The World Bank Health System Support and Strengthening Project (P164953) REPORT NO.: RES46755 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SYSTEM SUPPORT AND STRENGTHENING PROJECT APPROVED ON SEPTEMBER 27, 2018 TO CENTRAL AFRICAN REPUBLIC HEALTH, NUTRITION & POPULATION AFRICA WEST Regional Vice President: Ousmane Diagana Country Director: Abdoulaye Seck Regional Director: Dena Ringold Practice Manager/Manager: Magnus Lindelow Task Team Leader: Mahoko Kamatsuchi The World Bank Health System Support and Strengthening Project (P164953) ABBREVIATIONS AND ACRONYMS Abbreviation Definition COVID19 Coronavirus disease 2019 CRI Corporate results indicator FCV Fragility, conflict, violence GBV Gender-based violence GEMS Geo-enabled monitoring and supervision Human immuno-deficiency virus infection /Acquired immune deficiency HIV/AIDS syndrome MICS Multiple indicators cluster survey MOH Ministry of Health MTR Mid-term review NHSC National health steering committee PBF Performance-based financing PBF TU Performance-based financing technical unit PDO Project development objective SENI Health System Support and Strengthening Project SP Sulfadoxine-pyrimethamine SYSCOHADA An accounting system The World Bank Health System Support and Strengthening Project (P164953) BASIC DATA Product Information Project ID Financing Instrument P164953 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 27-Sep-2018 31-Dec-2021 Organizations Borrower Responsible Agency Central African Republic Ministry of Public Health and Population Project Development Objective (PDO) Original PDO To increase utilization and improve the quality of essential health services in targeted areas in the territory of the Recipient. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-D3750 27-Sep-2018 12-Dec-2018 07-Feb-2019 31-Dec-2021 43.00 19.46 23.98 TF-A8196 27-Sep-2018 12-Dec-2018 07-Feb-2019 31-Dec-2021 10.00 4.46 5.54 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Health System Support and Strengthening Project (P164953) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Project status 1. There has been significant progress made by the Government and by the project coordination team towards the achievement of the project development objectives. Overall disbursement stands at US$23.87 million (45%), and the disbursement ratio rose to 25 percent from 3 percent in December 2020. The implementation progress is moderately satisfactory, and progress toward to the achievement of the project development objectives is moderately unsatisfactory, owing to issues with the results framework, which are being addressed as part of this restructuring. 2. Component 1 (improve the quality and utilization of essential health services at facility through performance-based financing (PBF)) is now progressing well, with the completeness of the project coordination team, and the setting up of the counter-verification agencies to verify the health services delivered. In addition, health facilities have received overdue subsidy payments and these payments are now on track. Component 2 (strengthening the health system, including addressing gender-based violence (GBV)), large progress was noted in the establishment of a national health information system (NHIS) which is an inter-agency and multi-partnership endeavor. The recruitment of data managers in all districts of the country has also greatly contributed to the monitoring and evaluation of the project, and reliable and up-to-date data are more accessible. The government has managed effective partnerships with multiple collaborations. Great progress was also noted in the implementation of a holistic approach for GBV, which is composed not only of medical response to the GBV survivors, but also the psychosocial care, and a community social mobilization strategy for prevention. The distribution of essential drugs directly to very remote health centers was achieved, as well as the deployment of midwives in the project areas were recruited as part of the health system strengthening component. There are no outstanding project audits to date. This would be the first restructuring of this project. 3. The very high levels of insecurity and instability that marked the period of the presidential elections have made it difficult to distribute essential medicine and health supplies in some areas. Also, the unforeseen occurrence of the COVID-19 pandemic and its impact on the health system, in addition to dilapidated roads, lack of a national supply chain system and limited number of banks in country (at least 40 percent of health facilities do not have bank accounts) still poses major constraints to project implementation. In addition, these factors had a major negative impact on the focus, development and operationalization of the national community health strategy, which heavily affects the consideration of community health service-related indicators. 4. During the mid-term review (MTR) in April 2021, it was confirmed that the current strategy for the distribution of funds and health supplies to the health facilities will continue, given that there is no other viable option. The regular use of the geo-enabled monitoring and supervision system (GEMS) tool has contributed to improved governance as well as to regular monitoring of implementation activities, including verification of subsidy payments, delivery of essential drugs to health facilities, baseline assessments for GBV, and tracking of missions conducted by the project. B. Rationale for restructuring 5. During the MTR, the discussions regarding the results indicators and progress in achieving them revealed that the data originally used to determine end-project target values was based on outdated and partial information. For example, the last household survey available at that time was the 1996 Demographic Health Survey and the Multiple Indicator Cluster Survey (MICS) 2010 of which only indicators related to HIV/AIDS were available. Since then, new The World Bank Health System Support and Strengthening Project (P164953) data have become available through the improvement of the NHIS which was almost non-existent in 2017-18, and recently published household surveys (MICS 2018-2019) which indicate that several of the original target values were overestimated and some miscalculated. Therefore, the target values are being revised to be aligned with the new data. 6. The community-level interventions experienced a delay related to the project's community essential service delivery activities due to the COVID-19 pandemic that occupied the entire health sector and the country, and the security and political disruptions caused by general elections. All of these factors led to the inability to further develop the community health service delivery strategy, which has impacted achievement of several indicators, namely for deworming, vitamin A, family planning distribution as well as community referrals. The national community health strategy, which still needs updating, will eventually be put in place in accordance with the guidelines of the national community health policy. 7. Implementation experienced significant delays due to the COVID19 pandemic, which impacted not only the health system but the overall economy of the country. Other devastating infectious disease outbreaks occurred during the first half of the project, such as measles, yellow fever, and vaccine-derived polio, which also disrupted delivery of services. Still further delays were encountered during the period of the presidential elections, which brought about instability and insecurity. As a result, the closing date will be extended to September 30, 2022 to allow sufficient time to carry out project activities that aim to achieve project development objectives. 8. It was expected that the government would contribute US$1 million to the project in counterpart funding. Because funds were diverted from the limited national budget to support the purchase of childhood vaccines, there is no funding available for the project. It was also agreed between the Bank and the Government that the IDA funds, along with funds from GFF, are sufficient to carry out the remaining activities to reach project objectives, so this legal covenant will be deleted from the financing agreement. II. DESCRIPTION OF PROPOSED CHANGES 9. The proposed changes are as follows: (a) Revision of the results framework: The initial targets were determined based on projections using data that were available at the time (the last household survey available at that time was the Demographic Health Survey of 1996; there was also a partial Multiple Indicator Cluster Survey (MICS) from 2010. With more recent data available (MICS 2018-19, the reproductive, maternal-child and adolescent health Investment Case) and with the improvement of the National Health Information System, there is now more reliable and updated information to calculate these targets (see Table 1). With these revisions, the team expects the PDO to be achieved. (b) Extension of the closing date from December 31, 2021 to September 30, 2022: The project funds are expected to be fully disbursed by the revised closing date. Three large scale procurements for essential medicine, additional purchase of GBV post-rape kits, cold chain equipment for routine vaccination, quarterly payments of NGOs for the five GBV focus districts, and counter-verification entities for the verification of the PBF quality and quantitative service delivery are envisioned to ensure timely disbursement by the new closing date. The World Bank Health System Support and Strengthening Project (P164953) (c) Removal of the legal covenant related to counterpart funding. Table 1. Revised Results Framework PDO Indicators by Objectives/ Original Revised End CRI Baseline Comments Outcomes End Target Target Improve utilization & quality of essential health services in facilities & communities through PBF Adjustment based People who have received on more recent and essential health, nutrition, and Yes 0 474,066 450,640 reliable population (HNP) services demographic data Number of children immunized Yes 0 98,186 -- No change Adjustment based Number of women and children on more recent and who received basic nutrition Yes 0 192,496 179,658 reliable services demographic data Adjustment based Number of deliveries attended by on more recent and Yes 0 183,384 172,796 skilled health personnel reliable demographic data Quality average score of health -- No change centers in targeted areas 0 80 (Percentage) Quality average score of district 74 85 -- No change hospitals (Percentage) Intermediate Results Indicators by Original Revised End Baseline Components End Target Target Improve utilization & quality of essential health services in facilities & communities through PBF Pregnant women receiving ante- 0 569,000 Adjustment based on natal care visits (at least 4) (Number) more recent and 251,613 reliable demographic data (the annual target was twice the estimated number of pregnant women in The World Bank Health System Support and Strengthening Project (P164953) the project districts). Children 6-59 months receiving Delete; community- vitamin A supplementation (twice based interventions 0 67,532 X per year) in total catchment area not operational (Number) Delete; the supplies for this depend on another Women and adolescents who partner. UNFPA no received family planning services 0 203,331 X longer has family (Number) planning supplies available for the country Adjustment based on Women receiving post-natal care more recent and 0 173,958 89,979 visit (at least 2) (Number) reliable demographic data The continued Pregnant women receiving two availability of inputs doses of intermittent preventive 0 107,519 69,887 for this indicator treatment (SP) for malaria (Number) depends on another partner. People receiving health services free No change 0 372,351 -- of charge (Number) Delete; community- People referred to health facilities by 0 292,652 X based interventions community workers (Number) not operational Poor accessibility, Quality satisfaction score of conflict and difficulty beneficiaries for health services in 70 85 80 in supply distribution district hospitals. (Percentage) anticipated beyond control of project Children (1-5 years old) receiving a Delete; community- deworming tablet in total catchment 0 67,532 X based interventions area (Number) not operational Facilities receiving performance 0 80 -- No change payments on time (Percentage) The World Bank Health System Support and Strengthening Project (P164953) Reinforcing institutional capacity for Health system strengthening incl. establishing district hospitals integrated GBV services Completeness of country health data in health management information 3 80 -- No change system (Percentage) Districts hospitals with integrated 0 3 -- No change GBV services (Number) Accessibility issues anticipated beyond the control of the project. Delays or inability to distribute supplies Availability of tracer drugs at health 84 94 85 in some districts centers (Percentage) could be expected. Feedback of challenges was evidenced, reported and documented. This target was erroneously calculated with a rate of progress of 5% per year at the preparation stage of the project (the Health professionals employed full- target of 4,306 for 0 4,306 1506 time in health facilities (Number) the intervention districts is, according to the SARA/HeRAMS1 survey, more than all the qualified staff in the country). Completeness of country health data in health management 3 80 -- No change information system (Percentage) 1 SARA: Service availability readiness assessment; HeRAMS: Health Resources Availability Monitoring System The World Bank Health System Support and Strengthening Project (P164953) III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Loan Closing Date(s) ✔ Disbursement Estimates ✔ Legal Covenants ✔ Implementation Schedule ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ PBCs ✔ Components and Cost ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ The World Bank Health System Support and Strengthening Project (P164953) IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_LOANCLOSING_TABLE LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications IDA-D3750 Effective 31-Dec-2021 30-Sep-2022 30-Jan-2023 TF-A8196 Effective 31-Dec-2021 30-Sep-2022 30-Jan-2023 OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 2019 3,256,212.51 3,000,000.00 2020 11,525,662.89 10,000,000.00 2021 24,451,634.70 20,000,000.00 2022 13,766,489.90 15,000,000.00 2023 0.00 6,000,000.00 2024 0.00 0.00 OPS_DETAILEDCHANGES_LEGCOV_TABLE LEGAL COVENANTS Loan/Credit/TF Description Status Action The Recipient shall, not later than six (6) months after the Effective Date, cause the PBF TU to customize its existing accounting software to ensure that its IDA-D3750 Complied with No Change accounting software has been updated to comply with the SYSCOHADA accounting system, which shall be applied to the Project. The World Bank Health System Support and Strengthening Project (P164953) Not later than six (6) months after the Effective Date, the Recipient shall appoint an external auditor with IDA-D3750 Complied with No Change terms of reference, qualifications and experience satisfactory to the Association. The Recipient shall, not later than six (6) months after the Effective Date, cause the PBF TU to recruit, and IDA-D3750 Expected soon No Change thereafter retain, an internal auditor with qualification and experience satisfactory to the Association. The Recipient shall, not later than six (6) months after the Effective Date, cause the PBF TU to recruit, and IDA-D3750 thereafter retain, an accountant and a procurement Complied with No Change specialist with qualification and experience satisfactory to the Association. Counterpart Funding (i): The Recipient shall, not later than one (1) month after the Effective Date, open and maintain until the completion of the Project, a separate account for the IDA-D3750 Complied with No Change exclusive purpose of financing activities under the Project (“Counterpart Funding”), to deposit amounts of up to one million United States Dollars (US$1,000,000) in the aggregate. Counterpart Funding (ii): The Recipient shall, not later than six (6) months after Marked for IDA-D3750 the Effective Date, commit to deposit the sum of (three Complied with Deletion hundred thousand) United States Dollars (US$300,000) in Project Account. Counterpart Funding (iii): The Recipient shall, no later than June 30, 2020 (or June 30 of the second year of Project implementation, if Marked for IDA-D3750 Not complied with after the year 2020), deposit the sum of (four hundred Deletion thousand) United States Dollars (US$400,000) in Project Account. The World Bank Health System Support and Strengthening Project (P164953) Counterpart Funding (iv): The Recipient shall, no later than June 30, 2021 (or June 30 of the third year of Project implementation, if after Marked for IDA-D3750 Not yet due the year 2021), deposit the sum of (three hundred Deletion thousand) United States Dollars (US$300,000) in Project Account. The Recipient shall at all times during Project implementation maintain, the National Health Steering IDA-D3750 Complied with No Change Committee (“NHSC”) with composition and mandate acceptable to the Association. The Recipient shall establish, and at all times during IDA-D3750 Project implementation, maintain the PBF Technical Complied with No Change Unit (“PBF TU”) within the MOH. The PBF TU shall, at all times during Project implementation, retain the following staff, inter alia, each with terms of reference, qualifications and IDA-D3750 experience satisfactory to the Association: (i) a Complied with No Change coordinator; (ii) a procurement specialist; (iii) a financial management specialist; (iv) a monitoring and evaluation specialist; and (v) a social and environmental specialist. The Recipient shall, not later than three (3) months after the Effective Date, cause the PBF TU to recruit, and throughout Project implementation, retain Independent Verification Agencies, with qualifications, After delay complied IDA-D3750 No Change experience, and terms of reference satisfactory to the with Association, for purposes of carrying out independent verification of the services to be financed by the PBF Payments under Part 1.1 of the Project. The Recipient shall ensure that relevant environmental and social mitigation measures and clauses are included IDA-D3750 Complied with No Change in the tender documents in accordance with the Safeguards Instruments. The World Bank Health System Support and Strengthening Project (P164953) The Recipient shall ensure that all terms of reference for any technical assistance or studies carried out under the Project are consistent with the Bank’s social and IDA-D3750 Complied with No Change environmental safeguard policy requirements, as well as the Recipient’s own environmental and social laws and regulations. The Recipient shall ensure that all technical assistance under the Project, shall only be undertaken pursuant to terms of reference reviewed and found satisfactory by the Association, such terms of reference to ensure that IDA-D3750 Complied with No Change the technical assistance takes into account, and calls for application of the Association’s environmental and social safeguards policies and the Recipient’s own laws relating to the environment and social aspects. The Recipient shall ensure that employees, agents, service providers, contractors and subcontractors carry out the Project in conformity with acceptable environmental and social standards, practices and IDA-D3750 codes of conduct (which shall, inter alia, contain Complied with No Change measures that prohibit, endeavor to prevent and address Project-related gender based violence and sexual exploitation and abuse), the provisions of the Recipient’s environmental and social laws. The Recipient shall, throughout Project implementation, cause the PBF TU, to maintain and publicize the availability of a Project-level grievance redress mechanism and a feedback mechanism, in form and substance satisfactory to the Association, in order to IDA-D3750 hear and determine fairly and in good faith all Complied with No Change complaints and feedback raised in relation to the Project, and take all measures necessary to implement the determinations made by said grievance feedback and redress mechanism in a manner satisfactory to the Association. IDA-D3750 The Recipient shall furnish to the Association, not later Complied with No Change than November 30 of each year, the annual work plans and budgets approved by the Steering Committee for the Association’s review and approval; except for the The World Bank Health System Support and Strengthening Project (P164953) annual work plan and budget for the Project for the first year of Project implementation, which shall be furnished no later than one (1) month after the . Effective Date. The World Bank Health System Support and Strengthening Project (P164953) . Results framework COUNTRY: Central African Republic Health System Support and Strengthening Project Project Development Objectives(s) To increase utilization and improve the quality of essential health services in targeted areas in the territory of the Recipient. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 Improve utilization & quality of essential health services in facilities & communities through PBF People who have received essential health, nutrition, and population (HNP) 0.00 158,021.00 316,044.00 450,640.00 services (CRI, Number) Rationale: Action: This indicator has been Revised Adjustments made to coincide with the adjustments made on the three sub-targets below. Number of children immunized (CRI, 0.00 32,729.00 65,457.00 98,186.00 Number) Number of women and children who have received basic nutrition services 0.00 64,165.00 128,330.00 179,658.00 (CRI, Number) Action: This indicator has been Revised Number of deliveries attended by 0.00 61,128.00 122,256.00 172,796.00 skilled health personnel (CRI, Number) The World Bank Health System Support and Strengthening Project (P164953) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 Rationale: Action: This indicator has been Adjustment following the slowdown in activities during the post-election crisis Revised Quality average score of health centers in 0.00 60.00 70.00 80.00 targeted areas (Percentage) Quality average score of district hospitals 74.00 85.00 (Percentage) Rationale: This is not a new indicator, but this indicator was moved up from Intermediate indicators to PDO indicators to provide another quality PDO Action: This indicator is New indicator. PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 Improve utilization & quality of essential health services in facilities & communities through PBF Ante-natal care visits (at least 4) received 0.00 189,667.00 379,334.00 251,613.00 by pregnant women (Number) Rationale: Action: This indicator has been Revised Adjustment based on new demographic data (the annual target was twice the estimated number of pregnant women in the project districts). The World Bank Health System Support and Strengthening Project (P164953) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 Children 6-59 months receiving vitamin A supplementation (twice per year) in total 0.00 22,511.00 45,021.00 67,532.00 catchment area (Number) Rationale: Action: This indicator has been Marked The National Community Health strategy not yet operational due to COVID19, conflict. for Deletion Women and adolescents who received 0.00 67,777.00 135,554.00 203,331.00 family planning services (Number) Rationale: Action: This indicator has been Marked The supplies for this depends on another partner. UNFPA no longer has family planning supplies available for the country, as clearly indicated in for Deletion April 2021. The provision of essential community-based services is not yet operational. Post-natal care visits received by women 0.00 57,986.00 115,972.00 89,979.00 (Number) Rationale: Action: This indicator has been Revised Adjustment based on more recent and reliable demographic data Pregnant women receiving two doses of intermittent preventive treatment (SP) 0.00 35,840.00 71,679.00 69,887.00 for malaria (Number) Rationale: The continued availability of inputs for this indicator depends on another partner. There are difficulties in ensuring the availability of supply for this Action: This indicator has been Revised indicator. People receiving health services free of 0.00 118,113.00 242,132.00 372,351.00 charge (Number) Action: This indicator has been Revised The World Bank Health System Support and Strengthening Project (P164953) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 People referred to health facilities by 0.00 92,832.00 190,305.00 292,652.00 community workers (Number) Rationale: Action: This indicator has been Marked The National Community Health strategy not yet operational due to COVID19, conflict for Deletion Quality satisfaction score of beneficiaries for health services in district hospitals. 70.00 77.00 81.00 80.00 (Percentage) Rationale: Action: This indicator has been Revised Poor accessibility, conflict and difficulty in supply distribution anticipated beyond control of project Quality average score of district hospitals 74.00 78.00 82.00 85.00 (Percentage) Rationale: Action: This indicator has been Marked This intermediate indicator will be moved up to become a PDO indicator. for Deletion Children (1-5 years old) receiving a deworming tablet in total catchment area 0.00 22,511.00 45,021.00 67,532.00 (Number) Rationale: Action: This indicator has been Marked The National Community Health strategy not yet operational due to COVID19, conflict for Deletion Facilities receiving performance 0.00 60.00 70.00 80.00 payments (Percentage) Action: This indicator has been Revised Reinforcing institutional capacity for HSS incl. establishing district hospitals integrated GBV ser. The World Bank Health System Support and Strengthening Project (P164953) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 Completeness of country health data in health management information system 3.00 60.00 70.00 80.00 (Percentage) Action: This indicator has been Revised Districts hospitals with integrated GBV 0.00 1.00 2.00 3.00 services (Number) Action: This indicator has been Revised Availability of tracer drugs at health 84.00 86.00 88.00 85.00 centers (Percentage) Rationale: Accessibility issues anticipated beyond the control of the project. Delays or inability to distribute supplies in some districts could be expected. Action: This indicator has been Revised Feedback of challenges was evidenced, reported and documented. Health professionals employed in health 1,239.00 1,366.00 1,434.00 1,506.00 facilities (Number) Rationale: This target was erroneously calculated with a rate of progress of 5% per year at the preparation stage of the project (the target of 4,306 for the Action: This indicator has been Revised intervention districts is, according to the SARA / HeRAMS survey, more than all the qualified staff in the country). IO Table SPACE The World Bank Health System Support and Strengthening Project (P164953)