)
(% of GDP)
15 10 5 0 5 10 15
0-4
15-19
30-34
45-49
60-64
75-79
percent of total population
Age distribution, 2008
Male Female
0
50
100
150
200
1990 1995 2000 2007
Uganda Sub-Saharan Africa
Under-5 mortality rate (per 1,000)
-3
0
3
6
9
12
15
95 05
GDP GDP per capita
Growth of GDP and GDP per capita (%)
189
Uganda
B alance o f P ayments and T rade 2000 2008
(US$ millions)
Total merchandise exports (fob) 456 1,787
Total merchandise imports (cif) 1,043 2,912
Net trade in goods and services -703 -2,102
Current account balance -644 -811
as a % of GDP -10.4 -8.2
Workers' remittances and
compensation of employees (receipts) 238 489
Reserves, including gold 719 2,673
C entral Go vernment F inance
(% of GDP)
Current revenue (including grants) 10.8 13.0
Tax revenue 9.9 12.5
Current expenditure 10.4 11.5
T echno lo gy and Infrastructure 2000 2008
Overall surplus/deficit -13.2 -5.0
Paved roads (% of to tal) .. 23.0
Highest marginal tax rate (%) Fixed line and mobile phone
Individual 30 30 subscribers (per 100 people) 1 28
Corporate 30 30 High technology exports
(% of manufactured exports) 4.3 10.6
External D ebt and R eso urce F lo ws
Enviro nment
(US$ millions)
Total debt outstanding and disbursed 3,497 2,249 Agricultural land (% of land area) 62 64
Total debt service 74 74 Forest area (% of land area) 20.6 18.4
Debt relief (HIPC, M DRI) 1,434 1,805 Nationally protected areas (% of land area) .. 31.9
Total debt (% of GDP) 56.5 15.7 Freshwater resources per capita (cu. meters) 1,498 1,273
Total debt service (% of exports) 10.5 2.3 Freshwater withdrawal (billion cubic meters) .. ..
Foreign direct investment (net inflows) 161 788 CO2 emissions per capita (mt) 0.06 0.08
Portfo lio equity (net inflows) 0 -32
GDP per unit o f energy use
(2005 PPP $ per kg of o il equivalent) .. ..
Energy use per capita (kg of o il equivalent) .. ..
Wo rld B ank Gro up po rtfo lio 2000 2008
(US$ millions)
IBRD
Total debt outstanding and disbursed 0 0
Disbursements 0 0
Principal repayments 0 0
Interest payments 0 0
IDA
Total debt outstanding and disbursed 2,115 1,004
Disbursements 190 172
P rivate Secto r D evelo pment 2000 2008 Total debt service 9 8
Time required to start a business (days) – 25 IFC (fiscal year)
Cost to start a business (% of GNI per capita) – 100.7 Total disbursed and outstanding portfo lio 36 73
Time required to register property (days) – 77 o f which IFC own account 36 64
Disbursements for IFC own account 0 51
Ranked as a major constraint to business 2000 2008 Portfo lio sales, prepayments and
(% of managers surveyed who agreed) repayments for IFC own account 6 0
Electricity .. 63.3
Tax rates .. 11.0 M IGA
Gross exposure 43 158
Stock market capitalization (% of GDP) 0.6 1.2 New guarantees 0 115
Bank capital to asset ratio (%) 9.8 10.3
Note: Figures in italics are for years other than those specified. 2008 data are preliminary. 2/25/10
.. indicates data are not available. – indicates observation is not applicable.
Development Economics, Development Data Group (DECDG).
0 25 50 75 100
Control of corruption
Rule of law
Regulatory quality
Political stability
Voice and accountability
Country's percentile rank (0-100)higher values imply better ratings
2008
2000
Governance indicators, 2000 and 2008
Source: Kaufmann-Kraay-Mastruzzi, World Bank
IBRD, 0
IDA, 1,004
IMF, 9Other multi-lateral, 560
Bilateral, 193
Private, 25
Short-term, 458
Composition of total external debt, 2008
US$ millions
190
Millennium Development Goals Uganda
With selected targets to achieve between 1990 and 2015(estimate closest to date shown, +/- 2 years)
Go al 1: halve the rates fo r extreme po verty and malnutrit io n 1990 1995 2000 2008
Poverty headcount ratio at $1.25 a day (PPP, % of population) 68.7 64.4 60.5 51.5
Poverty headcount ratio at national poverty line (% of population) .. .. 33.8 37.7
Share of income or consumption to the poorest qunitile (%) 4.9 7.3 6.0 6.1
Prevalence of malnutrition (% of children under 5) 19.7 21.5 19.0 ..
Go al 2: ensure that children are able to co mplete primary scho o ling
Primary school enro llment (net, %) 51 .. .. 95
Primary completion rate (% of relevant age group) .. .. 57 54
Secondary school enro llment (gross, %) 12 11 16 23
Youth literacy rate (% of people ages 15-24) 70 .. 81 86
Go al 3: e liminate gender disparity in educat io n and empo wer wo men
Ratio of girls to boys in primary and secondary education (%) 82 .. 93 98
Women employed in the nonagricultural sector (% of nonagricultural employment) .. .. .. 39
Proportion of seats held by women in national parliament (%) 12 18 18 31
Go al 4: reduce under-5 mo rtality by two -thirds
Under-5 mortality rate (per 1,000) 175 164 149 130
Infant mortality rate (per 1,000 live births) 106 100 92 82
M easles immunization (proportion of one-year o lds immunized, %) 52 57 59 68
Go al 5: reduce maternal mo rtality by three-fo urths
M aternal mortality ratio (modeled estimate, per 100,000 live births) .. .. .. 550
B irths attended by skilled health staff (% of to tal) 38 38 39 42
Contraceptive prevalence (% of women ages 15-49) 5 15 23 24
Go al 6: halt and begin to reverse the spread o f H IV/ A ID S and o ther majo r diseases
Prevalence of HIV (% of population ages 15-49) 13.7 11.8 8.5 5.4
Incidence of tuberculosis (per 100,000 people) 163 319 340 330
Tuberculosis cases detected under DOTS (%) .. 60 51 51
Go al 7: halve the pro po rt io n o f peo ple witho ut sustainable access to basic needs
Access to an improved water source (% of population) 43 49 56 64
Access to improved sanitation facilities (% of population) 29 31 32 33
Forest area (% of to tal land area) 25.0 22.8 20.6 18.4
Nationally protected areas (% of to tal land area) .. .. .. 31.9
CO2 emissions (metric tons per capita) 0.0 0.0 0.1 0.1
GDP per unit o f energy use (constant 2005 PPP $ per kg of o il equivalent) .. .. .. ..
Go al 8: develo p a glo bal partnership fo r develo pment
Telephone mainlines (per 100 people) 0.2 0.2 0.3 0.5
M obile phone subscribers (per 100 people) 0.0 0.0 0.5 27.0
Internet users (per 100 people) 0.0 0.0 0.2 7.9
Personal computers (per 100 people) .. 0.0 0.2 1.7
Note: Figures in italics are for years other than those specified. .. indicates data are not available. 2/25/10
Development Economics, Development Data Group (DECDG).
Uganda
0
25
50
75
100
125
2000 2002 2004 2006 2008
Primary net enrollment ratio
Ratio of girls to boys in primary & secondary education
Education indicators (%)
0
10
20
30
2000 2002 2004 2006 2008
Fixed + mobile subscribers
Internet users
ICT indicators (per 100 people)
0
25
50
75
100
1990 1995 2000 2007
Uganda Sub-Saharan Africa
Measles immunization (% of 1-year olds)
191
Annex 15: Maps
AFRICA: East Africa Public Health Laboratory Networking Project
Yat ta P lateau
Ndoto M
tns.
Lot ik ipi P lain
Mau Escarpment
Cherangany Hi l l s
ChalbiChalbiDeser tDeser t
Ngangerabel i P lain
Bi lesha P lain
Daniss
a Hi l l
s
Mt. KenyaMt. Kenya(5,199 m)(5,199 m)
E A S T E R NE A S T E R N
R I F T VA L L E YR I F T VA L L E Y
C O A S TC O A S T
N O R T HN O R T HE A S T E R NE A S T E R N
N YA N Z AN YA N Z AKarunguKarungu
LodwarLodwar
LokicharLokichar
KangatetKangatet
KitaleKitale
EldoretEldoret
ButereButere NyahururuNyahururuFallsFalls
KerichoKericho
NarokNarokLolgorienLolgorien
MagadiMagadi
NamangaNamanga
KonzaKonzaMachakosMachakos
KibweziKibwezi
VolVol
TsavoTsavo
KwaleKwale
GarsenGarsen
BodheiBodhei
KolbioKolbioBuraBura
NguniNguni
IkuthaIkutha
KituiKitui
MackinnonMackinnonParkPark
LokichokioLokichokio
KarunguKarungu
KakumaKakuma
EmbuEmbu
NanyukiNanyuki
ThikaThika
GilgilGilgil
MbalambalaMbalambala
Garba Garba TulaTula
MandoMandoGashiGashi
WajirWajir
El WakEl Wak
TarbajTarbaj
RamuRamu
BunaBuna
MoyaleMoyaleSololoSololo
MarsabitMarsabit
North HorrNorth Horr
South HorrSouth Horr
MaralalMaralalKapedoKapedo
MarigatMarigat
Archer’sArcher’sPostPost
IsioloIsiolo
ManderaMandera
KisumuKisumuNakuruNakuru
GarissaGarissaNyeriNyeri
KakamegaKakamega
NAIROBINAIROBI
CENTRALCENTRAL
WESTERNWESTERN
NAIROBINAIROBIAREAAREA
Karungu
Lodwar
Lokichar
Kangatet
Kitale
Eldoret
Butere NyahururuFalls
Kericho
NarokLolgorien
Magadi
Namanga
KonzaMachakos
Kibwezi
Vol
Tsavo
Kwale
Shimoni
Malindi
Garsen Lamu
Bodhei
KolbioBura
Nguni
Ikutha
Kitui
MackinnonPark
Lokichokio
Karungu
Kakuma
Embu
Nanyuki
Thika
Gilgil
Mbalambala
Garba Tula
MandoGashi
Wajir
El Wak
Tarbaj
Ramu
Buna
MoyaleSololo
Marsabit
North Horr
South Horr
MaralalKapedo
Marigat
Archer’sPost
Isiolo
Mandera
KisumuNakuru
Garissa
Mombasa
Nyeri
Kakamega
NAIROBI
CENTRALNAIROBI
AREA
E A S T E R N
R I F T VA L L E Y
C O A S T
N O R T HE A S T E R N
N YA N Z A
WESTERN
E T H I O P I A
SOMALIA
TANZANIA
UGANDA
SUDAN
Ng’iro M
ilgis
Suam
Turk
wel
Tana
Mara
Galana
Athi
Ewaso
Thua
Tsavo
Loga Bogal
Lak Dera
Lak Bor
INDIANOCEAN
Lake
Victor ia
LakeTurkana
To Murle
To Juba
To Dila
To Imi
To Kismaayo
To Bur Gavo
To Dar Es Salaam
To Moshi
To Arusha
To Seronera
To Musoma
To Kampala
To Mbale
Yat ta P lateau
Ndoto M
tns.
Lot ik ipi P lain
Mau Escarpment
Cherangany Hi l l s
ChalbiDeser t
Ngangerabel i P lain
Bi lesha P lain
Daniss
a Hi l l
s
Mt. Kenya(5,199 m)
34°E 36°E 38°E 40°E 42°E
34°E 36°E 38°E 40°E
2°S
0°
2°N
4°N
4°S
2°S
0°
2°N
4°N
KENYA
0 40 80 160120
0 40 80 120 Miles
200 Kilometers
IBRD 33426R
MARCH 2008
KENYASELECTED CITIES AND TOWNS
PROVINCE CAPITALS
NATIONAL CAPITAL
RIVERS
MAIN ROADS
RAILROADS
PROVINCE BOUNDARIES
INTERNATIONAL BOUNDARIES
This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, o r any endo r s emen t o r a c c e p t a n c e o f s u c h boundaries.
KilimanjaroKilimanjaro(5895 m)(5895 m)
Iwem
bere
Ste
ppe
Nguru M
ts.
Mbeya Range
A R U S H AA R U S H A
M A R AM A R A
R U V U M AR U V U M A MTWARAMTWARA
I R I N G AI R I N G A
L I N D IL I N D I
D O D O M AD O D O M A
K I G O M AK I G O M A
M WA N Z AM WA N Z A
S H I N YA N G AS H I N YA N G A
R U K W AR U K W A
M B E Y AM B E Y AP WA N IP WA N I
TA B O R ATA B O R A
KAGERAKAGERA
SINGIDASINGIDATA N G ATA N G A
MOROGOROMOROGORO
Mbemkur
u
Matandu
Rufiji
Great Ruaha
Rungwa
Wam
iW
ami
Simiyu
Ruvuma
Mara
Kagera
Moyow
osi
Ugalla
Pangani
Kilo
mbe
ro
YalovaYalova
KaliuaKaliua
KasuluKasuluKondoaKondoa
ManyoniManyoni
KibondoKibondoKahamaKahama
NzegaNzega
BuoenBuoen
NjombeNjombe
MpuiMpui
MpandaMpanda
TundumaTunduma
SameSame
TunduruTunduru
MasasiMasasi
UteteUtete
MbeyaMbeya
MoshiMoshi
SongeaSongea
IringaIringa
KibahaKibaha
DODOMADODOMA
TaboraTaboraKigomaKigoma
ArushaArusha
MwanzaMwanza
SingidaSingida
MorogoroMorogoro
ZanzibarZanzibar
ShinyangaShinyanga
Kipengere Range
BabatiBabati
MANYARAMANYARA
MasaiMasaiSteppeSteppe
K E N Y AK E N Y A
UGANDAUGANDA
ZAMBIAZAMBIA
MOZAMBIQUEMOZAMBIQUE
RWANDARWANDA
BURUNDIBURUNDI
DEM
. R
EP.
OF
CO
NG
OD
EM.
REP
. O
F C
ON
GO
To To NakuruNakuru
To To MalindiMalindi
To To KasamaKasama
To To KasamaKasama
To To KasunguKasungu
To To LichingaLichinga
To To MarrupaMarrupa
To To ChiúreChiúre
To To NakuruNakuru
To To TororoTororo
To To KampalaKampala
To To KampalaKampala
To Kama
To Kama
Yalova
Kaliua
KasuluKondoa
Manyoni
KibondoKahama
Nzega
Buoen
Njombe
Mpui
Mpanda
Tunduma
Same
Tunduru
Masasi
Utete
KilwaKivinje
Wete
Lindi
Mbeya
Koani
Tanga
Moshi
Songea
Mtwara
Iringa
Kibaha
DODOMA
Mkoani
TaboraKigoma
Arusha
Mwanza
MusomaBukoba
Singida
Morogoro
Zanzibar
Mkokotoni
Shinyanga
Sumbawanga
Babati
Dar es Salaam
K E N Y A
UGANDA
ZAMBIA
MOZAMBIQUE
RWANDA
BURUNDI
DEM
. R
EP.
OF
CO
NG
O
A R U S H A
MANYARA
M A R A
R U V U M A MTWARA
KILIMANJARO
I R I N G A
L I N D I
D O D O M A
K I G O M A
M WA N Z A
S H I N YA N G A
R U K W A
M B E Y AP WA N I
TA B O R A ZANZIBARNORTH
PEMBANORTH
PEMBASOUTH
ZANZIBARSOUTH &CENTRALZANZIBARWEST
DAR ES SALAAM
KAGERA
SINGIDATA N G A
MOROGORO
Mbemkur
u
Matandu
Rufiji
Great Ruaha
Rungwa
Wam
i
Simiyu
Ruvuma
Mara
Kagera
Moyow
osi
Ugalla
Pangani
Kilo
mbe
ro INDIAN
OCEAN
Lake
Victor ia
LakeTanganyika
LakeMalawi
LakeRukwa
LakeNatron
LakeEyasi Lake
Manyara
To Nakuru
To Malindi
To Kasama
To Kasama
To Kasungu
To Lichinga
To Marrupa
To Chiúre
To Nakuru
To Tororo
To Kampala
To Kampala
To Kama
Iwem
bere
Ste
ppe
MasaiSteppe
Nguru M
ts.
Mbeya Range
Kipengere Range
Kilimanjaro(5895 m)
30°E
0°
2°S
8°S
10°S
0°
2°S
4°S
8°S
10°S
12°S
32°E 34°E 36°E
32°E 34°E 36°E 40°E
TANZANIA
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 33494R1
NOVEMBER 2007
TANZANIAMAIN ROADS
RAILROADS
PROVINCE BOUNDARIES
INTERNATIONAL BOUNDARIES
SELECTED CITIES AND TOWNS
PROVINCE CAPITALS
NATIONAL CAPITAL
RIVERS
BundibugyoBundibugyo
BushenyiBushenyi
IbandaIbanda
KiruhuraKiruhura
NtungamoNtungamo
HoimaHoima
IgangaIgangaBusiaBusia
SironkoSironko
BugiriBugiri
KabaleKabale
KamuliKamuliKaliroKaliro
ButalejaButaleja
BudakaBudaka
KayungaKayungaKyenjojoKyenjojo
KapchorwaKapchorwa
BukwoBukwo
KaseseKasese
KisoroKisoro
KitgumKitgum
KumiKumi
KaberamaidoKaberamaido
LiraLira
LuweroLuwero
NakasekeNakaseke
NakasongolaNakasongola
MasakaMasaka
KamwengeKamwenge
KalangalaKalangala
MasindiMasindi
MbararaMbarara
KanunguKanungu
MorotoMoroto
NakapiripiritNakapiripiritKatakwiKatakwiAmuriaAmuria
MoyoMoyo
KibaleKibale
PallisaPallisa
SorotiSoroti
FortFortPortalPortal
AruaArua
JinjaJinja
BubuloBubulo
MbaleMbale
TororoTororo
GuluGulu
NebbiNebbi
ApacApac
AmolatarAmolatar
MubendeMubende
RukungiriRukungiri
IsingiroIsingiro RakaiRakai
SembabuleSembabule
MpigiMpigi
MukonoMukonoMityanaMityanaWakisoWakiso
KibogaKiboga
KotidoKotido
KaabongKaabongAdjumaniAdjumani
YumbeYumbeKobokoKoboko
KilakKilak
MarachaMaracha
OyamOyam
DokoloDokolo
BusikiBusiki
BulisaBulisa
AbimAbim
KAMPALAKAMPALA
MO
YO
ADJU
MANI
SIRONKOSIRONKO
KA
YUN
GAA
KABA
ROLE
SEMBABULE
KISOROKISORO
KANUNGUKANUNGU
RUKUUN
GIRRI
KAPCHORWAKAPCHORWA
BUKWOBUKWO
MASINDIMASINDI
HOIMAHOIMA
KASESEKASESE
KABALEKABALE
KIBOGAKIBOGA
MITYANAMITYANA
KIBAALEKIBAALE
MUBENDEMUBENDE
MPIGIMPIGI
MBARARAMBARARA
IBANDAIBANDAKIRUHURAKIRUHURA
ISINGIROISINGIRORAKAIRAKAI
MASAKAMASAKA
NTUNGAMONTUNGAMO
BUSHENYIBUSHENYI
APACAPAC
AMOLATARAMOLATAR KABERA-KABERA-MAIDOMAIDO
KAMULIKAMULI
GULUGULU
NEBBINEBBI
LUWEROLUWERO
NAKASEKENAKASEKE
IGANGAIGANGA
KALIROKALIRO
KALANGALAKALANGALA
MUKONOMUKONO
JINJAJINJA
KUMIKUMI
KATAKWIKATAKWIAMURIAAMURIA
MOROTOMOROTO
SOROTISOROTI
PALLISAPALLISA
MBALEMBALEBUDAKABUDAKA
MANAPWAMANAPWA
LIRALIRA
K I T G U MK I T G U M
ARUAARUA
KOTIDOKOTIDO
KAABONGKAABONG
TOROROTORORO
KAMPALAKAMPALA
YUMBEYUMBEKOBOKOKOBOKO
PADERPADER
MAYU
GE
MAYU
GE
BUG
IRIBU
GIRI
WAKISOWAKISO
KAMWENGEKAMWENGE
KYENJOJOKYENJOJO
NAKAPIRIPIRITNAKAPIRIPIRIT
NAKASONGOLA
BUNDIBUGYOBUNDIBUGYO
BUSIABUSIA
MARACHAMARACHA
AMURUAMURU
OYAMOYAM
DOKOLODOKOLO
ABIMABIM
BULISABULISA
NAMU-NAMU-TUMBATUMBA
BUTALEJABUTALEJA
Ora
Alb
ert
Nile
Achwa
Victoria Nile
Oko
k
Locho
man
Siti
Nkusi
Kafu
Katonga
To To FaradjeFaradje
To To JubaJuba
To To LodwarLodwar
To To BeniBeni
To To BuniaBunia
To To BeniBeni
To To NyakanaziNyakanazi
To To KisumuKisumu
To To NakuruNakuru
To To KigaliKigali
To G
oma
To G
oma
Margherita PeakMargherita Peak(5110 m)(5110 m)
Mt. Elgon (4321 m)Mt. Elgon (4321 m)
DEM. REP. DEM. REP. OF CONGO OF CONGO
S U D A N S U D A N
K E N Y A K E N Y A
K E N Y A K E N Y A
TANZANIA TANZANIA TANZANIA TANZANIA
RWANDA RWANDA
To To Faradje Faradje
To To Juba Juba
To To Lodwar Lodwar
To To Beni Beni
To To Bunia Bunia
To To Beni Beni
To To Nyakanazi Nyakanazi
To To Kisumu Kisumu
To To Nakuru Nakuru
To To Kigali Kigali
To G
oma
To G
oma
Margherita Peak Margherita Peak (5110 m) (5110 m)
Bundibugyo
Bushenyi
Ibanda
Kiruhura
Ntungamo
Hoima
IgangaBusia
Sironko
Bugiri
Kabale
KamuliKaliro
Butaleja
Budaka
KayungaKyenjojo
Kapchorwa
Bukwo
Kasese
Kisoro
Kitgum
Kumi
Kaberamaido
Lira
Luwero
Nakaseke
Nakasongola
Masaka
Kamwenge
Kalangala
Masindi
Mbarara
Kanungu
Moroto
NakapiripiritKatakwiAmuria
Moyo
Kibale
Pallisa
Soroti
FortPortal
Arua
Jinja
Bubulo
Mbale
Tororo
Gulu
Nebbi
Apac
Amolatar
Mubende
Rukungiri
Isingiro Rakai
Sembabule
Mpigi
MukonoMityanaWakiso
Kiboga
Kotido
KaabongAdjumani
YumbeKoboko
Kilak
Maracha
Oyam
Dokolo
Busiki
Bulisa
Abim
KAMPALA
MO
YO
ADJU
MANI
SIRONKO
KA
YUN
GA
KABA
ROLE
SEMBABULE
KISORO
KANUNGU
RUKUN
GIRI
KAPCHORWA
BUKWO
MASINDI
HOIMA
KASESE
KABALE
KIBOGA
MITYANA
KIBAALE
MUBENDE
MPIGI
MBARARA
IBANDAKIRUHURA
ISINGIRORAKAI
MASAKA
NTUNGAMO
BUSHENYI
APAC
AMOLATAR KABERA-MAIDO
KAMULI
GULU
NEBBI
LUWERO
NAKASEKE
IGANGA
KALIRO
KALANGALA
MUKONO
JINJA
KUMI
KATAKWIAMURIA
MOROTO
SOROTI
PALLISA
MBALEBUDAKA
MANAPWA
LIRA
K I T G U M
ARUA
KOTIDO
KAABONG
TORORO
KAMPALA
YUMBEKOBOKO
PADER
MAYU
GE
BUG
IRI
WAKISO
KAMWENGE
KYENJOJO
NAKAPIRIPIRIT
NAKASONGOLA
BUNDIBUGYO
BUSIA
MARACHA
AMURU
OYAM
DOKOLO
ABIM
BULISA
NAMU-TUMBA
BUTALEJA
DEM. REP.OF CONGO
S U D A N
K E N Y A
K E N Y A
TANZANIATANZANIA
RWANDA
Ora
Alb
ert
Nile
Achwa
Victoria Nile
Oko
k
Locho
man
Siti
Nkusi
Kafu
Katonga
Lake Vic tor ia
LakeEdward
LakeGeorge
LakeKwania
Lake Kyoga
LakeSalisbury Lake
Opeta
Lake
Albe
rt
To Faradje
To Juba
To Lodwar
To Beni
To Bunia
To Beni
To Nyakanazi
To Kisumu
To Nakuru
To Kigali
To G
oma
Margherita Peak (5110 m)
Mt. Elgon (4321 m)
30°E
4°N
2°N
0°
4°N
2°N
0°
32°E 34°E
32°E 34°E
UGANDA
0 25 50 75
0 25 50 75 Miles
100 Kilometers
IBRD 33504R3
AUGUST 2008
UGANDA
DISTRICT CAPITALS
NATIONAL CAPITAL
RIVERS
MAIN ROADS
RAILROADS
DISTRICT BOUNDARIES
INTERNATIONAL BOUNDARIES
This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries.
N O R T H
P R O V I N C E
W E S TP R O V I N C E
S O U T H
P R O V I N C E
KIGALI CITY
E A S T
P R O V I N C E
N YA G ATA R E
G AT S I B O
K AY O N Z A
RWAMAGANA
K I R E H EN G O M A
B U G E S E R A
GASABO
KICUKIRO
B U R E R A
GICUMBI
R U L I N D OG A K E N K E
M U S A N Z A
RUBAVUN YA B I H U
NGOROREROR U T S I R O
K A R O N G I
N YA M A S H E K EN YA M A G A B E
N YA R U G U R U
R U S I Z I GISAGARA
H U Y E
N YA N Z A
R U H A N G O
MUHANGA
KAMONYI
NYARUGENGE
Bugarama
Rwumba Kitabi
Ruramba
KigembeMunini
Karama
Karaba
Gatagara
Masango
Rusatira
Shyorongi
Muhura
Kinyami
Mbogo
Kigarama
Sake
Rukara
Kiziguru
Gabiro
Gatunda
RilimaBugesera
Gikoro
Bicumbi
Gashora
Kanzi
Rwesero
Cyangugu
Bulinga
Ngaru
Mulindi
Muvumba
Kagitumba
Kirambo
Butaro
Nemba
Busogo
Muramba
Kagali
Nyondo
Kabaya
Mabanza
Murunda
GishyitaBwakira
Ngoma
Kidaho
Gikongoro
Gitarama
Butare
Kinihira
Burera
Rubavu Karago
Rutsiro
Gatsibo
Nyagatare
Kabarore
Mukarange
Kigabiro
Ndora
Gasaka
Ngoma
Kagano
RubengeraNyamabuye
Rukoma
Nyamata
Kicuro
RugengeNdera
Ruhango
Busasamana
Ngororero
MuhozaCyeru
Gakenke
Tare
Kamembe
Kibeho
Kibungo
Kirehe
Gisenyi
Mukamira
Gihingo
Nyanza
Kibuye
Rwamagana
Byumba
KIGALI
D E M . R E P .O F
C O N G O
B U R U N D I
T A N Z A N I A
U G A N D A
Lac Kivu
LacIhema
LacKivumba
LacHago
LacMikindi
LacRwanyakizinga
LacBurera
LacRuhondo
LacNasho
LacCywambwe
LacMpangaLac
Mugesera
LacRweru
LacCyohoha
Sud
Lac Muhazi
Kagera
Nyabarongo
Akany
aru
Kagi
tum
ba
Kagera
To Sake
To Rutshuru
To Kisoro
To Kabale
To Kikagati
To Kafunzo
To Bugene
To Lusahanga
To Kirundo
To Ngozi
To Kayanza
To Cibitoke
To Cibitoke
To Walangu
To Nyya-Ghezi
Virunga M
ts.
VolcanKarisimbi(4519 m)
30°00'E 31°00'E29°30'E 30°30'E
29°00'E
29°00'E
30°00'E29°30'E 30°30'E
2°00'S
2°30'S
2°00'S
1°00'S
1°30'S1°30'S
RWANDA
0 10 20 30
0 10 20 30 Miles
40 Kilometers
IBRD 33471R2
JUN
E 2008
RWANDA
This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, o r any endo r s emen t o r a c c e p t a n c e o f s u c h boundaries.
SELECTED CITIES AND TOWNS
AKARERE (DISTRICT) CAPITALS
INTARA (PROVINCE) CAPITALS
NATIONAL CAPITAL
RIVERS
MAIN ROADS
AKARERE (DISTRICT) BOUNDARIES
INTARA (PROVINCE) BOUNDARIES
INTERNATIONAL BOUNDARIES