The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) Strengthening Primary Health Care for Results (P152736) AFRICA | Tanzania | Health, Nutrition & Population Global Practice | Requesting Unit: AFCE1 | Responsible Unit: HAFH1 IBRD/IDA | Program-for-Results Financing | FY 2015 | Team Leader(s): Peter Okwero Seq No: 10 | ARCHIVED on 26-Jun-2020 | ISR42419 | Created by: Peter Okwero on 16-Jun-2020 | Modified by: Peter Okwero on 24-Jun-2020 Program Development Objectives Program Development Objective (from Program Appraisal Document) The Program Development Objective is to improve the quality of primary health care (PHC) services nationwide with a focus on maternal, neonatal and child health (MNCH) services. Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Implementation Status and Key Decisions The Program is in its fifth year of implementation and is on track to achieve its Program Development Objective (PDO). Four of the five PDO indicators have surpassed the end of Program targets including pregnant women attending 4 or more antenatal care visits; antenatal care attendees receiving at least 2 doses of intermittent preventive treatment for malaria; institutional deliveries; and the proportion of children 12-59 months receiving at least one dose of Vitamin A supplementation during the previous year. Similarly, seven out of thirteen intermediate results indicators have achieved annual (2019) targets. Based on a request from the Government of Tanzania, the Program was restructured to modify key Program results and Disbursement Linked Indicators (DLI). The restructuring also extended the Program’s Closing Date by one year, from June 2020 to June 2021. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P152736 IDA-56430 Effective USD 200.00 200.00 0.00 172.18 28.78 86% P152736 TF-A0261 Effective USD 20.00 20.00 0.00 11.43 8.57 57% P152736 TF-A0270 Effective USD 40.00 40.00 0.00 29.57 10.43 74% P152736 TF-A1567 Effective USD 4.50 4.50 0.00 3.98 0.52 88% P152736 TF-A9831 Effective USD 10.02 10.02 0.00 0.00 10.02 0% Key Dates (by loan) 6/26/2020 Page 1 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P152736 IDA-56430 Effective 28-May-2015 25-Aug-2015 05-Nov-2015 30-Jun-2020 30-Jun-2021 P152736 TF-A0261 Effective 28-May-2015 23-May-2016 20-Jul-2016 30-Jun-2020 30-Jun-2021 P152736 TF-A0270 Effective 28-May-2015 23-May-2016 20-Jul-2016 30-Jun-2020 30-Jun-2021 P152736 TF-A1567 Effective 23-May-2016 23-May-2016 20-Jul-2016 30-Jun-2020 30-Jun-2020 P152736 TF-A9831 Effective 01-Aug-2019 01-Aug-2019 20-Sep-2019 30-Jun-2020 30-Jun-2020 Program Action Plan Action Description Appoint Internal Auditor General as the independent verification entity. Source DLI# Responsibility Timing Timing Value Status Client Due Date 25-Nov-2015 Completed Completion Measurement Comments Action Description Submit basic reporting requirements for the sector as per the HBF requirement. Source DLI# Responsibility Timing Timing Value Status Client Due Date 30-Dec-2016 Completed Completion Measurement Comments Implement the ESSA through the following: Action Description i) Inclusion of HCWM in the CCHP ii) Monitor and report on the implementation of HCWM activities in the CCHP. Source DLI# Responsibility Timing Timing Value Status Technical Client Recurrent Yearly Delayed Completion Measurement HCWM guidelines prepared and training conducted While the Client appointed a Focal Person (July 2019) to oversee implementation of ESSA, general progress remains Comments slow. These Client was advised to pay greater attention to the ESSA. Action Description Review the existing procurement vetting mechanisms with a view to reducing backlog Source DLI# Responsibility Timing Timing Value Status 6/26/2020 Page 2 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) Client Due Date 30-Jan-2017 Completed Completion Measurement Comments Operationalize MSD system that issues out stock notices to facilities within one day as prescribed in the 2013 Public Action Description Procurement Regulation Act (Section 140) and the 2013 Public Procurement sub-regulations (Subsections 1 to 6). Source DLI# Responsibility Timing Timing Value Status Client Due Date 31-May-2018 Completed Completion Measurement Comments Action Description Conduct annual procurement audits of the program as well as Value for Money (VFM) audits by PPRA and CAG Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems Client Recurrent Yearly Completed Completion Measurement Submission of report Draft report for the value for money audit is ready and will shared with the WB by end of January 2019. The Comments procurement audit is underway, and the report will be shared in April 2019. Action Description Establish a PHCfoR Technical Committee and hold regular meetings to monitor implementation progress Source DLI# Responsibility Timing Timing Value Status Permanent Technical Recurrent Quarterly Completed Secretary Completion Measurement Minutes of Meetings Comments Action Description Promote the use of performance scorecard to enhance accountability Source DLI# Responsibility Timing Timing Value Status RCH Director and Technical Recurrent Yearly In Progress Project Coordinator Completion Measurement Score Cards reports Comments 6/26/2020 Page 3 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Moderate Substantial Macroeconomic -- Moderate Moderate Sector Strategies and Policies -- Low Low Technical Design of Project or Program -- Moderate Substantial Institutional Capacity for Implementation and -- Substantial Substantial Sustainability Fiduciary -- Substantial Substantial Environment and Social -- Substantial Substantial Stakeholders -- Low Low Other -- -- -- Overall -- Moderate Substantial RiskComments Comments Overall risk rating has been changed to Substantial following revision of the rating for political and governance and technical design of project to substantial. The rating for political and governance was revised to substantial because of the increasingly centralized management of the budget and fund flow processes by MoFP, as a result both MoHCDGEC and PORALG have witnessed increased delays with release of funds, and in many instances, releases have not been made even when in the approved budget. Technical design of the Program was revised to substantial. The Program is complex in its design involving many parties (Central, Regional, District and Health Facility) and using various instruments (HBF, RBF and DHFF). This may not have been recognized initially, but with the changing governance situation, the Program's complexity has become apparent. Results PDO Indicators by Objectives / Outcomes To improve the quality of PHC services nationwide with a focus on MNCH services IN00861137 ►PHC facilities with 3- Star Ratings and Above (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 19.00 19.00 30.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2018 31-Dec-2020 The indicator was not updated a the assessment was not conducted. It still however remains offtrack. Comments IN00861138 ►Pregnant women attending 4 or more ante-natal care (ANC) visits (Percentage, Custom) 6/26/2020 Page 4 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) Baseline Actual (Previous) Actual (Current) End Target Value 41.20 63.70 80.40 68.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861139 ►ANC attendees receiving at least 2 doses of intermittent preventive treatment (IPT2) for malaria (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 42.52 81.20 87.30 80.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861140 ►Institutional deliveries (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 44.72 79.20 82.60 70.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861141 ►Proportion of children 12-59 months receiving at least one dose of Vitamin A during the previous year (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 51.00 100.00 100.00 90.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 30-Jun-2020 Comments Intermediate Results Indicators by Results Areas Intermediate Results Indicators IN00861142 ►Share of health in total government budget (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 8.50 8.00 9.00 9.75 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 This indicator has under-performed consistently. Comments IN00861143 ►Councils with unqualified opinion in the annual external audit report (Percentage, Custom) 6/26/2020 Page 5 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) Baseline Actual (Previous) Actual (Current) End Target Value 80.00 96.00 95.70 92.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861144 ►Completion of “Star rating" assessment of PHC facilities as per the two-year cycle (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 100.00 0.00 50.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 30-Jun-2020 Star rating exercise not conducted though was planned. Comments IN00861145 ►RBF facilities receiving timely RBF payment on the basis of verified results every quarter (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 100.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Because of delays with verification, RBF payments to HF delays Comments IN00861146 ►LGAs with functional Council Health Service Boards (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 86.30 84.00 92.00 100.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861147 ►Health facilities with continuous availability of the tracer medicines in the past year based on MoHCDGEC medicine list (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 30.60 95.90 96.30 80.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861148 ►Health facilities with functional CEmOC (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 81.00 81.00 160.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2018 31-Dec-2020 6/26/2020 Page 6 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) No update in December 2019. Information will be availed after verification is completed Comments IN00861149 ►Completeness of quarterly HMIS data entered in DHIS by LGA (by the end of month after quarter ends) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 89.50 99.00 99.40 96.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861150 ►RHMT’s required biannual data quality audits (DQA) for LGAs that meets national DQA standards (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 68.00 37.00 80.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 There has a marked drop in the indicator. Comments IN00861151 ►Completion of annual capacity building activities compared to agreed annual plans (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 50.00 37.00 90.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861152 ►Dispensaries with skilled HRH (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 91.00 83.00 89.00 90.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861153 ►RHMTs conduct quarterly supportive supervision visits for the LGAs that meets national supervision standards and is reported in DHIS2 (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 100.00 100.00 100.00 Date 25-Aug-2015 31-Dec-2018 31-Dec-2019 31-Dec-2020 Comments IN00861154 ►People who have received essential health, nutrition, and population (HNP) services (Number, Corporate) Baseline Actual (Previous) Actual (Current) End Target 6/26/2020 Page 7 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) Value 0.00 58,115,170.00 64,486,447.00 30,000,000.00 Date 28-May-2015 31-Dec-2018 31-Dec-2019 30-Jun-2020 Comments IN00861155 Number of children immunized (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 6,802,958.00 8,869,047.00 10,000,000.00 Date 28-May-2015 31-Dec-2018 31-Dec-2019 30-Jun-2020 IN00861156 Number of women and children who have received basic nutrition services (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 42,435,178.00 45,016,138.00 10,000,000.00 Date 28-May-2015 31-Dec-2018 31-Dec-2019 30-Jun-2020 IN00861157 Number of deliveries attended by skilled health personnel (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 8,877,034.00 10,601,262.00 10,000,000.00 Date 28-May-2015 31-Dec-2018 31-Dec-2019 30-Jun-2020 Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1 DLI 1: Recipient has completed foundational activities (Output, 35,000,000.00, 40%) Baseline Actual (Previous) Actual (Current) 2020-21 Value No Yes Yes -- Date 25-Aug-2015 31-Dec-2018 31-Dec-2018 -- DLI 1 RESULTS Update as of December, 31 2018. 5 Completed/Achieved (DLR 1.1, 1.2; 1.3; 1.4; 1.5). 1 Partially completed/Partially Achieved (DLR; 1.6) DETAILED ASSESSMENT: 1. A 5year capacity building plan for the program has been completed. 2. Data Quality Audit tool prepared: COMPLETED. National DQA guidelines and tool have been developed, tested and disseminated to all 26 regions in the country has been done. Dissemination to the second administrative level – 184 local government authorities is done. 3. Financial instructions for health facility accounts prepared and disseminated to all LGAs: COMPLETED. Financial Management Guidelines for Public Health Facilities have been developed and disseminated. 4 Verified Comments baseline data (for 2014) and targets for performance indicators: COMPLETED. Report is available. 5 List of operational health facilities and GPS locations prepared: COMPLETED (7,356 facilities have been mapped which includes public, private and faith-based organizations). The data are publicly available at www.hfrportal.ehealth.go.tz. 6.a Completion of BeMONC and CeMONC assessment in the five BRN RMNCAH regions: COMPLETED. 6.b Eight selected health centres in the five BRN RMNCAH regions meeting CeMONC standards: ACHIEVED. Target: 8; Actual:8. 6.c At least 70 percent of health centres in the five BRN RMNCAH regions meeting BeMONC standards: PARTIALLY ACHIEVED. Target: 70%; Actual: 54% (Source: Star rating reassessment). 6/26/2020 Page 8 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) ►DLI 2 DLI 2: Recipient has achieved Program annual results in institutional strengthening (Process, 65,000,000.00, 69%) Baseline Actual (Previous) Actual (Current) 2020-21 Value No No No -- Date 25-Aug-2015 31-Dec-2018 31-Dec-2018 -- DLI 2 RESULTS Update is as of December 2018. All 6 Completed/Achieved (DLR 2.1; 2.2; 2.3;2.4;2.5;2.6). DETAILED ASSSSMENT: 1. Share of health in total budget increased to 9.5%. 2. Percentage of council whose annual comprehensive Council Health Plan (CCHP) passes the first round of assessment: ACHIEVED. Target: 80%; Actual: 83.7%. 3. Action Plans of Audits of PORALG and MOH received within 2 months of the official release Comments of the controller and Auditor General(CAG) report: ACHIEVED, Action plans shared by both MOH and PORALG. 4. Percentage of PHC facilities with bank accounts opened according to guidelines from Ministry of Finance and Planning (MOFP)/CAG: ACHIEVED. Target: 100%; Actual: 100%. 5. Percentage of annual employment permits for PHC staff given to the 9 critical regions: ACHIEVED. 6. Percentage of completion of “Star Rating Assessment" of PHC facilities: COMPLETED. Target: 100%; Actual: 100%. ►DLI 3 DLI 3: PHC facilities have improved maternal, neonatal and child health services delivery and quality as per verified results and received payments on that basis each quarter (Intermediate Outcome, 81,000,000.00, 37%) Baseline Actual (Previous) Actual (Current) 2020-21 Value 0.00 1,724.00 1,724.00 -- Date 25-Aug-2015 31-Dec-2018 31-Dec-2018 -- As of December 31, 2018 1,724 facilities in eight regions (Mwanza, Shinyanga, Pwani, Tabora, Kagera, Comments Kigoma, Geita and Simiyu) out of 9 planned regions are now implementing RBF. ►DLI 4 DLI 4: LGAs have improved annual maternal, neonatal and child health services delivery and quality as measured by the LGA Balance Score Card . (Outcome, 80,500,000.00, 52%) Baseline Actual (Previous) Actual (Current) 2020-21 Value 0.00 0.00 0.00 -- Date 25-Aug-2015 31-Dec-2018 31-Dec-2018 -- Comments DETAILED ASSESSMENT: This is the 4th year of measuring this DLI the aggregated indicator is calculated and measure against 2018 targets. Below is an update on the DLI sub-indicators as of December 31, 2018. 1. Percentage of pregnant women attending four or more antenatal care visits (ANC4): ACHIEVED: Target: 50%; Actual: 63.70%. 2. Proportion of mothers who received 2 doses of intermittent preventive treatment (IPT2) for malaria during last pregnancy: ACHIEVED. Target: 70%; Actual: 81.20%. 3. Percentage of institutional deliveries: ACHIEVED. Target: 73%; Actual: 79.20%. 4. Percentage of women of reproductive age (15-49 years) using modern family planning methods: PARTIALLY ACHIEVED: Target: 36%; Actual: 35.4% 5. Percentage of pregnant women who receive adequate quantity of iron and folate tablets during their current ANC visit: ACHIEVED: Target: 46% Actual: 76% 6/26/2020 Page 9 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) 6. Proportion of children 12-59 months receiving at least one dose of Vitamin A supplementation during the past year: ACHIEVED. Target: 100%; Actual: 100%. 7. Percent of PHC facilities with “3 stars” rating or higher: PARTIALLY ACHIEVED. Target: 35%; Actual: 19%. 8. Number and percentage of Public primary health facilites with at least one skilled staff: ACHIEVED. Target: 77% Actual: 83% 9. Percentage of PHC facilities with continuous availability of 10 tracer medicines (medicines, vaccines, medical devices) in the past year: ACHIEVED. Target: 87% Actual: 96% 10. Percentage of LGAs with functional Council Health Service Boards (meeting quarterly): ACHIEVED. Target: 82% Actual: 84% 11. Percentage of completeness of quarterly DHIS 2 entry by LGA (MTUHA phase one forms by Day 30 after the end of each quarter): ACHIEVED. Target: 97%; Actual: 99% 12. Percentage of LGAs with unqualified opinion in the external audit report. ACHIEVED. Target: 84%; Actual: 90%. ACHIEVED. ►DLI 5 DLI 5: Regions have improved annual performance in supporting PHC services as measured by Regional Balance Score Card. (Outcome, 3,010,000.00, 51%) Baseline Actual (Previous) Actual (Current) 2020-21 Value 0.00 0.00 0.00 -- Date 25-Aug-2015 31-Dec-2018 31-Dec-2018 -- DLI 5 RESULTS; 1 Not achieved (DLR 5.1). 1 achieved (DLR 5.2). DETAILED ASSESSMENT: DQA training has been done to all regions throughout the country. 5.1. RHMTs required biannual data quality audits (DQA) for LGAs that meets national DQA standards. NOT ACHIEVED. Baseline: 0%; Target: 60%; Actual:20% . 5.2. Comments RHMT's Required annual supportive supervision visits for LGAs that meets national supervision standards. ACHIEVED. Target: 100%; Actual 100% ►DLI 6 DLI 6: MoHCDGEC and PO-RALG have improved annual PHC service performance as measured by National Balance Scorecard (Process, 6,400,000.00, 57%) Baseline Actual (Previous) Actual (Current) 2020-21 Value 0.00 0.00 0.00 -- Date 25-Aug-2015 31-Dec-2018 31-Dec-2018 -- DLI 6. RESULTS Update is as of December 31, 2018. 1 Completed/Achieved (DLR 6.3). 2 Partially completed/Partially achieved (DLR 6.2 & 6.4). 1 Not achieved/completed (DLR6.1) DETAILED ASSESSMENT: 6.1 Average of LGA performance score: NOT COMPLETED. Target: 80%; Actual: 53%. 6.2. Average of Regional performance scores: PARTIALLY COMPLETED. Target: 80% Actual: 70%. 6.3. Comments Percentage of unsupported expenditure in MOH/PORALG in their annual audit. ACHIEVED. Target: 0%; Actual: 0.1%. 6.4. Percentage of LGA's receiving CHF matching funds: PARTIALLY COMPLETED. Target: 57%; Actual: 55% ►DLI 7 DLI 7: Completion of annual capacity building activities at all levels as per the agreed annual plans. (Process, 15,000,000.00, 50%) Baseline Actual (Previous) Actual (Current) 2020-21 Value No No No -- Date 25-Aug-2015 31-Dec-2018 31-Dec-2018 -- 6/26/2020 Page 10 of 11 The World Bank Implementation Status & Results Report Strengthening Primary Health Care for Results (P152736) The Capacity Building Plan (under DLI #1) has been implemented as agreed in the plan as of May 31, 2018 Comments 6/26/2020 Page 11 of 11