Document of The World Bank Report No: 73337-BO RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF EXPANDING ACCESS TO REDUCE HEALTH INEQUITIES PROJECT (APL III)— FORMER HEALTH SECTOR REFORM - THIRD PHASE (APL III) PROJECT CREDIT 4382-BO APPROVED BY THE BOARD ON JANUARY 24, 2008 TO THE PLURINATIONAL STATE OF BOLIVIA December 10, 2012 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. ABBREVIATIONS AND ACRONYMS ENDSA National Health Household Survey / Encuesta Nacional Domiciliar de Salud FPS Social Investment and Productive Fund / Fondo Productivo y Social MSD Ministry of Health and Sports / Ministerio de Salud y Deportes PDI Project Development Indicators SAFCI Intercultural, Family and Community Health / Salud Familiar Comunitaria Intercultural SAFCO System of Financial Management and Government Control / Sistema de Administración Financiera y Control Gubernamental SEDES Departamental Health Service / Servicio Departamental de Salud SIAS Sistema de Información de Administración de Salud SICOF Health Information and Financial Control System SNIS National Health Information System / Sistema Nacional de Información en Salud y Vigilancia Epidemiológica SSPAM Health Insurance for the Elderly / Seguro de Salud para el Adulto Mayor SUMI Maternity and Childhood Health Insurance / Seguro de Salud Materno Infantil SUS Single Health System / Sistema Único de Salud UDAPE Economic and Social Policy Analysis Unit / Unidad de Análisis de Políticas Sociales y Económicas Regional Vice President: Hasan A. Tuluy Country Director: Susan G. Goldmark Director: Keith Hansen Sector Manager: Joana Godinho Task Team Leader: Andre C. Medici 2 BOLIVIA EXPANDING ACCESS TO REDUCE HEALTH INEQUITIES PROJECT (APL III)--FORMER HEALTH SECTOR REFORM - THIRD PHASE (APL III) P1 01206 CONTENTS A. DATASHEET........................................................................................................................ 4 A. SUMMARY ........................................................................................................................... 6 B. PROJECT STATUS .............................................................................................................. 6 C. PROPOSED CHANGES ...................................................................................................... 8 ANNEX 1 .................................................................................................................................... 13 ANNEX 2 .................................................................................................................................... 16 RESULTS FRAMEWORK AND MONITORING .................................................................. 16 3 A. DATASHEET Restructuring Status: Draft Restructuring Type: Level two Last modified on date : 12/10/2012 1. Basic Information Project ID & Name P101206: BO-Expanding Access to Reduce Health Inequities Project (APL III) Country Bolivia Task Team Leader Andre C. Medici Sector Manager/Director Joana Godinho Country Director Susan G. Goldmark Original Board Approval Date 01/24/2008 Original Closing Date: 01/31/2014 Current Closing Date 01/31/2014 Proposed Closing Date [if applicable] EA Category B-Partial Assessment Revised EA Category B-Partial Assessment-Partial Assessment EA Completion Date 03/15/2007 Revised EA Completion Date 2. Revised Financing Plan (US$m) Source Original Revised BORR 6.00 6.00 IDA 18.50 10.46 Total 24.50 16.46 3. Borrower Organization Department Location GOVERNMENT OF BOLIVIA Bolivia 4. Implementing Agency Organization Department Location Social Investment and Productive Bolivia Fund (SPF) Ministry of Health and Sports Bolivia (MDS) 4 5. Disbursement Estimates (US$m) Actual amount disbursed as of 11/20/2012 2.81 Fiscal Year Annual Cumulative 2013 3.00 5.81 2014 4.65 10.46 Total 10.46 6. Policy Exceptions and Safeguard Policies Does the restructured project require any exceptions to Bank policies? N Does the restructured project trigger any new safeguard policies? If yes, please select from N the checklist below and update ISDS accordingly before submitting the package. 7a. Project Development Objectives/Outcomes Original/Current Project Development Objectives/Outcomes (i) reduce occurrence of critical risk factors affecting maternal and infant health in the target areas so that current gaps between regions are reduced; (ii) reduce chronic malnutrition among children under 2 years of age in the target areas; (iii) increase health insurance coverage in the target areas and; (iv) upgrade the National Health Information System (Sistema Nacional de Información en Salud y Vigilancia Epidemiológica– SNIS) to ensure its integration into the Bolivia´s new health insurance program. 7b. Revised Project Development Objectives/Outcomes [if applicable] Not applicable. The project restructuring did not change Project Development Objectives or Outcomes. 5 EXPANDING ACCESS TO REDUCE HEALTH INEQUITIES PROJECT (APL III) FORMER HEALTH SECTOR REFORM - THIRD PHASE (APL III) P101206 - CREDIT 4382 RESTRUCTURING PAPER A. SUMMARY 1. The major changes to the Project and rationale are the following: (a) Reduce the scope of Project components; (b) Adjust the results framework to reflect changes in components; (c) Cancel SDR 4.85 million of the total Credit amount of SDR 11.7 million of which SDR9.8 million remain undisbursed; and (d) Reallocate funds among categories consistent with the reduced scope of the Project and reduced Credit amount. 2. The restructuring maintains the original Project Development Objectives (PDO) and should allow the Project to achieve its targets by the expected closing date, provided that it benefits from a minimum stability in terms of the client’s fiduciary and technical teams. B. PROJECT STATUS 3. The Project was approved by the Board of Executive Directors of the World Bank on January 24, 2008 and became effective in June 19, 2009. The Project Closing Date is January 31, 2014, and the current disbursement rate is 15%. The Project has never been restructured. 4. The Project Development Objectives are to: (i) reduce occurrence of critical risk factors affecting maternal and infant health in the target areas so that current gaps between regions are reduced; (ii) reduce chronic malnutrition among children under 2 years of age in the target areas; (iii) increase health insurance coverage in the target areas and; (iv) upgrade the National Health Information System (Sistema Nacional de Información en Salud y Vigilancia Epidemiológica– SNIS) to ensure its integration into the Bolivia´s new health insurance program. The Project finances four components: Component 1 – Stewardship Role of Health Authorities – Essential Functions in Public Health (US$ 7.7 million: US$ 4 million IDA plus US$3.7 million Government); Component 2 – Family, Community and Intercultural Health (US$ 11.6 million: US$ 9.9 million IDA plus US$ 1.7 million Government); Component 3 – Health Insurance (US$4.2 million: US$3.2 million IDA plus US$ 1 million Government) and Component 4 – Project Administration (US$ 2.2 million: US$ 0.9 million IDA plus US$ 1.3 million Government). 5. The Project overall implementation progress is unsatisfactory. After three years of implementation, the Project has implemented a small number of the proposed activities as 6 the Bolivian health reforms did not progress as much as expected; and the Project has disbursed only 15% of the Credit amount, making unlikely the full disbursement of the remaining funds by the Closing Date. 6. However, a number of Project activities have been already completed, such as: (i) the preparation of normative and justifications to launch the Single Health System (Sistema Único de Salud – SUS) and the implementation of the Intercultural, Family and Community Health (SAFCI) policy, which are the main pillars of the new health sector strategy in Bolivia to extend coverage and improve equity in access to health care; (ii) increased readiness to enroll population to be covered by the SUS1; (iii) the assessment of health networks; (iv) the development of specifications for health care provision at different levels; (v) the generation of better data and sector analysis for the decision making process in the health sector; (vi) the mapping of health network issues at the national and regional levels; (vii) the improvement of the health networks management with better trained staff; and (viii) an increased coordination between the Ministry of Health and Sports (Ministerio de Salud y Deportes – MSD) and the local governments, especially in relation to the increases in local contributions to the health sector budget. The complete list of activities already implemented by Component is detailed in Table 1 below. Table 1 - Activities and Outputs of the Project Already Completed by Component Components Activities and Outputs Component 1 –  Preparation of the draft for the General Law of Health; Strengthening of  Assessment of the information needs and tools required for stewardship role of health the public health system; authorities and essential  Preliminary design of the National Health Household Survey functions of public health (ENDESA) 2012;  Development and validation of the software to gather information at the regional and local levels, such as vital statistics, health human resources registration, primary health care and clinical electronic protocols;  Development of baseline studies for the Project Impact Evaluation;  Ten studies in health economics, mainly related to updating the Expenditure of National Accounts and Health Financing for 2003-2008;  Design and pilot testing of a national form to enroll families in SUS (Family Health Record - Carpeta Familiar);  Implementation of the Nutritional Surveillance Community Network of the Zero Under-nutrition Program;  Implementation of the First Census of Health Human Resources;  Design of the health quality regulatory framework, including standards and norms for clinical protocols, infrastructure and equipment requirements for health units (hospitals and 1 The Bolivian Single Health System (Sistema Unico de Salud – SUS) should be classified as a decentralized National Health Service. However, the Government refers to it as public health insurance. Families are registered by the Municipal Health Services through a family form ( Carpeta Familiar) and receive a SUS registration number. 7 ambulatories);  Database of multilateral and bilateral cooperation at the national, regional and local levels;  Training of health human resources, including seven workshops on the implementation of the Law 1178 (SAFCO) for health networks and health offices in Santa Cruz, Beni, Cochabamba, La Paz and Tarija (417 health workers trained). Component 2 – Family,  Assessment of health networks by Department and at Community and national level; Intercultural Health  Proposal for restructuring the Integrated Health Networks by Department;  Norm defining the functions and roles of primary and secondary levels of care and referral and counter-referral in Integrated Health Networks;  Registration of 1,200 traditional medicine workers at Department Level;  Development of maps and geo-referenced cartographic registration of health units and health networks at the regional level. Component 3 – Health  Agreement letters between the municipal governments and Insurance the MSD (Ministry of Health of Bolivia) to allocate 15% of funds to financing SUS implementation;  Development and implementation of software for the administrative and financial management of the public health insurances (SUMI and SSPAM) at the municipal level (Health Information and Financial Control System – SICOF);  Training of municipal health staff on administrative and financial management of the health public insurances (SUMI and SSPAM): 674 health staff trained (two per municipality);  Training of operational staff to manage information tools (SIAS) in 337 municipalities to enroll population on the Health Insurance for the Elderly (SSPAM) as part of the SUS platform;  Purchase and distribution of IT equipment for health units in 9 health regions (SEDES): 25 sets of equipment were acquired and distributed. C. PROPOSED CHANGES 7. Project restructuring follows changes in health policy in Bolivia during the last two years, and reflect the need to monitor and evaluate the support provided to mother and child health care, and carry out a social public consultation (Cumbre de Salud2) about 2 The Cumbre de Salud is the first participatory consultation process in the health sector promoted by the Ministry of Health in Bolivia. The Cumbre the Salud will be organized in a bottom-up process, where the Departments will organize regional conferences, with broad participation of the municipal health authorities, providers and citizens on the definition of local priorities. These instances will select the delegates to participate in the Cumbre de Salud, which is scheduled to the first semester of 2013. 8 SUS, which implementation was delayed due to the lack of an agreement regarding its institutional framework between the Executive and Legislative branches. The restructured Project will focus on increasing the MSD capacity to improve health outcomes and monitor and evaluate processes, strengthening the National Information System (SNIS), setting health quality standards, and training human resources for health management at the local level. The restructured Project will also continue to support the improvement of health services (infrastructure and equipment) in some vulnerable health care networks that have already been identified, in the country´s poorest areas, and already have complete design and architecture plans, according to technical criteria defined in the Project guidelines. (a) Reduce the scope of Project components 8. The Government has requested changes to Components 1 and 2, and the cancellation of activities not yet implemented under Component 3. The main changes proposed in Component 1 will improve the operational capacity of the SNIS. Changes in Component 2 will contribute to improving maternal and child health, and decreasing chronic malnutrition among children in the target areas by focusing the Project on expansion of health services (infrastructure and equipment), organization of health networks, and improvement of staff skills. Component 3 will contribute to increase population registration in the Family Health Record (Carpeta Familiar). The revised Components and Subcomponent Activities are presented bellow and detailed in Annex 1. 9. Component 1 - Stewardship Role of Health Authorities. Under Subcomponent 1.a Strengthening the SNIS, two new activities will be included: (i) development of an index to follow up the progress of mothers and children during the two first years of life; and (ii) support the organization and consolidation of the Cumbre de Salud; and three activities will be cancelled: (i) monitoring and evaluation of the Government’s Sector Development Plan for 2006-2010 as the Plan was not implemented by the Ministry of Health; (ii) the establishment of a National Health Research System as the Government has not supported health research under the Project; and (iii) the Demographic and Health National Survey 2011, as there were delays in data collection under the 2010 Census. Under Subcomponent 1.b Regulation, Results-based Management and Culture of Accountability, (i) Cumbre de Salud, which will be carried out in close coordination with bilateral and multilateral donors, will replace the activity strengthening of the coordination of international and multilateral donors; and (ii) Project evaluation will not require Project resources, as a Government agency (UDAPE), is leading an impact evaluation of this and other Bank-financed Projects (Bono and Zero Malnutrition Program). Finally, Subcomponent 1.c Development and Implementation of a National Program of Quality will be integrated into Component 2, to ensure that it will be implemented in close coordination with the investments on health networks. 10. Component 2 - Family, Community and Intercultural Health. Under Subcomponent 2.a Development and Strengthening of Intercultural Maternal and Infant Health Referral Network, the following activities will remain: (i) study to analyze and define health networks in target areas; and (ii) renovation of public health facilities and the carrying of FPS financial audits and the financing of the FPS operating costs. However, the scope and financing of this last activity will be reduced; and four activities 9 will be cancelled: (i) financing of expanded human resources; (ii) design of a program of regular continuing education for each referral network; (iii) financing of expenses of operational research; and (iv) creation of three regional equipment maintenance centers. Activities (i) and (ii) were already implemented with Government funds; and the Government will not implement activities (iii) and (iv). The Government also requested the cancellation of Subcomponent 2.b Strengthening of Local Management and Community Participation activities, as there has not been any progress on community participation under the management agreements between the Regional Departments and the MSD. As previously mentioned, activities planned under Subcomponent 1.3 Development and Implementation of a National Program of Quality, will be included in Component 2 to ensure close coordination with investments in health networks; the following activities will be included under this Subcomponent: (i) development of capacity in quality management; and (ii) development and implementation of quality management standards and instruments for the provision of health care; activities related to licensing, certification and monitoring of health facilities will be cancelled. 11. Component 3 - Health Insurance. The Government requested the cancellation of the activities in Subcomponents 3.a, Strengthening of the SUS enrollment system and 3.b, Development and Strengthening of the M&E Management Capacity in the National Unit for Technical and Financed Management and Departmental units. A new Subcomponent to support the rollout of a universal health insurance program record system will be included to ensure training of key personal and forms to enroll the population in the Family Health Record (Carpeta Familiar). This would contribute to the achievement of the PDO that addresses coverage of health insurance in the target areas and the increase of the population enrollment in the SUS. Some Component 3 activities related to strengthening the MSD capacity to plan, manage and carry out monitoring and evaluation of health coverage have already been implemented (Table 1). An activity related to the design of a monitoring and evaluation system for health insurance based on data collected in the Carpeta Familiar will be implemented in the restructured project. (b) Modifications to the Results Framework 12. The Results Framework has been revised to reflect changes in Project Subcomponents and reduction in the scope of the Components. Due to the delay in finalizing the legal framework and administrative mechanisms necessary to enroll the population on the Single Health System (SUS), the Government has proposed to eliminate two PDIs: percentage of target population enrolled in the Project areas; and health insurance management module reports. Project restructuring does not change the original targets of the remaining four PDIs and intermediate indicators. Annex 2 presents the revised Project Results Framework. (c) Partial Credit Cancellation 13. In line with changes in project scope, the Government has asked the Bank to cancel SDR 4,850,000 (approximately US$7.0 million). Table 2 shows the status of Project financing by Component. 10 Table 2 - Project Financing in SDR (08-31-2012) Components Current Disbursed Not Credit New New Amount to Amount (2) Disbursed Proposed Amount of be Disbursed of Credit (3)=(1)-(2) to be Credit after (1) Cancelled (5)= (1)- Restructuring (4) (4) (6)=(5)-(2) Component 1 2,500,000 645,384 1,854,616 990,000 1,510,000 864,616 Component 2 6,300,000 193,031 6,106,969 1,600,000 4,700,000 4,509,969 Component 3 2,000,000 127,761 1,872,239 1,872,239 127,761 0 Project 600,000 266,883 333,117 87,761 512,239 245,356 Management No Allocated 300,000 0 300,000 300,000 0 0 TOTAL 11,700,000 1,233,059 10,466,941 4,850,000 6,850,000 5,619,941 (d) Reallocation of Credit Proceeds 14. Table 3 shows the allocation of Project resources after the partial cancellation of funds. Table 3 - Credit Reallocation in SDR Category of Expenditure Allocation % of Financing Current Revised Current Revised Current Revised Component 1 - Goods, (1) Component 1 - Goods, 2,500,000 1,510,000 21% 22% consultant services, consultant services, Training and MSD Training and MSD Operating Costs Operating Costs Component 2 – (1) Component 2 - (a) Goods, consultant (e) Goods, consultant 3,200,000 400,000 27% 6% services, training services, training and and MSD MSD Operating Costs Operating Costs for Component 2 of the for Part 2 of the Project except for Project except for Component 2.i(b); Part 2(a) (ii); (f) Works, goods and 2,900,000 4,100,000 25% 60% (b) Works, goods and consultant services consultant (including audits) services under Component (including audits) 2.i(b) of the Project under Part 2(a) and; (ii) of the Project (g) FPS Operating Cost 200,000* 200,000* 2% 3% and and Component 2 of (c) FPS Operating the Project Costs under Part 2 of the Project Component 3 - Goods, Component 3 - Goods, 2,000,000 127,761 17% 2% Consultant Services, Consultant Services, Training and MSD Training and MSD Operating Costs for Part 3 Operating Costs for of the Project Component 3 of the Project Project Management - Project Management - 600,000 512,239 5% 7% Goods, consultant services Goods, consultant services (including audits) and (including audits) and MSD MSD Operating Costs for Operating Costs for Project Part 4 of the Project Management 11 Category of Expenditure Allocation % of Financing Current Revised Current Revised Current Revised Unallocated Unallocated 300,000 0 3% - Total Amount 11,700,000 6,850,000 100% 100% * 5% of the total cost of the works, goods and services under the FPS management. 15. Safeguards and Institutional Arrangements. The Project restructuring does not require changes in the safeguards and institutional arrangements as described in the original Project Appraisal Document and Financing Agreement. 12 ANNEX 1 Current and New Project Activities BOLIVIA: EXPANDING ACCESS TO REDUCE HEALTH INEQUITIES PROJECT (APL III)--FORMER HEALTH SECTOR REFORM - THIRD PHASE (APL III) Current Project Structure New Proposed Structure Components Sub- Activities Components Sub- Activities Components Components Component 1 - 1.1 – Strengthening the 1.1.1 – Design and Adaptation of technical Component 1 - 1.1 – Strengthening 1.1.1 – Design and Adaptation of Stewardship Role SNIS standards and processes of the SNIS in Stewardship the SNIS technical standards and processes of the of Health epidemiological surveillance Role of Health SNIS in epidemiological surveillance Authorities Authorities (previous 1.1.1). 1.1.2 - Monitoring and Evaluation, related to 1.2 – Strengthening 1.2.1 – Provision of technical assistance the oversight of the Government’s Sector the capacity of the to develop standard practices and Development Plan for 2006-2010 at national MSD and management tools (previous 1.2.1). (eliminated) Departmental and 1.1.3 – Development of a National System for Local Health 1.2.2 – Dissemination of Health Results Health Research (eliminated) Authorities Achieved through community meetings, workshops and publications (previous 1.2.4). 1.1.4 – Financing for the Demographic and 1.2.3 – Strengthening of the MSD´s Health National Survey 2011 (eliminated) Human Resources Policy (previous 1.2.5). 1.2 – Strengthening the 1.2.1 – Provision of technical assistance to capacity of the MSD develop standard practices and management and Departmental and tools Local Health 1.2.2 – Strengthening the Coordination of 1.2.4 – Development of an Index to Authorities International and Multilateral Donors follow up the Progress of Mothers and (eliminated) Children during the first two years of life 1.2.3 – Carrying out of the Project Evaluation (new activity). (eliminated) 1.2.4 – Dissemination of Health Results Achieved through community meetings, workshops and publications 1.2.5 – Strengthening of the MSD´s Human Resources Policy 13 Current Project Structure New Proposed Structure Components Sub- Activities Components Sub- Activities Components Components 1.3 - Development and 1.3.1 – Development of capacity in quality 1.2.5 – Support to the Cumbre de Salud Implementation of a management concepts (new activity). National Program of 1.3.2 – Development and implementation of Quality standards and instruments of quality management in the provision of health services Component 2 – 2.1 - Development and 2.1.1 – Study on the status of resources and Component 2 – 2.1 - Development and 2.1.1 – Study on the status of resources Family, Strengthening of capacities on health networks in target areas Family, Strengthening of and capacities on health networks in Community and Intercultural Maternal Community and Intercultural Maternal target areas Intercultural and Infant Health 2.1.2 – renovation of public health facilities Intercultural and Infant Health 2.1.2 – renovation of public health Health Referral Network and medical equipment and FPS financial Health Referral Network facilities and medical equipment and FPS audits and operating costs financial audits and operating costs 2.1.3 – Financing of Expanded Human Resources (eliminated) 2.1.4 - Design of a Program of Regular Continuing Education for Referral Networks (eliminated) 2.1.5 – Financing of Expenses of Operational Research (eliminated) 2.1.6 – Creation of three regional equipment maintenance centers (eliminated) 2.2 - Strengthening of 2.2.1 – Workshops on maternal and child 2.2 - Development and 2.2.1 – Development of capacity in Local Management and mortality and chronic malnutrition for local Implementation of a quality management concepts (previous Community social organizations and community leaders National Program of 1.3.1) Participation (eliminated) Quality (old 1.3) 2.2.2 – Training for health workers, 2.2.2 – Development and implementation organizations and community leaders on of standards and instruments of quality analyzing health data (eliminated) management in the provision of health 2.2.3 – Dissemination of community services (previous1.3.2) intersectoral health strategies and results (eliminated) 2.2.4 – collaborative preparation of health promotion materials (eliminated) 2.25 – Training of the DILOS for increased capacity on manage local health (eliminated) 14 Current Project Structure New Proposed Structure Components Sub- Activities Components Sub- Activities Components Components Component 3 – 3.1 – Enrollment of 3.1.1 – Training on the use of the enrollment Component 3 – 3.1 - Support the 3.1.1 - the carrying out of training in use Health Insurance Families and system (eliminated) Health rollout of a universal of the enrollment system for key Program Individuals Insurance health insurance personnel, operational personnel and Program program record system community leaders; and for the enrollment of families and 3.1.2 - the design, printing and individuals distribution nation-wide of a family health enrollment form (“Carpeta Familiar”). 3.1.2 – Implementation of a communication and social marketing strategy to health insurance enrollment (eliminated) 3.1.3 – Printing and distribution of the enrollment forms nationwide (eliminated) 3.2 – Strengthening No activities were listed. Most activities on 3.2 – Development of 3.2.1 - Conceptual design of a monitoring MSD´s capacity to plan, this component were implemented previously a Monitoring and and evaluation system for health manage and carry out to the restructuring proposed by the Evaluation System for insurance according the data collected in monitoring and Government. (eliminated) Health Insurance. the Carpeta Familiar. evaluation of health coverage 3.3 – Development of a No activities were listed Monitoring and Evaluation System for Health Insurance 15 ANNEX 2 Results Framework and Monitoring BOLIVIA: EXPANDING ACCESS TO REDUCE HEALTH INEQUITIES PROJECT (APL III)--FORMER HEALTH SECTOR REFORM - THIRD PHASE (APL III) Project Development Objectives (PDO): (i) Reduce occurrence of critical risk factors affecting maternal and infant health in the target areas so that current gaps between regions are reduced; (ii) Reduce chronic malnutrition among children under 2 years of age in the target areas; (iii) Increase health insurance coverage in the target areas and; (iv) Upgrade the National Health Information System (Sistema Nacional de Información en Salud y Vigilancia Epidemiológica – SNIS) so that it will be integrated in the Bolivia´s new health insurance program. Cumulative Target Values Target (T) Observed (O) No data (ND) Core PDO Level Results Unit of Baseline Data Source/ Responsibility for Frequency Indicators* Measure (2006) Methodology Data Collection 2009 2010 2011 2012 2013 Ratio between the percentage Maintain Ratio 0.66 0.90 (O) 0.86 (O) 1.03 (O) 0.80 (T) 0.85 (T) Yearly SNIS Ministry of Health of pregnant women receiving and SNIS four prenatal care in the areas of Project intervention and the rest of the country Ratio between the percentage Maintain Ratio 0.68 0.84 (O) 0.83 (O) 0.94 (O) 0.80 (T) 0.85 (T) Yearly SNIS Ministry of Health of institutional deliveries in the and SNIS areas of Project intervention and the rest of country Percentage of 2 year old Maintain Percentage 37.6 37.0 (T) 32.5 (T) 28.5 (T) 25.0 (T) 22.0 (T) Yearly SNIS Ministry of Health children with a height over -2Z and SNIS scores in the intervention areas ND 33.5 (O) 32.4 (O) of the Project Percentage of children Maintain Percentage 51.0 54.0 (T) 56.0 (T) 59.0 (T) 62.0 (T) 65.0 (T) Yearly SNIS Ministry of Health receiving exclusively breast and SNIS feeding at 6 months in the ND ND ND Project areas Percentage of target population Drop Percentage 0 32 (T) 54 (T) 74 (T) 80 (T) - Yearly SNIS Ministry of Health enrolled in the Project areas ND ND ND ND and UGTFN Health insurance management Drop Number of 0 20 40 60 80 - Yearly SNIS Ministry of Health module reports include Reports ND ND ND ND and UGTFN information about production INTERMEDIATE RESULTS Project restructuring will maintain the 12 intermediate indicators included in the PAD. 16