The World Bank Guinea Health Service and Capacity Strengthening Project (P163140) REPORT NO.: RES45616 DOCUMENT OF THE WORLD BANK RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF GUINEA HEALTH SERVICE AND CAPACITY STRENGTHENING PROJECT APPROVED ON APRIL 25, 2018 TO MINISTRY OF FINANCE HEALTH, NUTRITION & POPULATION AFRICA WEST Regional Vice President: Ousmane Diagana Country Director: Coralie Gevers Regional Director: Dena Ringold Practice Manager/Manager: Gaston Sorgho Task Team Leader(s): Ibrahim Magazi, Zenab Konkobo Kouanda The World Bank Guinea Health Service and Capacity Strengthening Project (P163140) I. BASIC DATA Product Information Project ID Financing Instrument P163140 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 25-Apr-2018 27-Jun-2023 Organizations Borrower Responsible Agency Ministry of Finance Ministry of Public health and Hygiene Project Development Objective (PDO) Original PDO Improve the utilization of reproductive, maternal, neonatal and child health services in target regions Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-62300 25-Apr-2018 27-Jun-2018 24-Dec-2018 27-Jun-2023 22.50 7.10 15.02 IDA-D3040 25-Apr-2018 27-Jun-2018 24-Dec-2018 27-Jun-2023 22.50 7.10 15.02 TF-A7042 25-Apr-2018 27-Jun-2018 24-Dec-2018 31-Dec-2021 10.00 10.00 0 The World Bank Guinea Health Service and Capacity Strengthening Project (P163140) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No II. SUMMARY OF PROJECT STATUS AND PROPOSED CHANGES Project Status 1. The Guinea Health Service and Capacity Strengthening Project (P163140) was approved by the World Bank Group’s Board of Executive Directors on April 25, 2018 and became effective on December 24, 2018. The total envelop of the project at approval was US$55.0 million: a credit from the International Development Association (IDA) in the amount of US$22.5 million, a grant from IDA in the amount of US$22.5, and a grant from the multi-donor trust fund for the Global Financing Facility in an amount of US$10.0 million. The project subsequently benefited from three other grants from the Global Financing Facility, totaling US$0.56 million, for specific health studies. The closing date of the project is June 27, 2023. 2. The Project Development Objective (PDO), which is relevant and achievable, is to improve the utilization of reproductive, maternal, neonatal and child health (RMNCH) services in target regions. The project target regions are Kankan and Kindia which account for approximately one-fourth of the Guinean population. The PDO indicators are as follows: - Number of deliveries assisted by trained health personnel; - Number of pregnant women who received 4 antenatal care visits; - Number of children (0-11 months) fully vaccinated; and - Number of women who have received modern contraception. 3. Thus far, progress towards achievement of the PDO, overall Implementation Progress, Monitoring and Evaluation, and overall Safeguards Rating have been Satisfactory or Moderately Satisfactory, while Financial Management, Project Management and Procurement have been Satisfactory. Multiple civil unrest periods, the Coronavirus Disease 2019 (COVID-19) pandemic and the presidential election period significantly impacted the pace of execution of the entire project, with a disbursement rate of 37.86 percent as of January 19, 2021. However, since the presidential election is over and the members of the new Government are appointed and all activities resumed, key project activities were launched early 2021. As of June 7, 2021 the disbursement rate stands at 43,3%. There are no overdue audit reports or Interim Financial Reports. 4. Two years after effectiveness, evaluation of the components and sub-components of the project revealed that there is a budget overrun for one sub-component while some money has been saved under other sub-components, as described below: 5. Component 1: Strengthen supply of basic RMNCH services in target regions (US$17.0 million) - Sub-Component 1.1: Increase availability of drugs, commodities, and access to water and electricity (US$6.0 million). All contracts related to this sub-component have been signed and the supplier (the United Nations International Children's Emergency Fund) has been paid. Drugs and commodities have been delivered to health facilities, activities related to water supply are expected to be completed by June 30, 2021, and all solar panels are expected to be installed by November 10, 2021. There is a US$9.8 million overrun for this sub-component. Indeed, costs estimates for this sub-component were underestimated during project evaluation because they were based on The World Bank Guinea Health Service and Capacity Strengthening Project (P163140) the costs of the previous health project. The previous health project only supported small health facilities (primary health centers), not hospitals, but this project supports both primary health centers and hospitals. - Sub-Component 1.2: Strengthen district-level capacity to recruit and improve the competencies of health workers (US$4.0 million). The project is on track with 399 health workers (182 technical health workers, 100 midwives, 102 nurses and 15 doctors) recruited. - Sub-Component 1.3: Strengthen the District Health Directorates (DHD) capacity to supervise and monitor RMNCH services delivery (US$7.0 million). The DHD were provided with resources to facilitate the supervision and monitoring of RMNCH services delivery. Activities are on track and expenditures are in line with the initial financial plan. 6. Component 2: Strengthen the demand for basic RMNCH services in target regions (US$13.0 million). - Sub-component 2.1: Implement an innovative district-level fee-financing scheme to mitigate out-of-pocket expenses for the indigent (US$8.0 million). Identification of the indigents in the target regions is completed but less indigents than initially planned (175,115/236,000) were identified and the identification process took more time than planned, which shortens the implementation of the health-related activities of this sub-component from 4 years to 2.5 years. So far, 123 809 indigent cards have been printed and 2,998 indigents have received their card. A total of 1,055 health care providers were trained on the guidelines for free health care for indigents, as planned, and 500 indigents benefited from the fee exemption program. Since the project identified less indigents than initially planned and the implementation of the project was shortened, US$3.0 million were saved under this sub-component. - Sub-component 2.2: Supporting the DHD recruitment, training, supervision, and mentoring of community health workers for outreach and basic RMNCH service delivery (US$5.0 million). The project has recruited 585 community relays and 261 community health workers has planned. However, payment of salaries begun in September 2020 while it should have started one year after the project’s effectiveness per the Project Appraisal Document. Consequently, US$1.0 million was saved in salaries under this sub-component. 7. Component 3: Strengthen the Ministry of Health’s health financing capacity to guide sector reform and long- term transformation (US$22.0 million). - Sub-component 3.1: Enhance the quality of RMNCH services and the quantity of RMNCH services for recipients in selected districts (through Results-Based Financing mechanism; US$17.0 million). The preliminary phases for the implementation of the Results-Based Financing mechanism have been completed (finalization of the list of indicators, training of 31 trainers and 600 providers, recruitment of contracting and verification agencies) but the program only launched in February 2021. Because of this delay, US$6.0 million will remain unused if not reallocated. - Sub-Component 3.2: Strengthen the capacity of the Ministry of Health in health financing and development of long-term reform strategies (US$5.0 million). The Bureau of Strategy and Development has been restructured to create the Economic Unit to carry out prospective and economic studies in the health sector. It was planned that, once created, an agency would have been recruited to support the Economic Unit by training their staff and helping them to elaborate key documents. However, as of April 6, 2021, the Economic Unit is still not in place. Consequently, US$3.0 million will be saved under this sub-component. 8. Component 4: 1. Strengthen project management, implementation and donor coordination capacity (US$3.0 million). The project provided support for the revision of the national health information system data. All the project reports have been submitted to the World Bank thus far. The World Bank Guinea Health Service and Capacity Strengthening Project (P163140) Rationale for Restructuring 9. Given the savings that were made under several sub-components because of the late start of activities and the budget overrun of the Sub-Component 1.1, the project financing plan can be restructured to address the overrun without changing the overall budget, PDO and results framework. 10. This Level 2 restructuring includes revisions of the costs of the Project Components: All 4 initial components and their corresponding sub-components will remain unchanged, but some allocations will be modified as described below. - Component 1 will increase from US$17.0 million to US$28.0 million including an increase of US$11 million of the initial amount of Sub-component 1.1 while total amounts of Sub-component 1.2 and 1.3 remain unchanged. - Component 2 will decrease from US$13.0 million to US$9.0 million encompassing a reduction of US$3 million and US$1 million of the total amount of the Sub-component 2.1 and Sub-Component 2.2 respectively. - Component 3 will decrease from US$22.0 million to US$15.0 million: Sub-component 3.1 will dropped from US$17 million to US$11 million and Sub-component 3.2 from US$5 million to US$4 million. - Component 4 will remain unchanged at US$3.0 million. III. DETAILED CHANGES REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Current Current Actuals + Proposed Disbursement % Ln/Cr/TF Expenditure Allocation Committed Allocation (Type Total) Category Current Proposed IDA-62300- G/W/NCS/CS/O 001 C 3,900,000.00 749,158.31 11,300,000.00 25.00 50 Currency: Pt1.1/1.3/2.2/3. XDR 2/4. GD/WK/NCS/CS/ HLTH SCE PT 3,900,000.00 884,037.52 2,700,000.00 50.00 50.00 1.2/2.1 PERFORMANCE PAYMENTS PT 7,800,000.00 0.00 1,600,000.00 50.00 50.00 3.1(a) Total 15,600,000.00 1,633,195.83 15,600,000.00 The World Bank Guinea Health Service and Capacity Strengthening Project (P163140) IDA-D3040- G/W/NCS/CS/O 001 C 3,900,000.00 748,923.63 11,300,000.00 25.00 50 Currency: Pt1.1/1.3/2.2/3. XDR 2/4 GD/WK/NCS/CS/ HLTH SCE PT 3,900,000.00 883,864.69 2,700,000.00 50.00 50.00 1.2/2.1 PERFORMANCE PAYMENTS PT 7,800,000.00 0.00 1,600,000.00 50.00 50.00 3.1(a) Total 15,600,000.00 1,632,788.32 15,600,000.00