Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) Sri Lanka - Second Health Sector Development Project (P118806) SOUTH ASIA | Sri Lanka | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2013 | Seq No: 12 | ARCHIVED on 20-Jun-2018 | ISR32511 | Implementing Agencies: Ministry of Finance and Mass Media, Ministry of Health, Ministry of Local Government and Provincial Councils Key Dates Key Project Dates Bank Approval Date:27-Mar-2013 Effectiveness Date:12-Sep-2013 Planned Mid Term Review Date:25-Jan-2016 Actual Mid-Term Review Date:25-Jan-2016 Original Closing Date:30-Sep-2018 Revised Closing Date:30-Sep-2018 Project Development Objectives Project Development Objective (from Project Appraisal Document) The project development objective (PDO) is to upgrade the standards of performance of the public health system and enable it to better respond to the challenges of malnutrition and non-communicable diseases. Has the Project Development Objective been changed since Board Approval of the Project Objective? No PHRPDODEL Components Name Support to priority areas under the National Health Development Plan:(Cost $190.00 M) Innovation, results monitoring and capacity building fund:(Cost $10.00 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO  Satisfactory  Satisfactory Overall Implementation Progress (IP)  Satisfactory  Satisfactory Overall Risk Rating  Moderate  Moderate Implementation Status and Key Decisions 6/20/2018 Page 1 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) In April 2018, the Ministry of Health, Nutrition and Indigenous Medicine (MoH) and the Ministry of Provincial Councils, Local Governments and Sport (MPCLGS) submitted the annual progress report for 2017. The report provides information against the end-of-project results, although the Government continues to implement activities in the project areas. The progress report presents provisional results for 20 indicators, including nine disbursement- linked indicators (DLIs) for which the data is currently being verified by the World Bank. Overall, the project continues to make good implementation progress, is likely to satisfactorily achieve its Project Development Objective and the commitment to achieve the agreed targets by the implementing teams in the MoH and the nine provinces is high. For example, the 2017 and end-of-project targets for the percent of centrally and provincially managed health facilities with emergency treatment units based on standard guidelines were surpassed. Similarly, the end-of-Project targets for the 'percent of persons over 40 years screened for selected non-communicable diseases (Diabetes, hypertension, cancer breast and oral) at healthy lifestyle centers' and the 'percentage of primary health care institutions having one month's buffer stock for 16 selected non-communicable disease drugs' was also significantly surpassed. One area of the concern is the increase in the health system’s response to the challenge of malnutrition. While indicators show an increase coverage of nutrition-related health services, maternal and nutrition outcomes have not substantially improved. Further analytical work in this area is being done. 6/20/2018 Page 2 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) 6/20/2018 Page 3 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) 6/20/2018 Page 4 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) 6/20/2018 Page 5 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance  --  Moderate  Moderate Macroeconomic  --  Moderate  Moderate Sector Strategies and Policies  --  Moderate  Moderate Technical Design of Project or Program  --  Moderate  Moderate Institutional Capacity for Implementation and Sustainability  --  Moderate  Moderate Fiduciary  --  Moderate  Moderate Environment and Social  --  Low  Low Stakeholders  --  Moderate  Moderate Other  --  --  -- Overall  --  Moderate  Moderate Results Project Development Objective Indicators PHINDPDOTBL  % of persons (over 40 years) screened for selected NCDs (diabetes, hypertension, cancer breast and oral) at healthy lifestyle centers (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 3.00 22.80 27.00 12.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceeded, by 167%. 6/20/2018 Page 6 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) PHINDPDOTBL  % of pregnant women with anaemia after the second trimester (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 34.00 24.00 26.23 20.00 Date 31-Dec-2006 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Unable to determine progress as the sources and the measurement of the data changed over time. The baseline figure was from the 2006/2007 DHS and for all pregnant women (not just women in the second trimester). A similar estimate from 2016 DHS is unavailable due to problems with the biomarker data, causing indicators like anemia rates to be excluded. In 2015, the Family Health Bureau started to measure anemia rates of women in the second trimester. However, FHB's measurement changed in 2016 as blood tests started to be provided with the first ANC visit in the first trimester. These issues will be further explored between now, Project Completion and the preparation of the Implementation Completion Report. Regardless, this indicator is not a good fit for measuring the progress of the PDO which focuses on the capacity of the health system to respond to the challenge of malnutrition. PHINDPDOTBL  % of centrally managed health facilities with ETUs for that level of facility based on standard guidelines (DLI 1) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 32.10 46.40 40.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceed, by 16%. PHINDPDOTBL  % of provincially managed health facilities with ETUs for that level of facility based on standard guidelines (DLI 2) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target 6/20/2018 Page 7 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) Value 0.00 54.57 82.00 50.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceed, by 64%. PHINDPDOTBL  % of MOH managed health facilities sending indoor morbidity data through e-IMMR (DLI 3) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 2.00 72.30 83.00 80.00 Date 30-Sep-2012 30-Dec-2016 30-Dec-2016 31-Dec-2017 Comments Target exceeded, by 4%. PHINDPDOTBL  % of provincially managed health facilities sending indoor morbidity data through e-IMMR (DLI 4) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 67.60 82.23 70.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceeded, by 17%. Overall Comments The progress towards achieving the Project Development Object – To upgrade the standards of performance of the public health system and enable it to better respond to the challenges of malnutrition and non-communicable diseases – is satisfactory. The PDO can be assessed in three parts. The first part (upgrade the standards of performance of the public health system) is measured by four indicators. The four indicators have been met or exceeded, with significant progress in establishing emergency treatment units at national and provincial hospitals and in improving the reporting of health morbidity by national and provincial health facilities. This area of the part of the PDO is satisfactory. The second part (enable the public health system to respond to the challenge of malnutrition) is measured by one outcome indicate of pregnant women with 6/20/2018 Page 8 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) anemia, a risk factor for infant malnutrition. Unfortunately, the sources of the data and the definition of exactly what was measured changed over time. As a result, it is difficult to assess the whether or the extent to which this indicator missed its target. Further investigation of this data will be undertaken in preparation of the Project Completion and ICR. Regardless, this indicator is not a good measure of the PDO which is focused on the capacity of the health sector to respond to the challenge of malnutrition. The project met or exceeded both intermediate indicator targets which were more closely aligned with measuring health sector capacity. To supplement this information, we looked one step further along the results chain to health service coverage to address malnutrition. These indicators show some progress (i.e. an increase in Vitamin supplementation, exclusive breastfeeding, growth monitoring and deworming while iron supplementation remained consistently high). Despite this and largely because of the difficulty in measuring the PDO indicator, this part of the PDO is rated as moderately unsatisfactory. The third part of the PDO (enable the public health system to respond to the challenge of non-communicable diseases) is measured by one indicator, measuring screening of the population for non-communicable diseases through the Healthy Lifestyle Centers more than doubled its expected target. This part of the PDO is rated as highly satisfactory. Given the ratings of the three parts of the PDO, the overall rating is satisfactory. Intermediate Results Indicators PHINDIRITBL  % of CEMOC facilities providing 24x7 CEMOC services. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 45.00 72.20 73.60 75.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target almost but not fully met, missed by 5%. PHINDIRITBL  % of training institutes managed by the Ministry of Health meeting national standards (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 38.20 47.00 40.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceed, by 18%. 6/20/2018 Page 9 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) PHINDIRITBL  % of laboratories in health facilities (base hospitals A and above) participating in the external quality assurance program for selected tests conducted by the Medical Research Institute (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.00 84.00 95.70 80.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceed, by 22%. PHINDIRITBL  Case detection rate for tuberculosis (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 69.00 62.90 60.00 77.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target not met, by 213%. End-result less than baseline. This indicator is not a good measure of the Project which was focused on key elements of the health system to define and meet standards. Technical and financial support to the TB program was provided by other partners. PHINDIRITBL  % of hospitals (base hospitals and above) that have obtained EPL and HWL (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 5.00 23.20 17.30 40.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target not met, by 65%. The MoH reports that significant increase in the number of environmental protection and hospital waste management licenses would require significant investment in waste water treatment facilities. 6/20/2018 Page 10 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) PHINDIRITBL  % of fully functioning quality management Units (QMUs) in MOH managed base hospitals and above (DLI 7) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 9.00 95.00 95.00 95.00 Date 30-Sep-2012 30-Dec-2016 30-Dec-2016 31-Dec-2017 Comments Target exceeded, by 49%. PHINDIRITBL  % of fully functioning quality management Units (QMUs) in provincially managed base hospitals and above (DLI 8) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 6.00 81.36 95.90 90.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceeded, by 7%. PHINDIRITBL  % of National Competitive Bidding (NCB) contracts awarded within the first nine months of the previous calendar year from 2014 onwards (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 63.90 70.00 80.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target not met, by 30%. There is some irregularity with the baseline which is reported as "0%" and then in 2013 reported as more than 70%. There was consistent year-on-year progress since 2015 (the mid-term review). Therefore, for the purpose of measuring the variance with the expected progress, 2015 is taken as the baseline. 6/20/2018 Page 11 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) PHINDIRITBL  % of the six-monthly cash forecast (for non-salary recurring and capital expenditures) released (DLI 9) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 81.00 90.00 90.00 90.00 Date 30-Sep-2012 30-Dec-2016 30-Dec-2016 31-Dec-2017 Comments Updated information for FY2017 will become available by June 30, 2018. It will be reported in the final ISR. PHINDIRITBL  % of MCH clinics that have an agreed package of equipment and supplies for the provision of care for pregnant women and children under five years. (DLI 5) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 81.67 95.00 95.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target met. PHINDIRITBL  % of Medical Officer of Health areas with at least three health and nutrition community support groups (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.00 93.00 97.60 90.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceeded, by 10%. 6/20/2018 Page 12 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) PHINDIRITBL  % of Medical Officer of Health areas with at least two healthy lifestyle centers (DLI 6) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.00 72.81 94.20 90.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceeded, by 5%. PHINDIRITBL  No. of provinces with at least one health facility providing rehabilitation services (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 8.00 8.00 7.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceeded, by 17%. All but one province has such facility. PHINDIRITBL  % of primary health care institutions having one month’s buffer stock for 16 selected NCD drugs (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 2.00 74.40 81.20 60.00 Date 30-Sep-2012 30-Dec-2016 31-Dec-2017 31-Dec-2017 Comments Target exceeded, by 37%. Overall Comments Of the intermediate indicators to benchmark the implementation progress, seven have exceeded their target, 1 indicator has met its target, 4 indicators have not met their target, and 1 indicator is still to be determined. This information is based on the 2017 data reported by the Ministry of Health. Those indicators which are tied to disbursement are currently being 6/20/2018 Page 13 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) verified and may be adjusted as a result of the field-level information. This will be reflected in the final ISR. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed P118806 IDA-52280 Effective USD 200.00 200.00 0.00 162.39 23.33 87% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P118806 IDA-52280 Effective 27-Mar-2013 19-Aug-2013 12-Sep-2013 30-Sep-2018 30-Sep-2018 Cumulative Disbursements Restructuring History There has been no restructuring to date. 6/20/2018 Page 14 of 15 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Sri Lanka - Second Health Sector Development Project (P118806) Related Project(s) There are no related projects. 6/20/2018 Page 15 of 15 Public Disclosure Copy