The World Bank Report No: ISR5978 Implementation Status & Results Burundi Health Sector Development Support (P101160) Public Disclosure Copy Operation Name: Health Sector Development Support (P101160) Project Stage: Implementation Seq.No: 6 Status: ARCHIVED Archive Date: 12-Oct-2011 Country: Burundi Approval FY: 2009 Product Line: IBRD/IDA Region: AFRICA Lending Instrument: Specific Investment Loan Implementing Agency(ies): Ministry of Public Health, Burundi Key Dates Board Approval Date 09-Jun-2009 Original Closing Date 30-Dec-2012 Planned Mid Term Review Date 30-Sep-2011 Last Archived ISR Date 12-Oct-2011 Effectiveness Date 30-Sep-2009 Revised Closing Date 30-Dec-2012 Actual Mid Term Review Date 03-Oct-2011 Project Development Objectives Project Development Objective (from Project Appraisal Document) To increase the use of a defined package of health services by pregnant women and children under the age of five. Has the Project Development Objective been changed since Board Approval of the Project? Yes No Component(s) Component Name Component Cost Component 1 - Increased financing for a redefined free package of services 20.00 Component 2 - Strengthening capacity of MSP and entities involved in RBF 5.00 Overall Ratings Previous Rating Current Rating Progress towards achievement of PDO Highly Satisfactory Highly Satisfactory Moderately Satisfactory Satisfactory Public Disclosure Copy Overall Implementation Progress (IP) Overall Risk Rating Implementation Status Overview A Midterm Review (MTR) has just taken place for the project and for the national Results Based Financing (RBF) program supported by the project. A summary of some of the main findings of this review is provided here. Utilization has been better than initially expected for the RBF indicators, and quality has also gone up rapidly, based on the average quality score of services as assessed quarterly by the RBF program. For example, the following changes took place between April-June 2010 (the first quarter of the national RBF program) and the seasonally comparable April-June 2011 quarter: (a) rise in births at health facilities by 25%; (b) rise in prenatal consultations by 20.4%; (c) rise in the number of children completely vaccinated by 10.2%; (d) rise in the average quality score from 46.3% to 71.1% for health centers, and from 51.6% to 73.7% for hospitals. Page 1 of 10 The World Bank Report No: ISR5978 The data also show that the since the national RBF program has started in April 2010, the differences in achievement rates among provinces have reduced substantially for most indicators, as have the differences among provinces in per capita levels of government financing going to health facilities – all signs of increased equity. Public Disclosure Copy Implementation has also overall progressed well. Before the start of the national RBF program in April 2010, there were concerns that implementation would be slow, at least initially, resulting in delayed payments to health facilities and a significant period of time before improvements are seen in indicators on the ground. In fact, the “financial circuit� comprising verification, validation and payment to facilities has functioned quite smoothly from the beginning, and improvements in indicators have come rapidly after the first six months (as seen above). Several development partners including the government (the largest contributor) and IDA co-finance a harmonized national program whereby the same system and parameters (e.g. same indicators and same tariff system) is used throughout the country. This is facilitated by the use of an automated Internet-based system that has been set up for the purposes of recordkeeping, data monitoring/analysis and invoicing, with an invoice produced each month for every partner, catering to the needs of the partner (e.g. some partners finance only some indicators and/or some provinces). The government has substantially increased its allocation to the Free Health Care / RBF program to 18.2 billion FBus in the 2012 budget, from 12.4 billion FBus in the 2011 budget. Locations No Location data has been entered Results Project Development Objective Indicators Public Disclosure Copy Page 2 of 10 The World Bank Report No: ISR5978 Indicator Name Core Unit of Measure Baseline Current End Target Percentage of children under five who slept Percentage Value 44.10 45.00 25.00 under an insecticide treated bed net Date 31-Dec-2009 30-Dec-2012 Public Disclosure Copy Comments The above baseline value of The above value of 45% is This indicator has been 44.10 % is from the 2009 from the 2010 DHS. Further proposed to be dropped, in PMS household survey, and updates can only be provided the Midterm Review that has had already been updated via the next household survey just taken place, for reasons from the 8% value from the which will take place in late summarized in the box on the 2005 MICS survey in previous 2012 (PMS survey). But this left. ISRs. indicator has been proposed to be dropped, in the Midterm Review that has just taken place. This is because: (1) bednets are being distributed in-kind in large amounts via various channels (campaigns, community mechanisms etc.), and not predominantly via health facilities; (2) this project finances mostly supply-side Results Based Financing where funds are provided directly to health facilities, not channeled through other means; (3) soy this indicator is not a good measure of the effectiveness and impact of the financing provided under this project. Coverage of DPT3/Pentavalent vaccine in Percentage Value 86.80 92.00 children immunized before reaching the age of Date 31-Dec-2009 31-Dec-2010 30-Dec-2012 one Comments (1) Alternative proxy indicator Three updates available: (1) Target value of 92% will be is percentage of children who 95.4% in late 2010 from the based on the 2012 PMS Public Disclosure Copy are completely vaccinated as 2010 DHS survey; (2) 89.5% household survey. For the measured by the national in 2010 according to the HMIS system (SNIS/ RBF program, per month, with HMIS (SNIS/EPISTAT) EPISTAT) from which data baseline of 25,287 in April system; and (3) 25,851 are also monitored, the target 2010. (2) Data from both children completely value is 89% in 2012. household surveys as well as vaccinated in December 2011 from routine administrative as measured by the RBF data sources will be program (alternative proxy monitored. Baseline value for indicator). The box above in the former had already been the ISR (actual value) is left Page 3 of 10 The World Bank Report No: ISR5978 updated from the 60.1% of blank since the 2010 DHS the 2005 MICS survey to survey uses a somewhat 86.8% from the 2009 PMS different methodology for household survey, in previous measurementthan the PMS Public Disclosure Copy ISRs. Baseline value for surveys, and the reported routine administrative sources baseline value is from the is 83% in 2009 from the HMIS 2009 PMS survey. (SNIS/EPISTAT). Contraceptive prevalence rate (modern Percentage Value 19.60 22.00 methods) Date 31-Dec-2009 31-Dec-2012 Comments (1) Alternative proxy indicator The DHS 2010 (conducted in Above target value of 22% is is total utilization of modern later 2010) found a value of based on the 2012 PMS family planning via health 18%. Utilization of family survey. For the PNSR routine centers and hospitals as planning (modern methods) data system from which data measured by the national reported in December 2011 are also monitored, thetarget RBF program, per month, with via RBF system (alternative value is 20%. baseline of 49,330 in April proxy indicator) was 60,994. 2010. (2) Data from both The box above in the ISR household surveys as well as (actual value) is left blank from routineadministrative since the 2010 DHS survey data sources will be uses a somewhat different monitored. Baseline value for methodology for the former had already been measurement than the PMS updated (in previous ISRs) surveys, and the reported from the 5%of the 2005 MICS baseline value is from the survey to 19.6% from the 2009 PMS household survey. 2009 PMS household survey. Baseline value for routine administrative sources is 13.7% in2009 from the PNSR or Programme National de Santé de la Reproduction (which feeds into the HMIS). Percentage of births assisted by skilled Percentage Value 64.40 68.00 Public Disclosure Copy personnel Date 31-Dec-2009 30-Dec-2012 Comments (1) Alternative proxy indicator The DHS 2010 found the Target value above of 68% is is number of births occurring value of this indicator to be based on the 2012 PMS at hospitals and health 60%, but this value is not household survey. The target centers based on data from reported in the above box in value for routine the national RBF program, this ISR since the administrative sources per month, with baseline of methodology is different than (PNSR) is 62%. 20,590 in April 2010. (2) Data that used in the PMS surveys from both household surveys (e.g. the DHS survey looks Page 4 of 10 The World Bank Report No: ISR5978 as well as from routine back five years as opposed to administrative data sources 2 years for the PMSsurveys, will be monitored. Baseline for this indicator). The PNSR value for the former had routine data system reports Public Disclosure Copy already (in previous ISRs) 59.9% for the percentage of been updated from the 32% births taking place in health of the 2005MICS survey to facilities). In December 2012, 64.4% from the 2009 PMS the national RBF program household survey. Baseline recorded 21,592 births in value for routine facilities (alternative proxy administrative sources (for indicator). percentage of births taking place in health facilities) is 56.3% in 2009 from the Programme National de Santé de la Reproduction (PSNR, which feeds into the HMIS). Coverage of PNC services for pregnant women Percentage Value 59.40 66.10 68.00 Date 31-Dec-2009 31-Dec-2010 30-Dec-2012 Comments (1) Alternative proxy indicator Above target value is based Above target value is based is number of "standard" on routine data for 2010 from on the 2012 PMS household prenatal consultations (3 per the PNSR system. Also, survey. pregnancy) at hospitals and 96,631 prenatal consultations health centers that are in the were reported in December national RBF program, per 2011 via the RBF program, month, with baseline of (alternative proxy indicator). 90,664 in April 2010. (2) The 2010 DHS found that Source for above baseline 98.9% of pregnant women value of 59.40 %is the had at least one prenatal Program National de Sante consultation. de la Reproduction (PNSR) which feeds into the HMIS, and it supercedes the Public Disclosure Copy baseline value reportedin the previous ISR which was for 2007. This indicator (referring to women having had 3 prenatal care consultations) was not measuredin the 2009 PMS household survey. The 2009 PMS survey found that 94.1% of pregnant women Page 5 of 10 The World Bank Report No: ISR5978 had at least one prenatal consultation. Average number of visits to a health provider Number Value 1.60 2.20 by children under the age of 5 Public Disclosure Copy Date 31-Dec-2009 30-Dec-2012 Comments 1) Alternative proxy indicator 570,491 consultations Above target value based on is number of child (under-5) reported in December 2012 2012 PMS household survey. curative care visits to via RBF program (alternative hospitals and health centers proxy indicator). that are in the national RBF program, per month (excl. repeats for same incident), with baseline of 433,283 in April 2010. (2) The baseline value reported above of 1.6 (per child per year) is an updated value obtained from the 2009 PMS household survey). The update had already beenreported in previous ISRs. Intermediate Results Indicators Indicator Name Core Unit of Measure Baseline Current End Target Percentage of health facilities that have had an Percentage Value 0.00 30.00 60.00 external verification visit (cumulative) Date 31-Dec-2009 31-Dec-2010 31-Dec-2012 Comments This refers to visits by the external agency conducting external verification (or "counter-verification"). See comments below for the percentage of health facilities that have had an "internal" Public Disclosure Copy verification visit in the previous six months. Percentage of health facilities that received Percentage Value 36.30 100.00 70.00 their payments within the agreed period Date 31-Mar-2010 31-Jul-2012 30-Dec-2012 Comments Source: March 2010 Health All health facilities that are in To be tracked via the next facility survey (FOSA) the nationwide Results Based health facility (FOSA) survey. Financing system continue to be receiving payments on time, consistently, as seen Page 6 of 10 The World Bank Report No: ISR5978 from payment records of the Burundi Central Bank (BRB). Percentage of health facilities that have Percentage Value 75.50 83.00 qualified personnel (a least an A2 nurse) in Public Disclosure Copy Date 31-Mar-2010 30-Dec-2012 rural areas Comments Source: March 2010 health To be tracked via the next facility survey (FOSA) health facility (FOSA) survey. Percentage of facilities that have had an Percentage Value 48.09 100.00 80.00 internal verification visit in the previous six Date 31-Mar-2010 31-Jul-2011 30-Dec-2012 months Comments Source for above is the March Source for above reported 2010 health facility survey current value is official (FOSA), and an "internal" visit records from the Ministry of is defined here as a visit by a Health and from the national verification team outside of RBF system. Only facilities in the health facility. The the national RBF program are terminology has been included in the denominator of changed from "external" as in the calculation. previous ISRs to "internal" here forpurposes of clarity; the indicator itself and how it is measured have not changed. As part of the robust verification structure of the national RBF program, there are also "external" visits i.e. is visits by a fully external independent agency not involved in anyother way with the RBF, and this has now been incorporated into another separate indicator using the terminology "external visit". Households with a covered latrine Percentage Value 31.70 45.00 Public Disclosure Copy Date 31-Dec-2005 31-Dec-2012 Comments The source for the above Updates can only be provided baseline value of 31.7 % is via the next household survey the MICS2005 household which will take place around survey (this indicator was not late 2012. But this indicator measured in the 2009 has been proposed to be PMShousehold survey). dropped, in the Midterm Review that has just taken place. This is because: (1) Page 7 of 10 The World Bank Report No: ISR5978 laitrines are mostly constructed through communities and households, and not through actions Public Disclosure Copy conducted by health facilities; (2) this project finances mostly supply-side Results Based Financing where funds are provided directly to health facilities; (3) so this indicator is not a good measure of the effectiveness and impact of the financing provided under this project. Number of community organizations that have Number Value 0.00 350.00 been trained and supported by facilitating Date 30-Sep-2009 31-Dec-2012 agencies Comments Percent of public and non-profit health facilities Percentage Value 50.90 97.74 80.00 that are involved in the RBF system Date 31-Mar-2010 30-Dec-2012 Comments Source: March 2010 health Source: Official records from facilities survey (FOSA) the Ministry of Health and from the national Results Based Financing system. Note that the value of 100% entered in the previous ISR as the actual value was a mistake. Percentage of health facilities that did not run Percentage Value 53.30 65.00 out of essential drugs in the previous three Date 31-Mar-2010 30-Dec-2012 months Comments (1) The source for the above The alternative proxy To be based on the next is the March 2010 health measures show percentages health facility (FOSA) survey. facilities survey (FOSA). It for this indicator of 64.4% for Public Disclosure Copy includes hospitals as well as health centers and 40.1% for health centers. (2) Alternative hospitals (using somewhat proxy measures are available different methodologies of based on the quality checklist measurement than the health evaluation done (every facility survey). quarter) under the national RBF program, but using different methodologies than for the health facility survey. (More details are given in the Page 8 of 10 The World Bank Report No: ISR5978 Aide Memoire for the Midterm Review.) These alternative measures show percentage values of 34% for health Public Disclosure Copy centers and 20.3% for hospitals, in the Aprill-June 2010 quarter (the first quarter of the national RBF program). Data on Financial Performance (as of 15-Feb-2012) Financial Agreement(s) Key Dates Project Loan No. Status Approval Date Signing Date Effectiveness Date Closing Date P101160 IDA-H4880 Effective 09-Jun-2009 07-Jul-2009 30-Sep-2009 30-Dec-2012 Disbursements (in Millions) Project Loan No. Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P101160 IDA-H4880 Effective XDR 16.80 16.80 0.00 12.83 3.97 76.00 Disbursement Graph Public Disclosure Copy Key Decisions Regarding Implementation N.A. Page 9 of 10 The World Bank Report No: ISR5978 Restructuring History There has been no restructuring to date. Public Disclosure Copy Related Projects P126742-Health Sector Development Support - Additional Financing Public Disclosure Copy Page 10 of 10