The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) REPORT NO.: RES38049 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT APPROVED ON MAY 20, 2015 TO THE REPUBLIC OF GUINEA HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Hafez M. H. Ghanem Country Director: Coralie Gevers Regional Director: Amit Dar Practice Manager/Manager: Gaston Sorgho Task Team Leader: Ibrahim Magazi, Lombe Kasonde The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) ABBREVIATIONS AND ACRONYMS Abbreviation Definition ATS Technical Health Agent (Agent Technique de Santé) BP Bank procedure BSD Bureau de Stratégie et Développement CHW Community health worker CMS Central Medical Store CRVS Civil Registration and Vital Statistics DHIS-2 District Health Information System DPS District health directorate (Direction préfectorale de la santé) ESMF Environmental and Social Management Framework FY Fiscal year GDP Gross domestic product GFF Global Financing Facility GNF Guinean franc HIS Health information system HMIS Health Management Information System IBF Input-based financing IDA International Development Association IPF Investment project financing KIT Koninklijk Instituut voor de Tropen (Royal Tropical Institute of Netherlands) M&E Monitoring and Evaluation MOH Ministry of Health NGO Nongovernmental organization OBF Output-based financing OP Operational policy PAD Project Appraisal Document Projet d’Amélioration des Services de Santé Primaire (Guinea Primary Health Services PASSP Improvement Project) PBF Performance-based financing PCU Project coordination unit PDO Project development objective The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) PHD Prefecture health directorate PMT Proxy means test PNDS National Health Plan 2015-2024 (Plan National de Développement de la Santé) PPSD Project Procurement Strategy for Development RBF Results-based financing REDISSE Regional Disease Surveillance Systems Enhancement RMNCH Reproductive, maternal, newborn, and child health SARA Service Availability and Readiness Assessment SDI Service Delivery Indicator UN United Nations UNICEF UN Children’s Fund USAID U.S. Agency for International Development WHO World Health Organization The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) BASIC DATA Product Information Project ID Financing Instrument P147758 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 20-May-2015 30-Sep-2020 Organizations Borrower Responsible Agency The Republic of Guinea Ministry of Health Project Development Objective (PDO) Original PDO The development objective of the proposed project is to: Improve the utilization of maternal, child health and nutrition services at the primary level of care in target regions. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-56570 20-May-2015 26-Jun-2015 30-Dec-2015 30-Sep-2020 8.30 7.92 .59 IDA-D0690 20-May-2015 26-Jun-2015 30-Dec-2015 30-Sep-2020 6.80 5.57 1.40 The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Background and Context 1. The health system in Guinea is marred by serious weaknesses, in large part brought about by the prolonged neglect of the sector, and further weakened by the 2013 Ebola epidemic. Government spending on health has been historically low and has only increased in the past six years. Prior to the 2013 West African Ebola Virus Disease (EVD) crisis, government health expenditure (funded by general tax revenues) accounted for between only 2-3% of total public expenditure. More recently, the Government of Guinea (GoG) increased its share of spending with the 2017 budget showing 8% of the government budget allocated to health (MOH, 2017). Table 1. Health Expenditure Data Per Capita Total Health Expenditure (CHE) Rate $37.46 (WHO GHED, 2016) (Govt + Private + Households) in US$ Govt/Public Share of Per Capita CHE - in % 38.8% (WHO GHED, 2016) - In US$ terms 14.54 (WHO GHED, 2016) Out-of-Pocket Expenditure as % of CHE 50% (WHO GHED, 2016) Govt/Public health expenditure as - % of GDP 1.33% (MOH Budget, 2017) - % of Public Budget 8% (MOH Budget, 2017) Source: WHO, MOH, 2017 2. The recent increase in public spending on health, however, is almost entirely allocated to health worker salaries. Only 6% of the health allocation is directed towards operational expenditure for the delivery of priority health programs, which is similar to previous years. 3. Overall, service delivery across the country remains worrying and additional resources targeted at the deconcentrated level are needed. The increase in public spending did not reach the frontline and this has had consequences on service delivery. There has been a decrease in health indicators and downward trends presented in the most recent DHS data (2018): Table 2. Service Delivery Trends Indicator 2012 (DHS) 2016 (MICS) 2018 (DHS) Antenatal care visits (4) (%) 57 51 35 The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) Complete immunization rate (%) 37 26 24 Chronic malnutrition: stunting rate (%) 31 32 30 Maternal Mortality Ratio 550 Child Mortality Rate 86 Infant Mortality Rate 56 Source: UNICEF MICS 2016, DHS 2018 4. The Primary Health Services Improvement Project (PASSP) was developed to re-start the utilization of high impact maternal and child health services at the community and health center level. During the Ebola crisis which began in 2013, much of the existing limited resources were redirected towards response efforts. As a result, utilization of maternal and child health services was very low. The Project Development Objective of the PASSP is to improve the utilization of maternal, child health and nutrition services at the primary level of care in target regions. The PASSP aims to strengthen both the supply and demand of such by a) increasing the number and performance of health workers and the availability of equipment and supplies, and b) strengthening the capacity of community health workers and community health insurance schemes to generate community level demand. The PASSP supports two of the poorest regions in Guinea, Faranah and Labe, reaching one fifth of the population. The project target regions were selected based on a number of criteria including Maternal Child Health and Nutrition (MCHN) indicators, available financing, and poverty incidence. 5. The implementation of the PASSP over the 2016-2018 period was pitted against a demanding Ebola response effort and the challenges that came with changing leadership. Several partners and the GoG continued to redirect human and financial resources to Ebola, which led to a delay in the start of the Project. Nonetheless, the PASSP made good progress in terms of service delivery improvements, increasing demand, recruitment and deployment of human resources, and identifying the indigent poor, through the various central and peripheral level implementers. B. Project Status 6. The Primary Health Services Improvement Project was approved by the Board on May 20, 2015 for an amount of USD 15.1 million (USD 8.3 million IDA credit and USD 6.8 million IDA grant). The Project became effective December 30, 2015 and the closing date remains September 30, 2020. To-date USD 12.5 million have been disbursed representing 81% of the net commitment. Table 1. Key dates and disbursement Net Disbursed Undisbursed % Board May 20, 2015 Commitm Disbursed Approval ent IDA- 8.30 7.33 1.18 88.30 Effectiveness December 30, 2015 56570 IDA- 6.80 5.24 1.73 77.05 Project September 30, 2020 D0690 Closing Date Total 15.10 12.57 2.91 81.20 The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) 7. Component 1: Commodities and trained human resources for MCHN services at primary level (US$6.0 million). UNICEF was contracted to procure medicines and medical supplies due to the weak capacity of local suppliers and lack of responses to the tender launched by the Pharmacie Centrale de Guinea (PCG). The items ordered have been distributed to all project health facilities by the PCG, who are in-charge of storage and distribution. Training of health facility supervisors in the basic package of services and proper use of tools has also been conducted. Indicators under this component need to better reflect the package of nutrition services provided at health facilities. Implementation could also be accelerated if resources are made available more quickly, which can be addressed by increasing the designated account ceiling. 8. Component 2: Strengthen community-level demand for MCHN services (US$4.0 million). This component introduced exemptions from select health costs for households identified as being vulnerable. The recruitment and training of NGOs providing technical assistance has been undertaken. It is estimated that 23,000 indigents will be identified in total, fewer than the estimates developed based on the poverty survey available at the time of project preparation. Additionally, for those indigents that have been identified, uptake remains poor. Indicators for this component therefore need to be updated. 9. Component 3: Strengthen government capacity to plan, implement, monitor and supervise activities (US$5.0 million). Under this component, District Health Departments have been supported to undertake formative supervision and monitoring missions to their district health centers and posts. Supervision activities have been conducted in nine health districts in the Project area. The Project has also supported the completion of various studies and surveys including SARA, DHS V, and the MOH Statistical Database. Data will be added to DHIS2 for the years 2010 – 2014. The Ministry of Health also now has a functioning RBF unit and a validated National RBF manual. 10. Contingency: US$ 100,000 remained unallocated as contingency funding (hence not budgeted against specific components), and used under component 3. C. Rationale for Restructuring 11. A mid-Term Review (MTR) of the Project held from March 17-30, 2019 highlighted that the Project is making good progress towards achieving its slated objectives. PDO and intermediate indicators are on track and disbursement is at 81%. However, the results framework (RF) requires revision in four areas: (i) The RF it does not fully capture the extent of nutrition services being provided. Child malnutrition is a serious health problem in Guinea with an estimated 8 percent of children suffering from moderate acute malnutrition (low weight for height) (MICS 2016). Nearly 32 percent of children in Guinea younger than 5 show signs of delayed growth and development. Nearly half of this group, approximately 15 percent, are severely stunted. Vitamin A supplementation is a high-impact intervention which is already being undertaken and tracked. Additional nutrition services provided also need to be captured to show how the project is addressing this challenge. (ii) The project over-estimated the total number of indigents. The 2012 Limited Poverty Evaluation Survey reports that 55.2 percent of the Guinean population (6,212,748 individuals) are considered to be poor (earning less than GNF8,815 per person per day) and it is on the basis of this estimates at the regional level that the target number of indigents were calculated. Adequately and accurately identifying indigents has been challenging and it is now estimated that a total of 23,300 indigents will receive exemption cards. For those indigents that have been identified, it is recognized that uptake remains poor. The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) (iii) The introduction of Results-Based Financing (RBF) quality checklists was planned based on the Mamou region pilot but was not implemented. Districts were to rely on supportive supervision methods, including quality checklists for supervision and the project would measure the extent to which the health facilities met the minimum checklist score. RBF will instead be rolled out through the new Kankan-Kindia Project (Guinea Health Service and Capacity Strengthening Project, P163140). (iv) The total beneficiaries figures need to be revised in line with the guidance received in FY19 on the Corporate Results Indicators (CRIs), clarifying that the ‘total’ CRI for people receiving HNP services should be the sum of the sub-CRIs for nutrition, assisted delivery, and children immunized. Reporting of CRIs should be cumulative since the beginning of the project. 12. Other issues arising from the MTR were around disbursement rates by component and Financial Management. (i) With the high disbursement rates of component 3, it was necessary to revisit the allocation of funding by component to allow for completion of supervision activities and to take into account the slow uptake of indigent services – component 2. (ii) The designated account withdrawal application ceiling needs to be increased to take into account the time needed to provide justifications without compromising critical recurrent payments such as the salaries of contracted health workers. II. DESCRIPTION OF PROPOSED CHANGES The level 2 restructuring proposes the following changes: 1) Add an additional indicator for nutrition to better capture the extent of nutrition services provided by health facilities. The current indicator which monitors Vit A distribution will be supplemented by an indicator on proportion of malnutrition recovery at the health centers: Children recovering from severe acute malnutrition (Number). 2) Reduce the end target number of indigents from 50,000 to 13,000 as the identification exercise suggest the total number of these beneficiaries who will receive cards is 23,243; 3) Remove an indicator on the Percent of health facilities and posts assessed monthly (by district team) meeting minimum checklist score which was included as the introduction of RBF was planned based on the Mamou region pilot. 4) Lower the total number of beneficiaries to 500,000 based on new CRI definitions; 5) The costs for each component will be revised to address financing overruns, without amending the overall budget. 6) The designated account withdrawal application ceiling will be increased from USD700,000 to USD1,000,000 to take into account the time needed to provide justifications without compromising critical recurrent payments such as the salaries of contracted health workers. The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Reallocation between Disbursement Categories ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) Component 1: Commodities Component 1: Commodities and and trained human resources trained human resources for 6.00 Revised 6.48 for MCHN services at primary MCHN services at primary level level Component 2: Strengthen Component 2: Strengthen community-level demand for 4.00 Revised community-level demand for 2.32 MCHN services MCHN services Component 3: Strengthen Component 3: Strengthen government capacity to plan, government capacity to plan, 5.00 Revised 6.20 implement, monitor and implement, monitor and supervise activities supervise activities TOTAL 15.00 15.00 OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-56570-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: GD, NCS, CS, TR, OP COST 5,250,000.00 3,772,602.35 5,300,000.00 55.00 55 iLap Category Sequence No: 3 Current Expenditure Category: CHW CASH TRANSFERS 800,000.00 780,202.60 800,000.00 100.00 55 iLap Category Sequence No: 4 Current Expenditure Category: UNALLOCATED 50,000.00 0.00 0.00 0 Total 6,100,000.00 4,552,804.95 6,100,000.00 The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) IDA-D0690-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: GD, NCS, CS, TR, OP COST 3,500,000.00 3,086,562.77 4,180,000.00 45.00 45 iLap Category Sequence No: 2 Current Expenditure Category: PAYMENT/HEALTH FACILITIES PT 2(1) 1,470,000.00 0.00 98,000.00 100.00 100 iLap Category Sequence No: 4 Current Expenditure Category: UNALLOCATED 30,000.00 0.00 0.00 0 iLap Category Sequence No: 3 Current Expenditure Category: CHW CASH TRANSFERS 0.00 0.00 722,000.00 45 Total 5,000,000.00 3,086,562.77 5,000,000.00 . The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) . Results framework COUNTRY: Guinea GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT Project Development Objectives(s) The development objective of the proposed project is to: Improve the utilization of maternal, child health and nutrition services at the primary level of care in target regions. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 Improve the utilization of maternal, child health and nutrition services at the primary level Births (deliveries) attended by skilled health 27,227.00 29,250.00 51,161.00 personnel (number) (Number) Percentage of Children (0-11months) Fully 57.00 55.00 65.00 Vaccinated (Percentage) Percentage of pregnant women receiving at least 4 Antenatal care visits from health provider 47.00 55.00 (Percentage) Number of children under 5 with confirmed malaria who received antimalarial treatment 50,610.00 61,740.00 73,800.00 (Number) Percentage of Children (0-1year) receiving Vitamin 0.00 60.00 A supplementation every 6 months (Percentage) Direct project beneficiaries (Number) 0.00 155,412.00 500,000.00 Female beneficiaries (Percentage) 0.00 75.00 The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Component 1: Commodities and trained human resources for MCHN services at primary level percentage stock outs of tracer drugs in health 41.00 46.00 10.00 center (Percentage) Number of new health workers recruited and in service at health centers 0.00 0.00 150.00 300.00 450.00 450.00 450.00 and posts (cumulative) (Number) Health personnel receiving 0.00 0.00 150.00 300.00 450.00 450.00 450.00 training (number) (Number) Health Centers offering Integrated Management of 0.00 0.00 20.00 40.00 60.00 80.00 80.00 Childhood illnesses (percent) (Percentage) People who have received essential health, nutrition, 0.00 93,457.00 176,221.00 and population (HNP) services (CRI, Number) Number of children immunized (CRI, 0.00 57,355.00 73,899.00 Number) Number of women and 0.00 18,686.00 51,161.00 children who have The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 received basic nutrition services (CRI, Number) Number of deliveries attended by skilled 0.00 27,227.00 29,250.00 51,161.00 health personnel (CRI, Number) Children recovering from severe acute malnutrition 0.00 10,000.00 (Number) Action: This indicator is New Children recovering from severe acute 8,441.00 10,681.00 malnutrition (Number) Action: This indicator is New Component 2: Strengthen community-level demand for MCHN services (Action: This Component has been Revised) Number of new indigents covered under exemption 0.00 0.00 5,000.00 5,000.00 7,000.00 13,000.00 13,000.00 mechanisms (Number) Rationale: Action: This indicator has Recent community surveys have revised downwards estimates of the total indigent population. This in-turn reduces the potential number of indigent women been Revised and children to be targeted by the project. Percentage of indigents satisfied with exemption 0.00 0.00 40.00 50.00 60.00 70.00 70.00 mechanisms (Percentage) The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Number of newly trained community health workers engaged in health 0.00 0.00 100.00 300.00 530.00 530.00 530.00 promotion and basic service delivery (Number) Component 3: Strengthen government capacity to plan, implement, monitor and supervise activities Percent of health facilities and posts assessed monthly (by district team) meeting 0.00 0.00 40.00 50.00 60.00 70.00 70.00 minimum checklist score (Percentage) Action: This indicator has been Marked for Deletion Percent of community workers and health workers at health center that 0.00 0.00 40.00 50.00 60.00 70.00 70.00 receive monthly supportive supervision (Percentage) Standardized MNCH District training program developed No No Yes Yes Yes Yes Yes and implemented (Y/N) (Yes/No) Work Plan Budget execution Rate (percent) 0.00 30.00 60.00 80.00 85.00 85.00 83.00 (Percentage) Health facilities reporting health management data 0.00 0.00 50.00 60.00 70.00 80.00 100.00 on time (Percentage) The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758) IO Table SPACE The World Bank GN PRIMARY HEALTH SERVICES IMPROVEMENT PROJECT (P147758)