Date of Submission to Coordination Unit:

A. GENERAL INFORMATION

1. Activity Name

The Libya Health Sector Support Advisory Services and Analytics (ASA) Program

2. Requestor Information

Name: H.E. Mr. Al-Taher Al Jehaimi;

Mr. Esam Garbaa

Title: Minister of Planning;

Director of International Cooperation

Organization and Address: Ministry of Planning,

Tripoli, Libya

Telephone/Fax: +218 21 444 2448.Email:

esam_planning@yahoo.com

3. Recipient Entity Name:

Mrs. Marie Francoise Marie-Nelly

Title: Country Director

Maghreb Department

Regional Middle East and North Africa Office

World Bank

Organization and Address: World Bank, Regional MENA Office

7, Rue Larbi Ben Abdellah,

Rabat-Souissi, Morocco

Telephone: 527 54 42 00 Email:

4. ISA SC RepresentativeName: Mrs. Ayat Soliman Title: Practice Manager,

GSU11 – Urban, DRM MNA

World Bank

Organization and Address: World Bank,

October 15, 2018 2018

Room J 6-111,

1818 H Street

NW Washington, DC 20433

Telephone: (202) 458-7441 Email: asoliman@worldbank.org

5. Type of Execution (check the applicable box)√ Type Endorsements Justification

Country-Execution Attach written endorsement from designated ISA

Joint Country/ISA-Execution

Attach written endorsement from designated ISA

(Provide justification for ISA-Execution)

√ ISA-Execution for Country Please see attached Government capacity remains weak, and therefore the ISA will administer activities. Additionally, there are several activities that are advisory support and analytics (ASA).

ISA-Execution for Parliaments

Attach written endorsements from designated Ministry and ISA

6. Geographic Focus√ Individual country (name of country): Libya

Regional or multiple countries (list countries):

7. Amount Requested (USD) Amount Requested for direct Project Activities:(of which Amount Requested for direct ISA-Executed Project Activities):

3,673,600 (2,373,600 – original: 2,373,600, AF:

1,300,000)

Amount Requested for ISA Indirect Costs:1 40,700 (original: 26,400, AF: 14,300)

Total Amount Requested: 3,714,300 (original: 2,400,000, AF: 1,314,300)

8. Expected Project Start, Closing and Final Disbursement DatesStart Date: July 1, 2017 Closing Date: June 30, 2021 End Disbursement

Date:October 31, 2021

9. Pillar(s) to which Activity RespondsPillar Primary

(One only)Secondary(All that apply)

Pillar Primary(One only)

Secondary(All that apply)

Investing in Sustainable Growth. This could include such topics as innovation and technology policy, enhancing the business environment (including for small and medium-sized enterprises as well as for local and foreign investment promotion), competition policy, private sector development strategies, access to finance, addressing urban congestion and energy intensity.

Enhancing Economic Governance. This could include areas such as transparency, anti-corruption and accountability policies, asset recovery, public financial management and oversight, public sector audit and evaluation, integrity, procurement reform, regulatory quality and administrative simplification, investor and consumer protection, access to economic data and information, management of environmental and social impacts, capacity building for local government and decentralization, support for the Open Government Partnership, creation of new and innovative government agencies related to new transitional reforms, reform of public service delivery in the social and infrastructure sectors, and sound banking systems.

√

Inclusive Development and Job Creation. This could include support of policies for integrating lagging regions, skills and labor market policies, increasing youth employability, enhancing female labor force participation, integrating people with disabilities, vocational training, pension reform, improving job conditions and

√

Competitiveness and Integration. This could include such topics as logistics, behind-the-border regulatory convergence, trade strategy and negotiations, planning and facilitation of cross-border infrastructure, and promoting and facilitating infrastructure projects, particularly in the areas of urban infrastructure, transport, trade

1 ISA indirect costs are for grant preparation, administration, management (implementation support/supervision) including staff time, travel, consultant costs, etc.

regulations, financial inclusion, promoting equitable fiscal policies and social safety net reform.

facilitation and private sector development.

B. STRATEGIC CONTEXT

10. Country and Sector Issues

Country-wide Challenges

Seven years after the 2011 popular revolution against Gaddafi and the subsequent NATO-led military intervention, the country’s political and security environment remains uncertain.

Libya faces continuing governance challenges. Despite there being an internationally backed government, the Government of National Accord, Libya remains divided among competing political, military, and institutional entities. These divisions complicate coordination within the health sector. Despite these challenges, cooperation among health authorities is ongoing through both formal and informal channels.

Given the conflict, the country’s socioeconomic and demographic situation has worsened. Households are becoming increasingly vulnerable, as many Libyans have lost jobs and income, and price inflation of goods and services (estimated at 28 percent) are rising faster than wage inflation. The population is vulnerable given their economic situation and the insecure environment in which they live. The Libyan Dinar has lost nearly 70 percent of its value against the US dollar and much of the money has moved to the informal economy prompting a shortage of liquidity in the formal market. People often wait in lines over night to get limited cash out of banks.

Sector-wide Challenges

a. Health Service Use

Given the epidemiological transition and the conflict situation, there is a need to highlight a few concerns. There is evidence of emerging or worsening problems related to mental health, trauma, and gender-based violence, as well as outbreaks of previously well-controlled infectious diseases due to migration and internal displacement from conflict. Quality of basic care, such as essential maternal, obstetric, neonatal and child care, is lacking. Among children under-5, there is a concern of them falling through the cracks and not receiving essential public health services (e.g. immunization) in a timely manner. Among adolescents, there is a concern of limited commodities, resulting in high fertility. Among adults, there is a concern over management of chronic illnesses (cardiovascular, diabetes) due to medication and staffing disruptions, and a rising burden from accidents and injuries – a result of the conflict. The situation is even worse when it comes to IDPs, migrants and those living in lagging regions such as the southern part of Libya

b. Health Service Delivery System

Resulting from its conflict, Libya has faced a drastic and adverse effect on its health service delivery. While demand for health care is rising, including for new and reemerging needs, service delivery has not adequately responded to these demands. The problem lies in the service delivery model and capacity from primary care to hospital care. The reasons for the failing delivery systems include staffing, financing, and governance, and limited access to adequate care and services, among others.

Since 2014, the conflict in Libya has pushed the public health system to the brink of collapse. Nearly 20% of public hospitals and primary care facilities have closed. Fewer than 1 out of every 6 primary health facilities is adequately stocked with essential medications, and shortages of available health workers have been widely reported in many parts of the country. According to the World Health Organization, fewer than 15% of the country’s more than 1,300 primary healthcare clinics currently offer antenatal care, and barely half are able to provide services for managing common chronic diseases like diabetes.2

The health sector challenges vary across the country, reflecting the uneven nature of the conflict. In Benghazi, where fighting gripped much of the city through 2016, the level of damage to health facilities is significantly greater than in Tripoli. In Sirte, which was held by ISIS for a year and a half, mental health needs are immense. In the South, which is much more remote and rural, personnel and infrastructure needs are particularly pronounced; in 2016, dozens of avoidable newborn deaths were reported at the only hospital in Sabha, the region’s largest city, due to lack of qualified staff and functioning equipment.

2 Data from WHO 2017 Libya Service Availability and Readiness Assessment (SARA).

The health workforce is also drained. Since 2011, many national and international skilled health workforce have left country—up to 50% of nurses at some facilities—and today, the shortage of specialized medical professionals and other functions such as midwives is a serious concern. The central and Benghazi regions are the lowest in the country when it comes to density of health workers. In addition, the system is suffering from the phenomenon of “ghost” health personnel, whereby a substantial number of health workers are on the payroll, though they do not appear in their assigned work places.

c. Health Finance and Governance

Budgets have sharply declined and most of the resources are allocated towards salaries, but not operations. Some basic care, including immunization, are covered in the public system, but the release of funds seems to be slow. Many staff are complaining of not being paid. Many programs are delayed in its delivery, as there is limited or no operations budgets. For operations, there is high reliance on external financing coming through humanitarian assistance – most of which are off-budget and through nongovernmental organizations. This of course creates further fragmentation and lack of coherence in adequately responding to needs.

Governance structures, and accountability mechanisms are lacking, and provider performance is a concern . Many mechanisms, controls and monitoring systems do not exist. Lack of data is a concern with routine health information systems being unreliable. Provider performance information is not available. Survey data are limited.

To address these health concerns, there is a dire need to build strategy for a new model of care that strengthens the health care delivery system, particularly first-line primary health care and essential hospital services. Special emphasis is required on governance and access.

11. Alignment with Transition Fund ObjectiveThis ASA, initially approved in 2017, is well aligned with the Transition Fund objectives. Its primary alignment is with enhancing economic governance, as it will support the government to reform public service delivery in the health sector. While doing this, it will help develop accountability mechanisms, and enhance financial management and oversight. Furthermore, the ASA is also aligned with the scope of inclusive development and job creation. Under this secondary alignment, it seeks to conduct a workforce analysis with the health sector that should help the government develop human resources in line with health policies and strategies, including enhancing female labor force participation.

The request for additional financing (below) further supports and expands upon these aims. It proposes activities designed to identify key needs and challenges facing public service delivery in the health sector, strengthen the capacity of local and district health officials, assist officials with prioritization and funding allocation decisions in the setting of budget constraints, improve accountability mechanisms for the health workforce, and strengthen data collection, monitoring, and oversight activities within the health sector. This has been highlighted in the last G7 meeting in Tunis.

12. Alignment with Country’s National StrategyAmong Ministry of Health (MOH) priorities identified for the coming years (2017 and beyond), include the need to develop:

A reproductive maternal, neonatal, child and adolescent health care (RMNCAH) strategy along with an implementation plan. This includes strengthening basic and comprehensive Emergency maternal obstetric and neonatal care (EmONC), and training in basic and comprehensive EmONC services.

A multi-sectoral non-communicable disease control (NCD) and mental health strategy and implementation plan.

The MOH has already led efforts on a Service Availability and Readiness Assessment (SARA). Released in 2017, this provided situation assessment of health facilities. The MOH also aims to have future/upcoming surveys conducted, including maternal and infant mortality survey, and a Noncommunicable disease (NCD) risk factor survey [STEPwise approach to surveillance (STEP)].

The MOH has identified a need for a strategic review of and assistance in the budget and need-based financial allocations, capacity building of program managers and mid-level decision makers on results-based management, project management including financial management and fiscal controls and emergency preparedness and response. They have also highlighted their need to have a mechanism to respond to the current emergency situation, by identifying alternate means of financing.

Another area of priority identified is the need for an efficient and a relatively quick mechanism for enhancing the capacity of different types of health workforce. The MOH has requested for a workforce analysis.

MOH is also seeking for better coordination of the international community when it comes to donors’ support.

[These priorities were presented by the National Center for Disease Control (NCDC, 2016-2017), in February 2017.]

The Libya MOH has requested for expanding the technical assistance from the Bank in the following three areas: (a) health financing and governance, (b) human resources for health (HRH), and (c) health care service delivery.

The Bank team has a comparative advantage in the area of health financing and public financial management. The MOH has requested the Bank team to have a forward-looking perspective. Their immediate needs are to understand how to allocate their budget in such a budget constraint environment and to pilot an integrated model of service delivery. They are keen to understand how to use their budget more efficiently towards value for money, and to allocate it more equitably within the country. The government has also requested for some capacity building in health financing.

The Bank has provided assistance in many countries to diagnosing the human resources situation through a workforce analysis, and to providing evidence for development of the HRH strategy. This is a key element to address the shortcomings of health service delivery. The MOH has requested for Bank’s assistance, and the Bank team could help with this first step.

The Bank team has been helping several countries, including fragile, conflict and violence (FCVs), address their weak primary health care program and help them to streamline and strengthen the health delivery systems including essential hospital services. Many partners are coming to provide humanitarian assistance in Libya. Several partners are engaged at some level of care, but no one is looking at the situation comprehensively and strategically. This could lead to fragmentation in the model of care, and not benefit from the effects of economies of scope and scale. This additional funding will further contribute, among other things, the coordination among different stakeholders and strengthen the existing collaboration platforms. From the Bank team’s recent engagement with some key partners, it seems that currently there is a growing gap in the available technical assistance in the three areas above.

C. PROJECT DESCRIPTION

13. Project Objective

To support the strengthening of health service delivery to the population in Libya.

14. Project ComponentsThe ASA (Analytics and Advisory Services) for which the initial funding was approved in FY2017 commits to focusing on strengthening health service delivery.  It aims to identify areas to use cost effective interventions, to find alternate solutions to bring health care to the devastated population in a timely and affordable manner, and to improve efficiency, and governance and management of service delivery. There are three components:

Component 1: Human resources for health Component 2: Health service delivery model Component 3: Health financing and governance

Rationale for the additional funding;

- Libya is embarking on a number of health sector reforms with regard to service delivery, human resources and financing. The basic package of services is almost finalized with the support of the EU, and the MOH is keen to test an integrated model of service delivery at the primary and secondary levels of care. The additional funding will primarily support the implementation of such a pilot in selected facilities in coordination with the MOH and other partners. It will also build on the lessons learnt from last year and expand the use of innovation and technology with regard to monitoring and supervision.

- Bank’s engagement with Libya for the health sector is currently limited to this ASA. Considering the close relationships built with the counterparts and their high level of commitment towards the activities of this ASA, additional funding would provide more opportunities for the Bank to contribute to Libya’s health sector reform and institutional capacity building agenda as the country struggles with a multitude of challenges.

Given the evolving priorities and growing needs within the sector, this proposal for additional funding complements and expands upon these components. Specifically it would provide support for: (a) conducting nationally representative surveys, geospatial analyses, and other rapid data collection activities to better assess health workforce needs and challenges related to access, utilization, and delivery of quality care; and (b) for implementing a pilot project to field test and assess the MOH-endorsed new integrated model of healthcare delivery centered around primary care, including: (i) the selection and costing of a basic service package; (ii) capacity building for facility managers, supervisors, and health officials; and (iii) enhanced monitoring and evaluation capacities.

Component 1: Human resource management, enhancing staffing skills, and management systems

In Libya, an HRH strategy is urgently needed. Conflict has impacted health workforce numbers and distribution, although reliable HRH data are lacking. As many expats have left the country, hospitals are reportedly understaffed and cannot perform. At the primary care level, many health personnel have been displaced, and dual practice is reportedly common. Capacity of existing medical education programs to supply new health personnel is unknown. The private sector is growing, but there is no private sector policy in place. Staff performance has been a concern, and staff skills mix are inadequately responding to population health needs. Libya urgently needs quality data to guide decisions around optimizing the distribution of its current workforce, improving their skill set and performance, and expanding the cadre of workers to meet new needs. It could also benefit from greater capacity to plan and forecast staffing needs and linking these needs to production, recruitment, and placement of new workers. A timely yet comprehensive workforce analysis and a HRH strategy will be key.

Activities: A set of targeted activities are proposed, reflecting the scope of the approved TF and expanded here in key ways. These include: (i) a workforce analysis, to draw heavily upon a nationally representative health workforce survey developed with the MOH over the past year for which implementation is planned in the near future, as well as other data collection activities; (ii) a report and recommendations towards interventions in human resources for health, specifically tailored to Libya’s unique challenges amid conflict and constraints on the health system as well as urgency for prompt

action and reforms3; and (iii) health workforce training needs assessment and consultations.

Over the past year, consultations with the MOH have led to the development of a Libya-tailored health workforce survey. Per MOH priorities, it will target the primary care level initially, reflecting the central role of primary care in the envisioned new model of care. It will sample both providers and facility managers. It will be conducted across multiple cities and villages in different regions to provide a nationally representative sample with a statistically robust sampling design allowing comparisons between cities. The study will assess the following categories: (a) stock of health workers; (b) distribution of health workers, including prevalence of dual practice and willingness of health workers to relocate to underserved or highly vulnerable areas; (c) performance of health workers, including productivity, supervision, absenteeism, and incentives; and (d) perceived barriers among providers to provision of quality care. Survey results will be analyzed using statistical software. This study will greatly inform the health workforce analysis proposed under the original TF. . Pending completion at the primary care level, opportunities for expansion of the survey to the hospital level will be explored. Key findings can be further examined through qualitative methods relying upon provider focus groups or key stakeholder interviews in a sampling of cities or facilities.

A comprehensive HRH report and recommendations will follow the workforce analysis. This report will draw upon findings from the above survey as well as other sources, including stakeholder interviews. The following areas will be addressed: (a) Public sector role and capacity in planning and forecasting human resource needs for health; (b) interventions to increase stock and improve distribution and performance of HRH, including opportunities for rotation mechanisms and mobile outreach teams; (c) financing available for policy and interventions; (d) private sector impact on workforce distribution, including the role of dual practice; and (e) challenges and opportunities within the Libyan medical education sector, including readiness for online education and training programs to supplement traditional medical education programming. Emphasis will be provided for female labor force participation, such as the programs on nursing and midwifery, and on their barriers to environments in which they work. The report will include international lessons learned for MOH to prepare/update their HRH policy and strategy.

Through the survey and HRH report, key health workforce training needs will be identified. These needs will cover both clinical and managerial deficits. Consultations will be held to prioritize these needs, identify those amenable to improvement amid the country’s context, and develop programs to address them in a timely manner. Key management capacity needs will be addressed under the service delivery pilot project(s) proposed under Component 2. Opportunities for using alternative training and education tools, such as online learning platforms, will also be explored, including a situational analysis of Libya’s internet infrastructure.

Partnership: Efforts would be coordinated with several partners working on strategies for capacity building and HRH assessment, including but not limited to WHO on the nursing program and with UNFPA on the midwifery program.

Component 2: Designing health delivery system including PHC and essential hospital services

The health delivery system is fragmented. Different levels of health facilities and services report to different administrative authorities; policies and strategies to build the health delivery systems are limited; primary care has been historically underdeveloped; and ongoing conflict has led to further governance fragmentation. Because of the conflict, only one-third of primary health care (PHC) clinics are fully functional and only 40% offer basic maternal and child health care. General medical curative services, general surgical services, patient services, and emergency services are available in at least 60% of hospitals, but only 50% of hospitals have the capacity to offer maternity services. Only 9% of hospitals have appropriate staffing and care for mental health patients. Hospitals are therefore unable to provide the essential package of care. Quality of care and motivation of providers are a concern, and the budget and payment mechanisms do not incentivize performance of care. Medical commodities are in short supply [SARA, 2017].

3 Reference: World Bank. 2012. Directions in Development. Toward Interventions in Human Resources for Health in Ghana: Evidence for Health Workforce Planning and Results.

The government is looking at a new model of care, concentrating on primary health care and essential hospital services. In consultations over the past year, the government has expressed keen interest in moving forward with such efforts. To make the system more cost effective, efficient, and responsive to the country’s challenging situation, the building of a more integrated health delivery system will be critical. However, the health delivery system lacks the planners with sufficient capacity and experience to develop a system.

Activities: The activities will be divided into three phases: (i) rapid diagnostics and design of the integrated model of care; (ii) implementation of pilot programs in at least two cities to test the integrated model of care; and (iii) evaluation of the pilots with lessons learnt, and recommendations for refinement and scale up. Building upon the initial TF, this proposal requests additional funding to rigorously develop, implement, and assess the results of the pilot(s) in close coordination with the MOH and other stakeholders, including the use of nationally representative surveys, geospatial analysis techniques, and timely roll out of the pilot itself.

For phase (i), a rapid diagnostics will be run along with designing the integrated model of care. It will examine gaps in administrative and programmatic links between primary and secondary health care, especially for programs such as maternal, obstetric and neonatal care and referrals, mental health, trauma and gender-based violence, and non-communicable diseases. It will assess patient’s perceptions of service delivery, barriers and constraints through a nationally representative facility-based survey of patients visiting primary care facilities. This was developed with the MOH over the past year and has already been piloted in the field. The rapid diagnostics will also employ geospatial analysis techniques to identify gaps in service availability and access at the city, district, and national level, with a focus on identifying populations with limited access to priority basic services and skilled providers, as well as spatial gaps between services at primary and secondary facilities. Collectively, these analytical activities will feed into the design of a pilot project (or set of pilot projects) that will address both patient demand and supply side issues to develop a more effective model of care. The analysis will also provide input in to the dynamics damage and needs assessment, which looks at the effect of the conflict and how health service delivery has been affected in both hard and software components.

For phase (ii), the pilot design in service delivery (using the integrated model of care) will focus on identifying and field testing innovations to improve the delivery of essential health services for the population. Several aspects need to be closely examined, including: (a) which services should be included in a basic service package at the primary care level, how much they will cost, and what level of resources, including skilled health workers, they will require; (b) what is the capacity of facility managers and local and district health officials to carry out key monitoring and oversight functions, including basic data collection, planning for resource stocking and budget allocation, and monitoring provider attendance and performance; (c) what policies or systems exist for referring patients to secondary level services; and (d) what range of service delivery modalities should be employed in a conflict setting to ensure more patients are getting the care they need, such as through community based mobile and outreach services. To answer those questions, the pilot will support facility level service costing exercises, development of data collection tools, and training of managers and health officials on planning and oversight functions, among other activities. By field testing these approaches, the pilot will identify viable options for improving the efficiency of service delivery, accountability mechanisms, and performance incentives; develop mechanisms for monitoring provider performance and patient satisfaction; and enhance the capacity of local and district level officials.

For phase (ii), pilot sites will be identified in close consultation with the MOH and other development partners, drawing upon the analytical work performed in phase (i). At least two different cities or regions will be selected initially, with multiple facilities within each city or region supported. The ASA will provide advisory support to the government (who is the implementing agency). Most financing for service provision (salaries and operating costs) are expected to be mobilized through budgets. The ASA will support systems strengthening, capacity building, and monitoring and oversight. Third party monitoring (or remote sensing technology) will be put in place. For this, appropriate entities will be selected, such as international nongovernmental organizations (INGOs) and local NGOs. Provider performance monitoring as well as patient satisfaction aspects will be considered along with other key indicators. However, close

monitoring will be conducted to learn and to modify activities within the pilot sites.

For phase (iii), pilot sites should be evaluated through process evaluation using administrative data after 12 months of implementation. Methodological approaches will be explored to monitoring and evaluation of these initiatives to ensure good value and quality. Recommendations will be provided for refinement and scale-up.

Partnership: Close collaboration will be maintained with partners, especially European Union (EU) and the GIZ, who are also supporting pilot implementation to strengthen service delivery. EU is also interested in partnering on the development of the public private partnership framework. Close coordination and collaboration will also be maintained with WHO, who are leading the efforts in preparing the essential package of care.

Component 3: Health financing and governance

Budgets have sharply declined and most resources are allocated towards salaries, and away from operations budget. Some basic care, including routine immunization, are covered as part of the budget but the release of funds seems to be often delayed. Many staff are complaining of not being paid. Many programs are delayed in its delivery, as they have limited or no operations budgets. For operations, there is high reliance on external financing coming through humanitarian assistance, which is off-budget and through nongovernmental organizations. This of course creates further fragmentation and lack of coherence in adequately responding to needs. MOH realizes its resources are not spent efficiently. For example, it is expected that Libya pays much higher prices for vaccines than what can be secured through UNICEF. It is also expected that drugs are procured at above international reference pricing. Many drugs procured by Libya are branded rather than generics. Libya can benefit from several cost-reducing policies.

Activities: Three specific activities were planned: (a) advisory support on planning and budgeting (2018-2020), (b) capacity building in health financing, and (c) design of a resource pooling mechanism. These are in various stages of execution.

The MOH is quite constrained as budgets have fallen drastically. Of the budget that is available to them, most are for staff salaries. Operations budget has declined several-folds. The MOH has requested the Bank team for assistance to help them rationalize their budget and spending. Their immediate needs are to understand how to allocate their budget in such a budget constraint environment. They are keen to understand how to use their budget more efficiently towards value for money, and to allocate it more equitably within the country. The Bank team will provide advisory support to MOH in reviewing their budgets, and in providing recommendations. Additionally, the Bank team will also provide a report and recommendation on areas where the MOH can achieve some allocative efficiency.

For a better understanding of health financing functions and lessons learnt from other countries, the ASA is supporting participation of Libyan delegation for training programs and south-south learning events. In FY18, the Bank delivered key capacity building exercises in this regard, including a flagship course customized for the Libyan needs, held in Tunis in April 2018.

When resources are constrained, they must be used more carefully. While budgets have declined, external financing, through humanitarian assistance, is providing the much-needed resources, such as for cold chain, drugs and vaccines, personnel training, and facility rehabilitation. There is keen interest among all development partners to strengthen and improve service delivery. It will be crucial to harmonize efforts to help the country in this area. Pooling of resources around the essential health delivery package may be key to scaling up this support. The Bank team is leading efforts to consider this support among partners and to design a pooling mechanism. Subject to the availability and reliability of data, a simple public health financing review will be conducted at the facility level to inform the policy makers on the best way to allocate public funds.

Partnerships: Close coordination will be maintained with WHO, who is taking lead in conducting a national health accounts (NHA) for previous years. Partnership will also be formed with the Bank’s governance and public finance management teams.

15. Key Indicators Linked to Objectives Overall, through a collaborative and coordinated approach in engagement, the country is expected to benefit several folds: (a) in identifying key needs related to health workforce and service delivery and developing evidence based policies and strategies to address them; (b) in allocating budgets in a more efficient manner to respond to needs; (c) in developing a monitoring mechanism and indicators to monitor health sector performance; (d) in reaching the vulnerable and displaced; and (e) in building capacity and steps towards building an “effective” health delivery system.

Indicators under the Fund Development Objectives include Cross Pillar 5: Documents produced and endorsed; and Staff trained.

Other key indicators include: Patient satisfaction Personnel attendance rate at health facilities (or reduction in staff absenteeism)

D. IMPLEMENTATION

16. Partnership Arrangements (if applicable)Health was identified as among the priority sectors for Bank’s engagement in Libya. This was identified through the Bank supported Libya Economic Dialogue platform that brings together a broad spectrum of Libyans to discuss and consult on issues of urgency for Libya. The Bank management has supported this platform’s recommendation and is starting to engage.

Development partners are eager for Bank to be engaged on Libya Health. The Bank team has met repeatedly with several development partners and has received overwhelming support for engagement. WHO and UNICEF are eager for the Bank to engage in the health sector considering the Bank's technical and financial comparative advantage. The Bank team expects to develop close technical partnerships with them in the areas of human resource for health. Several other development partners, such as the European Union, expressed their interest to form partnership with the Bank. The Bank team expects to develop close coordination and collaboration with the EU in the area of service delivery model development. The Bank is entering into the engagement in health in Libya after several years of conflict. Other development partners have been already engaged in Libya through humanitarian assistance. As humanitarian assistance continues, and the reconstruction phase is just beginning, this engagement from the Bank is timely. It is still a period of transition from humanitarian assistance to reconstruction.

17. Coordination with Country-led Mechanism/Donor Implemented Activities The World Health Organization (WHO) is the co-lead in donor coordination, along with the European Union (EU). Over the past year, the Bank has conducted multiple missions in Tunis with key partners, including MOH representatives, UN agencies, bilaterals and INGOs. The Bank team continues to closely coordinate with all partners, especially with WHO and UNICEF. This helps the Bank team keep abreast of the happenings on the ground.

As data remain a challenge, the Bank team is coordinating closely with other partners so that there is a culture of sharing data and information. Partnership and data sharing between the Bank and WHO, for example, has led to highly productive initial geospatial analyses assessing access to healthcare and distribution of health workers at the city, district, and country level. Additionally, the Bank team expects to engage with other local nongovernmental agencies and consulting firm(s) to be more engaged in the country. The composition of the team that the Bank brings is appropriate to respond to needs of an FCV country.

18. Institutional and Implementation ArrangementsThe World Bank team has continued its technical assistance to Libya during the conflict. The only way it could do so, is by using a “reverse” mission model along with 1-day visits to Tripoli whenever possible. This is a well-accepted model for operating in extremely difficult environments of fragility, conflict and violence (FCV). The ASA team will follow this practice and will be inviting government counterparts to Tunis (or other places) to engage in technical discussions through workshops, and training programs. The team has included within the budget resources to allow for such visits and stay of the government.

The ASA will use a third-party mechanism (TPM) and Feedback mechanism (FM) process (see footnote for description). 4 TPM and FMs have been employed in many World Bank-financed projects around the world.

The ASA for which initial funding has been approved, as well as this request for additional funding, have been fully prepared according to World Bank policies and procedures. Both are proposed as a programmatic ASA financed under a World Bank executed trust fund following the World Bank’s standard operational policies and procedures, including procurement and financial management policies.

19. Monitoring and Evaluation of ResultsFor TPM, an independent consultancy firm or non-government organization will be selected for this assignment. In order to combine the independent expertise of the selected firm with local knowledge, the firm will employ local consultants to implement some of the assigned activities.

The assigned activities may consist of some or all of the following:

Preparation and capacity building Periodic site visits Periodic assessment of local context and conditions Design and management of a shared feedback mechanism for the projects (including for quality of services and

patient satisfaction) Qualitative patient satisfaction feedback

Firm qualification criteria may include some or all of the following:

Provide information showing that they are qualified in the field of the assignment. Provide information on the technical and managerial capabilities of the firm. Provide information on their core business and years in business. Provide information on the qualifications of key staff. Provide an indication of the methodologies to be employed in the assignment, including cross-verification of

findings Provide information on the recruitment methods for the consultants

For various activities, the Bank team will be meeting government counterparts at least every six months (if not more regularly) to jointly review progress of the various activities supported under the ASA. For the pilot sites, quarterly

4 Third party monitoring (TPM) is defined as monitoring by parties that are external to a projects direct beneficiary chain and management structure (e.g., local or international civil society organizations, academia representatives, consulting firms, etc.) to assess whether desired social, environmental, or other impacts are being achieved and undesirable impacts avoided. It can significantly improve the knowledge about project implementation, impacts, targeting, and problems; gain the support of project beneficiaries and other stakeholders; give credibility to project findings; and ultimately improve project development effectiveness. Feedback mechanisms (FMs) constitute a locally-based, formalized way to accept, assess, and resolve community feedback or complaints (typically referred to as grievance redress mechanisms - GRMs). They are increasingly used to improve the outcome of development projects by providing timely and results-oriented information about project implementation and ensure that the projects reflect beneficiary needs.

progress reports will be requested to be shared with both government counterparts and the Bank team. Joint progress reviews will be done (remotely) in Tunis between the government counterparts and the Bank team. The Reports will be developed and disseminated, and workshops will be held inviting various key stakeholders to engagement for change. Towards the end of each fiscal year, there will be a workshop to discuss the findings of that FY, as well as plan activities for the next FY. The Project Development Objective (PDO) indicators will be reviewed annually, while the intermediate indicators will be reviewed bi-annually.

The Bank will use the monthly health coordination platform (WHO is co-leading the effort where all partners, government, UN, development partners, INGOs are invited) for consultation, sharing and moving agendas. Presentations and Report summaries (and reports at times) will be translated into Arabic.

E. PROJECT BUDGETING AND FINANCING

20. Project Financing (including ISA Direct Costs5)Cost by Component Transition Fund

(USD)Country

Co-Financing

(USD)

Other Co-Financing

(USD)

Total(USD)

Component 1: Human Resources for Health(a)

750,000 (original: 500,000,

AF: 250,000)

750,000

Component 2: Health Service Delivery(a)

2,573,600(original: 1,573,600,

AF: 1,000,000)

2,573,600

Component 3: Health Finance and Governance(a)

350,000(original: 300,000,

AF: 50,000)

350,000

Total Project Cost 3,673,600 (original: 2,373,600

AF: 1,300,000)

0 0 3,673,600

21. Budget Breakdown of Indirect Costs Requested (USD) Description Amount (USD)

For grant preparation, administration and implementation support:Grant administration 40,700 (original: 26,400, AF:

14,300) Total Indirect Costs 40,700 (original: 26,400, AF:

14,300)

5 ISA direct costs are those costs related to the ISA’s direct provision of technical assistance within the project. Also see Paragraph 47 of the Operations Manual.

F. Results Framework and Monitoring

Project Development Objective (PDO):

PDO Level Results Indicators*

Unit of Measure

Baseline

Cumulative Target Values**

FrequencyData Source/Methodology

Responsibility for Data

Collection

Description (indicator definition

etc.)YR 12018

YR 22019

YR 32020

YR 42021

-Targ

etIndicator One: Patient satisfaction

Percent (not started yet)

60% Bi-annually Pilot sites. Third party monitoring

World Bank Baseline data will be collected and target will be adjusted at the start of the pilot

Indicator Two: Personnel attendance rate at health facilities (or reduction in staff absenteeism)

Percent 20%(June 2017

estimate)

(not started yet)

40% Quarterly Pilot sites. Facility based information systems, and third-party monitoring

World Bank Baseline data will be collected and target will be adjusted at the start of the pilot

MENA TF Indicator: Documents produced and endorsed

Number 0 6 Annually World Bank

MENA TF Indicator: Public sector staff trained.

Number 55 100 Annually World Bank

INTERMEDIATE RESULTS

Intermediate Result (Component One): Human Resources

Intermediate Result indicator One: Workforce analysis study initiated

Yes/No Yes Yes World Bank

Intermediate Result indicator Two: Report and recommendations prepared on Workforce analysis and toward interventions in human resources for health

Yes/NoReport/ Workshop

No Yes World Bank

Intermediate Result (Component Two): Health Service Delivery Model

Intermediate Result indicator One: Patient exit survey and provider survey conducted

No (task started and ongoing)

Yes World Bank

Intermediate Result indicator Two: Design and implementation plan for the health service delivery pilot with monitoring indicators

Report/Workshop

No (task started and ongoing)

Yes World Bank

Intermediate Result indicator Three: Pilot site program initiated

Workshop No Yes World Bank

Intermediate Result indicator Four: Pilot site program annual monitoring report

Report/Workshop

No Yes World Bank

Intermediate Result (Component Three): Health Finance and Governance

Intermediate Result indicator One: Custom made flagship course for the Libyans

Workshop Yes (complete

d)

Yes World Bank

Intermediate Result indicator Two: Report and recommendations prepared on where cost reducing and efficiency gains can be achieved

Report/Workshop

No (task started and ongoing)

Yes World Bank