The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) Health Services Improvement Project (P145335) EASTERN AND SOUTHERN AFRICA | Zambia | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2014 | Seq No: 14 | ARCHIVED on 22-Jun-2022 | ISR44973 | Implementing Agencies: Ministry of Finance (Republic of Zambia), Ministry of Health Key Dates Key Project Dates Bank Approval Date: 21-Mar-2014 Effectiveness Date: 31-Mar-2015 Planned Mid Term Review Date: 30-Apr-2018 Actual Mid-Term Review Date: 30-Apr-2018 Original Closing Date: 30-Jun-2019 Revised Closing Date: 31-Dec-2020 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) The project development objective is "to improve health delivery systems and utilization of maternal, newborn and child health andnutrition services in project areas." Has the Project Development Objective been changed since Board Approval of the Project Objective? Yes Board Approved Revised Project Development Objective (If project is formally restructured) The project development objective is "to improve health delivery systems and utilization of maternal, newborn and child health and nutrition services in project areas, and to prepare for and provide an immediate and effective response to the EVD emergency. Components Table Name Component 1: Strengthening capacity for primary and community level MNCH and nutrition services:(Cost $27.95 M) Component 2: Strengthening utilization of primary and community level MNCH and nutrition services through results based financing ap proaches:(Cost $25.54 M) Component 3: Strengthening project management and policy analysis:(Cost $10.40 M) Component 4: Contingent Emergency Response Component (CERC):(Cost $3.11 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Overall Risk Rating Substantial Substantial Implementation Status and Key Decisions The Zambia Health Services Improvement Project was approved by the World Bank’s Executive Board on March 21, 2014 and became effective on March 31, 2015. During project implementation, the contingency emergency response component (CERC) was triggered to help ensure the country 6/22/2022 Page 1 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) was prepared for the Ebola Virus Disease outbreak to which US$3.1 million (SDR 2,255,000) of the project proceeds was reallocated. By end of the project on December 31, 2020, the project activities reached a total population of 3.4 million people - 18.6% of Zambia’s total population. The project achieved positive gains by putting in place platforms for health system reforms by introducing performance-based financing through DLIs at the national level, and results-based financing (RBF) at the district level, health facility (hospitals and health centers) and community levels. Further, the project enhanced the capacities of nurses and midwives through specialized pre-service and in-service training and continuous professional development (CPD) in Reproductive, Maternal, Neonatal, Child and Adolescent Health and Nutrition (RMNCAH-N); health financing; and drugs and medical supply chain management. The RBF contributed to an upward trend in key RMNCAH-N indicators, facilitated fiscal decentralization through direct disbursement of funds from the central level to beneficiary health facilities, strengthened managerial autonomy at the PHC level, and helped reinforce referral linkages and improvements in the quality of care for MNCH services at health facilities. All these improvements in service delivery systems led to corresponding improvements in maternal child health and nutrition outcomes in project areas. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Substantial Substantial Macroeconomic -- Substantial Substantial Sector Strategies and Policies -- Moderate Moderate Technical Design of Project or Program -- Moderate Moderate Institutional Capacity for Implementation and -- Moderate Moderate Sustainability Fiduciary -- High Substantial Environment and Social -- Low Low Stakeholders -- Moderate Moderate Other -- -- -- Overall -- Substantial Substantial Results PDO Indicators by Objectives / Outcomes Improve health delivery systems for MNCH and nutrition services IN00936715 ►Deliveries by skilled health providers in the project areas (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 27.00 78.00 63.00 80.00 Date 31-Dec-2012 30-Sep-2019 31-Dec-2020 31-Dec-2020 6/22/2022 Page 2 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) The proportion of skilled attendance at birth increased from 27% in 2012 to 76.1 in December 2019. However, this declined to 63% by December 2020 due to the impact of COVID-19 that affected access to Comments: health services on MNCH and nutrition. IN00936779 ►Health facilities (health post, health centres and district hospitals) offering integrated management of childhood Illnesses (IMCI) based on new standard guidelines in the project areas (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 64.00 67.00 65.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 This indicator has been achieved and surpassed the end target. Comments: Improve utilization of MNCH and nutrition services IN00936776 ►Under-2 children received monthly growth monitoring and promotion (GMP) based on new standard guidelines in the project. areas (Custom). (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 37.00 45.00 45.00 Date 31-Dec-2013 31-Mar-2020 31-Dec-2020 31-Dec-2020 This indicator has been achieved. The recommendation at MTR to strengthen the community service delivery platform by: (i) training health staff and community volunteers; (ii) procurement and distribution of GMP equipment; (iii) updating under five cards and health facility registers based on new guidelines; Comments: and (iv) accelerating implementation of GMP based on new standard guidelines by increasing the frequency of mobile services to Outreach Sites, helped to increase GMP monitoring and improve GMP uptake for under two children in health facilities and adjacent Outreach Sites. IN00936778 ►Fully immunized children at 12 months of age in the project areas. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 80.00 99.40 99.80 95.00 Date 31-Dec-2012 30-Sep-2019 31-Dec-2020 31-Dec-2020 The indicator has been achieved and surpassed the target. Comments: Provide an immediate and effective response to the Ebola Virus disease (EVD) emergency IN00936777 ►High risk districts with strengthened surveillance for rapid detection and isolation of EVD cases. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 100.00 50.00 Date 31-Dec-2018 01-Apr-2020 31-Dec-2020 31-Dec-2020 6/22/2022 Page 3 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) The indicator has been achieved based on the end target. Forty (40) at-risky districts were identified for Ebola virus disease (EVD) depending on whether districts were bordering with DRC the origin of EVD, districts with international airports, districts with Refugee camps, the civil war in DRC at the time of EVD Comments: outbreak, several people were running away from the affected EVD and war-torn areas in DRC and entering the northern part of Zambia. Later during implementation two (2) additional EVD risky districts were identified and capacitated bringing the total risky districts to 42. Intermediate Results Indicators by Components Component 1: Strengthening capacity for primary and community level MNCH and nutrition services IN00936780 ►Health workers trained in MNCH and nutrition competencies in the targeted provinces (Cumulative, Custom, DLI) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 419.00 419.00 400.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 The indicator was achieved. This refers to health workers trained in the 3-months in-service induction training for nurses and midwives that was designed as bridging in-service training course between the new and old curriculum. The last graduates under the old curriculum for nurses and midwives was in Comments: December 2017. The first graduates on new pre-service curriculum started from 2018 and therefore the 3- months in-service induction training for nurses and midwives was discontinued the same year. IN00936784 ►Regional hubs and staging posts equipped countrywide (Cumulative, Custom, DLI) (Number, Custom, PBC) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 7.00 7.00 7.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 This indicator was achieved Comments: IN00936791 ►Nurses and midwives trained in MNCH and nutrition competencies based on enhanced pre-service & in-service training and CPD in project areas (Cumulative, Custom, DLI) (Number, Custom, PBC) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 14,346.00 18,639.00 15,000.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 The indicator was achieved and substantially surpassed the target Comments: IN00936792 ►Rural health facilities (health post, health centers and district hospitals) with at least one qualified health worker in the project areas (Custom) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 19.00 98.00 98.00 95.00 6/22/2022 Page 4 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 The indicator was achieved and surpassed the the target Comments: IN00936794 ►Health facilities (health post, health centers and district hospitals) conducting GMP based on new standard guidelines in the project areas (Custom) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 33.00 33.00 30.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 This indicator was achieved and surpassed the target. The baseline (Actual) at MTR was 20% due to Comments: contributions from Other donors and partially from the World Bank. IN00936796 ►Outreach sites in targeted provinces conducting GMP based on new standard guidelines in the project areas (Number, Custom, PBC) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 703.00 2,227.00 1,000.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 This indicator was achieved and substantially surpassed the target Comments: IN00936798 ►Health facilities (health centers and hospitals) conducting cervical cancer screening in project areas (Custom) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 4.00 7.00 8.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 IN00936801 ►Structures protected by indoor residual spraying in project areas (Custom) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 2,848,342.00 1,100,000.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 New indicator to measure coverage of IRS based on the second project restructuring. This was a one-time Comments: support during the 2018/2019 malaria season IN00936803 ►Health care providers and tutors Trained in essential newborn care (ENC) competency-based training (Cumulative, Custom) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 149.00 375.00 200.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 Comments: A total of 375 Health workers were trained in the revised advanced neonatal care course: 6/22/2022 Page 5 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335)  25 central level Trainer of Trainers  150 HWs in the expansion program  140 Provincial Trainer of Trainers  60 tutors clinical instructors from Nursing schools in the five project provinces Component 2: Strengthening utilization of primary and community level MNCH and nutrition services IN00936783 ►Health facilities (health centers and district hospitals) implementing the RBF approach in Project areas (Cumulative, Custom) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 70.00 964.00 964.00 900.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 IN00936787 ►Protocols and guidelines at community and primary care levels updated and disseminated (Cumulative, Custom) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 6.00 6.00 6.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 IN00936790 ►People who have received essential health, nutrition, and population (HNP) services (Number, Corporate) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 2,255,190.00 3,404,047.00 3,000,000.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 IN00936793 People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) (Number, Corporate Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 1,485,141.00 2,072,273.00 2,400,000.00 IN00936795 Number of children immunized (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 190,000.00 240,162.00 250,000.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 IN00936797 Number of women and children who have received basic nutrition services (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 1,896,640.00 2,969,000.00 2,450,000.00 6/22/2022 Page 6 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 IN00936799 Number of deliveries attended by skilled health personnel (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 221,377.00 190,000.00 0.00 300,000.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 IN00936800 ►Women attending ANC within the first three months of Pregnancy in the project areas (Custom, DLI) (Percentage, Custom, PBC) Baseline Actual (Previous) Actual (Current) End Target Value 9.00 59.00 33.80 50.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 New indicator to measure coverage of ANC during the First trimester. Comments: IN00936802 ►Lactating women accessing post-natal care within six days in the project areas (Percentage, Custom, PBC) Baseline Actual (Previous) Actual (Current) End Target Value 37.00 89.00 73.90 85.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 IN00936804 ►Neighborhood health committees (NHCs) implementing the RBF approach in the project areas (Cumulative, Custom) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 2,450.00 2,450.00 3,000.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 Indicator introduced to measure coverage of community RBF Comments: Component 3: Strengthening project management and policy analysis IN00936782 ►Health policy analysis conducted and results disseminated nationally (Cumulative, Custom) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 5.00 5.00 3.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 Indicator achieved and surpassed the end target Comments: IN00936786 6/22/2022 Page 7 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) ►Districts with community information system integrated DHIS-2 in project areas (Cumulative, Custom) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 40.00 40.00 45.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 IN00936789 ►NHCs implementing community health management information system (CHMIS) in targeted in the project areas (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 2,091.00 2,091.00 2,200.00 Date 31-Dec-2013 30-Sep-2019 31-Dec-2020 31-Dec-2020 Component 4: Contingent Emergency Response Component (CERC) IN00936781 ►High-risk districts with fully functional event-based surveillance systems in place (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.00 5.00 40.00 40.00 Date 31-Dec-2018 01-Apr-2020 31-Dec-2020 31-Dec-2020 IN00936785 ►Staff trained in field epidemiology training program (FETP), surveillance and response (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.00 10.00 0.00 30.00 Date 31-Dec-2018 01-Apr-2020 31-Dec-2020 31-Dec-2020 With two months left for implementation, there was not enough time to conduct Field Epidemiology training. Hence ZNPHI made a request to use funds for training to support data entry backlog for COVID- Comments: 19 cases, instead. IN00936788 ►Personnel (including community volunteers) trained in risk communication (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 40.00 50.00 284.00 150.00 Date 31-Dec-2018 01-Apr-2020 31-Dec-2020 31-Dec-2020 Performance-Based Conditions 6/22/2022 Page 8 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) IN00936805 ►PBC 1 Capacity to implement comprehensive pre-service training program on MNCH and nutrition for nurses and midwives strengthened (Number, Intermediate Outcome, 2,000,000.00, 100.00%) March 31, 2015 to Baseline Actual (Previous) Actual (Current) December 31, 2020 Value 0.00 8,723.00 9.00 9.00 Date -- 30-Sep-2019 31-Dec-2020 -- The capacity to implement comprehensive pre-service training program on MNCH and nutrition for nurses and midwives strengthened by strengthening the targeted eight (8) Nurse and Midwifery Training Institutions in the five Target Provinces based on the capacity building plans that were developed. Further, during implementation, one training institution from Western Province was added, bringing the total number to nine Comments: (9) Nurse and Midwifery Training Institutions that were strengthened by the end of the project. In addition, the enhanced pre-service curriculum for nurses and midwives was implemented countywide. This resulted in training of 12,036 nurses and midwives on the enhanced pre-service curriculum in RMNCH-N. Please note the actual previous is a wrong entry indicating the number of nurses and midwives trained instead of the institutional training capacity built. IN00936806 ►PBC 2 Vacancies for nurses/midwives in primary health facilities in Targeted Provinces filled by newly recruited nurses and midwifes who have completed the 3-induction in-service training in MNCH-N (Number, Intermediate Outcome, 2,600,000.00, 57.69%) March 31, 2015 to Baseline Actual (Previous) Actual (Current) December 31, 2020 Value 0.00 419.00 419.00 419.00 Date -- 30-Sep-2019 31-Dec-2020 -- The three (3) month induction in-service training in MNCH - nutrition was introduced as a stop gap measure for newly graduates in nursing and midwifery who have not be trained on the enhanced pre-service curriculum in RMNCH-N so that they are introduced to the new technologies in management of MNCH and nutrition. The 3- month induction course was stopped in December 2017 following graduation of nurses and midwives whose Comments: training based on the enhanced pre-service curriculum in RMNCH-N. The DLI was subsequently dropped during the project restructuring and a total of SDR 1,100,000 from DLR#2.4 and DLR#2,5 was dropped as disbursement linked results were no longer relevant. The total funds were converted to input financing and reallocated to Category 6 to support scaling up selected high impact interventions to reduce maternal and neonatal mortality. IN00936807 ►PBC 3 Nurses and Midwives in primary health facilities in targeted provinces who have completed the continuing professional development (CPD) training in MNCH and nutrition (Number, Output, 2,000,000.00, 100.00%) March 31, 2015 to Baseline Actual (Previous) Actual (Current) December 31, 2020 Value 0.00 5,204.00 6,184.00 -- Date -- 30-Sep-2019 31-Dec-2020 -- Comments: The initial eight (8) Nurse and Midwifery Training Institutions were strengthened based on the capacity building plans that were developed. Later one Training Institutional was added bringing the total number to nine (9) Nurse and Midwifery Training Institutions that were strengthened by the end of the project. Further, seven (7) in-service training departments at level 2&3 hospitals were rehabilitated and equipped with training equipment 6/22/2022 Page 9 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) and materials, strengthen the skills labs for practical training. The CPD training was taking place at training institutions and hospitals with in-service departments This increased the number of health providers trained in CPD with competences and skills in management of MNCH-N in project areas to 6,184. This indicator was fully achieved by 2018. IN00936808 ►PBC 4 Primary health facilities in Targeted Provinces stocked with all tracer drugs (Percentage, Outcome, 2,300,000.00, 30.43%) March 31, 2015 to Baseline Actual (Previous) Actual (Current) December 31, 2020 Value 33.30 44.70 44.70 44.70 Date -- 30-Sep-2019 31-Dec-2020 -- This indicator was dropped during the second project restructuring. It was noted that moving forward, this indicator will not be achieved mainly due to: (i) the low levels of government spending in the health sector and consequently affecting the ability to procure essential drugs and supplies; and (ii) the allocation of resources to the health sector had shrunk given the country’s poor economic performance and the high public debt, which Comments: could further be exacerbated by the COVID-19 pandemic. During project Appraisal this DLI was allocated an extra SDR300,000 beyond the total allocation to DLIs. The allocation to DLI#4 was corrected to SDR2,300,000. The undisbursed amount of SDR1,250,000 was reallocated to the new DLR 4.7. Later converted to input financing and reallocated to Category 5 to support the CERC for Ebola Virus Disease. IN00936809 ►PBC 5 Number of regional essential commodities storage and distribution hubs established (Number, Intermediate Outcome, 2,000,000.00, 100.00%) March 31, 2015 to Baseline Actual (Previous) Actual (Current) December 31, 2020 Value 0.00 7.00 5.00 -- Date -- 30-Sep-2019 31-Dec-2020 -- The project supported the development, adoption, and implementation of the National Supply Chain Strategy (2015-2017). The following enhancements were made to: (i) the storage and distribution capacity, particularly for the “last mile” distribution through the seven hubs that were established throughout the country;(ii) central storage system at Medical Stores Limited; (iii) information technology (IT)-related infrastructure through Comments: acquisition of additional Warehouse Management System (WMS) licenses and other IT related accessories including expansion of the warehouse server capacity; and (iv) transport fleet through procurement of six hard top Land Cruiser station wagons and four 3.5-ton trucks to facilitate last mile distribution of essential commodities and supplies to the health facilities. IN00936810 ►PBC 6 The electronic Zambia Inventory Control System (eZICS) is piloted and implemented in Targeted Provinces (Text, Outcome, 2,000,000.00, 10.00%) March 31, 2015 to Baseline Actual (Previous) Actual (Current) December 31, 2020 Value None -- None None 6/22/2022 Page 10 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) Date -- 30-Sep-2019 31-Dec-2020 -- The project supported the evaluation of the eZICS pilot. The results from the evaluation concluded that the eZICS performed as designed and met and exceeded user expectations on all key design objectives and that it was seen to be a robust application by the users. The key design evaluation objectives included: (i) expansion of the product list from 40 SKUs to provide coverage for all products required by health facilities; (ii) the creation, testing and deployment of interfaces to the WMS in use, Warehouse Expert and SAGE, to be determined by the databases requirements; (iii) increased use of bar code-based capability to include batch Comments: numbers; and (iv) training and deployment with a focus on a fixed training or at least five days with hands on practice. Following the MOH policy shift to implement the electronic Logistics Management Information System (eLMIS) throughout the country as opposed to scaling up the electronic Zambia Inventory Control System (eZICS) pilot, A total of SDR 1,800,000 from DLR# 6.2, 6.3, 6.4 and 6.5 were dropped - DRLs no longer relevant and were converted to input financing and reallocated to Category 6 to support scaling up selected high impact interventions to reduce maternal and neonatal mortality. IN00936811 ►PBC 7 Number of women registered during the first trimester of their pregnancy in targeted provinces (Percentage, Intermediate Outcome, 1,300,000.00, 70.38%) March 31, 2015 to Baseline Actual (Previous) Actual (Current) December 31, 2020 Value 9.00 59.00 33.80 33.80 Date -- 30-Sep-2019 31-Dec-2020 -- This indicator was included formally in the RF in 2018. The DLI baseline in 2013 was 9%. There was an incremental in the number of women attending ANC within the first three months of pregnancy. This increased by twofold form 16.7% in 2017 to 39.7% in 2018 and increased to 51.8% in 2019. This reduced 33.8% by December 31, 2020, due to the impact of COVID-19 on access to ANC services. Zambia experienced persistent disruptions for reproductive and maternal health services between March 2020 and June 2021 Comments: ranging from 9% to 15% due to the impact of COVID-19 pandemic. The family planning decreased by 9%; hospitalization decreased by 11%; the fourth antenatal care visit decreased by 13% and institutional deliveries decreased by 15%. Achieving this DLI was marked with implementation delays and most DLRs were achieved partially over time. The unachieved SDR385,000 was reallocated to new DLR# 7.7. This DLR was later dropped during the second restructuring, converted to input financing, and reallocated to Category 5 to support the CERC for Ebola Virus Disease. IN00936812 ►PBC 8 Mothers who delivered at health facilities in Targeted Provinces and who received post-natal care. (Percentage, Intermediate Outcome, 2,000,000.00, 69.00%) March 31, 2015 to Baseline Actual (Previous) Actual (Current) December 31, 2020 Value 37.00 89.00 73.90 73.90 Date -- 30-Sep-2019 31-Dec-2020 -- This indicator was included formally in the Results framework in 2018. The DLI baseline was 37% in 2013, progressive increase in women attending postnatal services within six days was very slow. There was however a marked increase from 46.7% in 2017 to 69.1% in 2018 and 85.7% in 2019.. This reduced to 73.9% Comments: by December 31, 2020 due to the impact of COVID-19 on access to postnatal services. The unachieved SDR620,000 was reallocated to new DLR#8.7 that was later dropped during the second restructuring, converted to input financing, and reallocated to Category 5 to support the CERC for Ebola Virus Disease. 6/22/2022 Page 11 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) IN00936813 ►PBC 9 Outreach sites in targeted provinces conducting GMP based on new standard guidelines in the project areas (Number, Output, 1,700,000.00, 100.00%) March 31, 2015 to Baseline Actual (Previous) Actual (Current) December 31, 2020 Value 0.00 703.00 2,227.00 -- Date -- 30-Sep-2019 31-Dec-2020 -- This indicator was formally included in the Results framework in 2018. In 2018, 327 Outreach sites were performing GMP based on new standard guidelines. With accelerated implementation based on MTR Comments: recommendations to strengthen the community platform for delivery of services, the number of outreach sites increased to 703 in 2019, and 2,227 by December 31, 2020 .The unachieved SDR887,500 was reallocated to new DLR #9.7 which was achieved in December 2020. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P145335 IDA-53940 Closed USD 52.00 49.57 2.43 44.71 0.00 100% P145335 TF-16639 Closed USD 15.00 13.77 1.23 13.77 0.00 100% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P145335 IDA-53940 Closed 21-Mar-2014 11-Feb-2015 31-Mar-2015 30-Jun-2019 31-Dec-2020 P145335 TF-16639 Closed 11-Feb-2015 11-Feb-2015 31-Mar-2015 30-Jun-2019 30-Jun-2020 Cumulative Disbursements 6/22/2022 Page 12 of 13 The World Bank Implementation Status & Results Report Health Services Improvement Project (P145335) Restructuring History Level 2 Approved on 28-Jun-2019 ,Level 2 Approved on 23-Jun-2020 ,Level Approved on 18-Nov-2020 Related Project(s) There are no related projects. 6/22/2022 Page 13 of 13