The World Bank Essential Health Services Access Project (P149960) REPORT NO.: RES32931 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF ESSENTIAL HEALTH SERVICES ACCESS PROJECT APPROVED ON OCTOBER 14, 2014 TO REPUBLIC OF THE UNION OF MYANMAR HEALTH, NUTRITION & POPULATION EAST ASIA AND PACIFIC Regional Vice President: Victoria Kwakwa Country Director: Ellen A. Goldstein Senior Global Practice Director: Timothy Grant Evans Practice Manager/Manager: Toomas Palu Task Team Leader: Hnin Hnin Pyne The World Bank Essential Health Services Access Project (P149960) ABBREVIATIONS AND ACRONYMS AF Additional Financing BEmONC Basic Emergency Obstetric and Neonatal Care DLI Disbursement Linked Indicator EHSAP Essential Health Services Access Project FM Financial Management FY Fiscal Year GOM Government of Myanmar IBRD International Bank for Reconstruction and Development IDA International Development Association IFR Interim Unaudited Financial Report IMCI Integrated Management of Childhood Illnesses M&E Monitoring and Evaluation MNCH Maternal, Newborn and Child Health MOHS Ministry of Health and Sports MOPF Ministry of Planning and Finance PDO Project Development Objective S/RHD State/Regional Health Department SDR Special Drawing Rights UHC Universal Health Coverage The World Bank Essential Health Services Access Project (P149960) BASIC DATA Product Information Project ID Financing Instrument P149960 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 14-Oct-2014 30-Jun-2019 Organizations Borrower Responsible Agency Republic of the Union of Myanmar Ministry of Health and Sports Project Development Objective (PDO) Original PDO The Project Development Objective (PDO) is to increase coverage of essential health services of adequate quality, with a focus on maternal, newborn and child health (MNCH). Current PDO The Project Development Objective (PDO) is to increase coverage of essential health services of adequate quality, with a focus on maternal, newborn and child health (MNCH), and, in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-55420 14-Oct-2014 05-Feb-2015 08-Apr-2015 30-Jun-2019 100.00 55.16 36.34 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Essential Health Services Access Project (P149960) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Overall implementation progress 1. Overall implementation progress of EHSAP is mixed, and remain Moderately Satisfactory. 2. Component 1 (84% of the financing) is progressing as planned and is satisfactory. Independent verification report of the Year 2 DLI achievement, which was conducted at the end of Sept 2017, indicated 100% achievement of five of the seven DLIs (readiness of health facilities, receipt of health facility funds, outreach visits for antenatal and postnatal care, regular supervision visits by State/Region and Township health authorities). The two DLIs with partial achievement are DLI#4 on inclusive township health plan (where only 60 out of 100 townships achieved the target), and DLI#7 on training of midwives on Basic Emergency Obstetric Care and Integrated Management of Childhood Illnesses (where only 84 out of 100 target townships achieved the target). DLI#7 required that the township to have midwives trained in both BEmOC and IMCI. 3. Report on Year 3 DLI achievement is under preparation. Once it has been received, the verification and oversight of the verification by an external group of experts will take place. 4. Implementation of Component 2 (16% of the financing), however, still lags despite some improvement. Frequent leadership change with hiccups in the handover of responsibility and authority, irregular review and decision meetings, unclear and redundant internal processes for review and approval of the program plans and budgets. This was further delayed with the crisis in Rakhine unfolding in 2017 and subsequent humanitarian crisis of unprecedented scale, all the attention and energy of the MOHS senior leadership and technical leads of the central programs (who are in charge of component 2 delivery) were diverted to prioritize MOHS’s health response in Rakhine, leaving the Component 2 activities on the back burner. Due to delays—for all reasons provided—the implementation progress is moderately unsatisfactory. The central programs already have in hand their work plan and budget proposals to implement their activities. 5. The project is being restructured for the following reasons: (a) With the change of the Government fiscal year from April 1-March 31 to October 1 - September 30 already put into effect, a revision of the disbursement calendar to reflect this change will be carried out. To address this change, year 4 will begin October 1. The project closing will need to be extended. (b) With the postponement of additional financing (US$ 100m IDA + US$ 10m GFF), restructuring is needed to incorporate the changes to the DLI targets for Year 3 and Year 4, which were agreed to during the preparation of the additional financing. The restructuring is proposed to meet the implementation milestones of the completion of Year 3 and the DLI reporting and independent verification. (c) The extension of IFR reporting period from 45 days to 60 days. (d) SDR 2.44 million was returned to the health operation after it was allocated for the Immediate Response Mechanism at the request of the Government in 2016. The World Bank Essential Health Services Access Project (P149960) 6. There are no outstanding audits/financial reports and legal covenants are in compliance. II. DESCRIPTION OF PROPOSED CHANGES 7. Proposed restructuring would include: (a) Extension of the project period by 21 months, from June 30, 2019 to March 31, 2021, to adjust to the change in the Government’s Fiscal Year, as well as to allow sufficient time for Component 2 implementation, requiring a change in Implementation Schedule. (b) Recalibration of the DLI targets for Year 3 and Year 4, which involves lowering the target number of townships meeting the DLIs. As Additional Financing was prepared in Year 3, the MOHS technical teams had been working under the assumption of the re-structured targets for Year 3 and Year 4. Implementation for Year 3 was formed with an understanding that the target number of townships achieving the DLIs would be lowered for Year 3 and 4. (c) Modification of the Results Framework for two reasons: (i) DLI targets, which are a part of the RF, are proposed to be changed; and (ii) as a result of reallocation from IRM, the indicator on procurement of goods under IRM will be deleted. (d) Extension of the IFR reporting period from 45 days to 60 days, the primary reason being that the collecting of financial data from township continues to be done manually and this lengthens the time required for the union level to compile and submit the IFR. (e) Reallocations between Disbursement Categories to reflect the returning of SDR 2.44 million from Category (3) to Category (2), which was initially reallocated from Category (2) to Category (3) for purposes of the Immediate Response Mechanism to respond to the 2015 floods and landslides, based on the Government’s ultimate decision not to utilize ESHAP funds for this purpose. III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Loan Closing Date(s) ✔ Reallocation between Disbursement Categories ✔ Disbursement Estimates ✔ Financial Management ✔ Other Change(s) ✔ Implementing Agency ✔ The World Bank Essential Health Services Access Project (P149960) DDO Status ✔ Project's Development Objectives ✔ Components and Cost ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Procurement ✔ Implementation Schedule ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ 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-55420 Effective 30-Jun-2019 31-Mar-2021 31-Jul-2021 OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-55420-001 | Currency: XDR The World Bank Essential Health Services Access Project (P149960) iLap Category Sequence No: 1 Current Expenditure Category: EEPs under P1 54,880,000.00 23,113,154.45 54,880,000.00 100.00 100.00 iLap Category Sequence No: 2 Current Expenditure Category: G,NCS,CS(incl audit),TR,WS,OC, P2 8,080,000.00 1,902,400.42 10,520,000.00 100.00 100.00 iLap Category Sequence No: 3 Current Expenditure Category: Emergency Expenditure under P3 2,440,000.00 0.00 0.00 100.00 100.00 Total 65,400,000.00 25,015,554.87 65,400,000.00 OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 2015 25,000,000.00 0.00 2016 25,000,000.00 25,000,000.00 2017 25,000,000.00 25,000,000.00 2018 25,000,000.00 20,000,000.00 2019 0.00 20,000,000.00 2020 0.00 10,000,000.00 . The World Bank Essential Health Services Access Project (P149960) . Results framework COUNTRY: Myanmar Essential Health Services Access Project Project Development Objectives(s) The Project Development Objective (PDO) is to increase coverage of essential health services of adequate quality, with a focus on maternal, newborn and child health (MNCH), and, in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline End Target 2015 2019 Expanded coverage of essential health services, especially for women and children (Action: This Objective is New) Deliveries with skilled birth attendant (Percentage) 71.00 82.00 Deliveries which are followed by adequate postnatal care 78.00 85.00 (Percentage) Children under 6 months who are being exclusively breast-fed 24.00 40.00 (Percentage) Townships in which the township hospital and at least 60% of other Health Facilities have met a minimum readiness level of 14 DLI 1 0.00 180.00 out of 20 to provide essential MNCH services (Number) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target 2015 2019 Strengthening service delivery at the primary health care level (Action: This Component is New) The World Bank Essential Health Services Access Project (P149960) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target 2015 2019 Township in which township health department have been supervised at least twice in a fiscal year by State/Region Health DLI 6 0.00 180.00 Department officials using checklist (Number) Townships in which all rural health centers and atleast 50% of subcenters have been supervised atleast twice in a fiscal year by DLI 5 0.00 180.00 Township Health Department using checklist (Number) Townships in which the township hospital and atleast 80% of other health facilities have received Health Facility Grants in DLI 2 0.00 180.00 accordance with Project Operations Manual (Number) Townships in which atleast 80% of required number antenatal and postnatal visits and deliveries have been carried out by basic DLI 3 0.00 180.00 health staff (Number) Townships in which at least 60% of midwives have been trained DLI 7 0.00 180.00 to deliver BeMOC and IMCI (Number) Townships in which the Township Health Departments have prepared an integrated and inclusive Township Health Plans DLI 4 0.00 180.00 (Number) Townships where atleast 60% of the health facilities had no 0.00 100.00 stock-out of supplies in the past year. (Number) Systems Strengthening and Capacity Building (Action: This Component is New) Service readiness scorecard implemented (Yes/No) No Yes Goods procured and distributed as outlined in the CERIP No No (Yes/No) Action: This indicator has been Marked for Deletion Townships where data quality assessments are carried out 0.00 180.00 (Number) The World Bank Essential Health Services Access Project (P149960) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target 2015 2019 Health Care Waste Management guidelines and policy developed No Yes and implemented (Yes/No) Improved fund flows (recurrent) to front line health facilities-- No Yes Training on guidelines developed (Yes/No) Improved supervision (supervision standards and checklists No Yes developed) (Yes/No) Communications strategy developed and implemented (Yes/No) No Yes Health Financing Strategy for UHC developed, approved, and No Yes communicated (Yes/No) Essential Package of Health Services including quality standards No Yes defined, costed, approved, and publicly communicated (Yes/No) IO Table SPACE Disbursement Linked Indicators Matrix DLI_TBL_MATRIX DLI 1 Supply side readiness at township level Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Number 16,000,000.00 50.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 2015-2016 50.00 4,000,000.00 2016-2017 100.00 4,000,000.00 The World Bank Essential Health Services Access Project (P149960) 2017-2018 140.00 4,000,000.00 2018-2019 180.00 4,000,000.00 Action: This DLI is New DLI_TBL_MATRIX DLI 2 Health Facility Funds Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 16,000,000.00 50.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 2015-2016 50.00 4,000,000.00 2016-2017 100.00 4,000,000.00 2017-2018 140.00 4,000,000.00 2018-2019 180.00 4,000,000.00 Action: This DLI is New DLI_TBL_MATRIX DLI 3 Increased outreach for antenatal and postnatal care Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Number 12,000,000.00 50.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 The World Bank Essential Health Services Access Project (P149960) 2015-2016 50.00 3,000,000.00 2016-2017 100.00 3,000,000.00 2017-2018 140.00 3,000,000.00 2018-2019 180.00 3,000,000.00 Action: This DLI is New DLI_TBL_MATRIX DLI 4 Inclusive township health plans Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 8,000,000.00 50.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 2015-2016 50.00 2,000,000.00 2016-2017 100.00 2,000,000.00 2017-2018 140.00 2,000,000.00 2018-2019 180.00 2,000,000.00 Action: This DLI is New The World Bank Essential Health Services Access Project (P149960) DLI_TBL_MATRIX DLI 5 Supervision by Township health departments Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 12,000,000.00 50.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 2015-2016 50.00 3,000,000.00 2016-2017 100.00 3,000,000.00 2017-2018 140.00 3,000,000.00 2018-2019 180.00 3,000,000.00 Action: This DLI is New DLI_TBL_MATRIX DLI 6 Supervision by State/Region Health Departments Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 8,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 2015-2016 50.00 2,000,000.00 2016-2017 100.00 2,000,000.00 2017-2018 140.00 2,000,000.00 The World Bank Essential Health Services Access Project (P149960) 2018-2019 180.00 2,000,000.00 Action: This DLI is New DLI_TBL_MATRIX DLI 7 Skilled front-line providers to provide essential health services for women and children Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 12,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 2015-2016 50.00 3,000,000.00 2016-2017 100.00 3,000,000.00 2017-2018 140.00 3,000,000.00 2018-2019 180.00 3,000,000.00 Action: This DLI is New Verification Protocol Table: Disbursement Linked Indicators DLI_TBL_VERIFICATION DLI 1 Supply side readiness at township level The MOH has a proper standing instruction and guidance of the composition of essential MNCH services. Readiness score card is used to assess the readiness level. Description Readiness level is measured by a composite index that covers domains of health system standards, such as staffing, drugs/vaccine availability, basic equipment, record keeping, and health care waste management. The World Bank Essential Health Services Access Project (P149960) Each of the ten tracer elements are scored 0, 1 or 2 (similar to the Apgar score). Any major deficiency or total absence of the element results in a score of “0”. Full compliance according to MOH standards would result in a score of “2”. Minor deficiencies would result in a score of “1”. The total minimum score of a facility is “0”, and the maximum score is “20”. A score of “14” counts as a “pass grade”, while any lower grade means that the facility has underperformed as regards to the DLI. Health Departments at the Township and State/Region and Ministry of Health and Sports. Data source/ Agency Department of Medical Research carries out the first verification. The verification is then reviewed and assessed by a Verification Entity committee of External experts. Independent assessor review all the township reports and visits randomly selected townships and health facilities at village Procedure level, ensuring that the guidelines, essential supplies and skill are readily available and followed. DLI_TBL_VERIFICATION DLI 2 Health Facility Funds Health Facility Funds are included in the budget and transferred to the Health Facilities at the township and below, and FM Description reports are submitted as per Guidelines in a timely fashion. Director-Finance (DPH) and Director-Finance (DMS) Data source/ Agency Department of Medical Research carries out the first verification. The verification is then reviewed and assessed by a Verification Entity committee of External experts. Availability of budget and guidelines for an effective utilization of operational funds. Demonstration that GOM expenditure on agreed EEP exceeded the amount advanced by IDA and evidence of additional IDA fund reflected in GOM allocation; and both be documented in IUFR. The township will receive a “pass” score if all of the following criteria are met: Procedure  records are well kept;  Complete and timely FM reports are received by S/RHD and DPH and DMS;  all expenditures are made in accordance to the guidelines (no ineligible expenditures);  no evidence of abuse of funds; The World Bank Essential Health Services Access Project (P149960) DLI_TBL_VERIFICATION DLI 3 Increased outreach for antenatal and postnatal care The purpose of this DLI is to promote front line health providers to provide antenatal (AN) visits (at least four per pregnancy), postnatal (PN) visits for mother (at least four visits per delivery); post-natal (PN) visit for newborn (at least once within 3 days of delivery). For the township to get a “pass” score, it has to achieve the following elements: 80% of Description total AN visit target (total number of registered pregnancies in a fiscal year multiplied by four); 80% of total PN visit target for woman (total number of mothers who received first visit on postnatal care multiplied by four); and 80% of total PN visit target for newborn (number of live births). Department of Public Health, Department of Medical Services, Programs on Maternal Health, Child Health Data source/ Agency Department of Medical Research carries out the first verification. The verification is then reviewed and assessed by a Verification Entity committee of External experts. Verification includes review of records of the facility and the health worker, as well as random spot checks and enquiry from Procedure villages. DLI_TBL_VERIFICATION DLI 4 Inclusive township health plans The purpose of this DLI is to incentivize Township Health Departments to prepare an annual integrated and inclusive Description Township Health Plan. Department of Public Health (including Basic Health Unit) Data source/ Agency Department of Medical Research carries out the first verification. The verification is then reviewed and assessed by a Verification Entity committee of External experts. Review of Township Planning document which includes identification of the most vulnerable groups – social, geographical, ethnicity, risky behavior etc., evidence of consultation meetings with communities to get their inputs and feedbacks on the Procedure health services. The World Bank Essential Health Services Access Project (P149960) DLI_TBL_VERIFICATION DLI 5 Supervision by Township health departments The purpose of this DLI is to support effective supervision of the front line services by Township health department. Using a Description checklist enhances the quality of the supervision. Township Health Departments and the Department of Public Health Data source/ Agency Department of Medical Research carries out the first verification. The verification is then reviewed and assessed by a Verification Entity committee of External experts. Independent verification agency visits a 20% sample of the facilities and reviews completed checklists. The DLI target is met if hard evidence can be provided that the supervision has taken place and paid indeed attention paid to services statistics, Procedure facility and financial data and follow-up to previous supervision. DLI_TBL_VERIFICATION DLI 6 Supervision by State/Region Health Departments The purpose of the DLI is support effective supervision of the township level by the State/Region Health Departments. Description State/Region Health Departments, Department of Public Health Data source/ Agency Department of Medical Research carries out the first verification. The verification is then reviewed and assessed by a Verification Entity committee of External experts. Independent Verifications Agency visits a 20% sample of facilities and reviews completed supervision checklist. The Check list is completed by State/Region Health Department and is reviewed by Department of Public Health and a sample is Procedure verified by the Independent Verification Agency. DLI_TBL_VERIFICATION DLI 7 Skilled front-line providers to provide essential health services for women and children The DLI involves skills building of midwives and other front line providers in basic emergency obstetrics and neonatal care Description and integrated management of childhood illnesses, including use of necessary equipment and consumables. The World Bank Essential Health Services Access Project (P149960) Department of Public Health and Maternal Health, Child Health Programs. Data source/ Agency Department of Medical Research carries out the first verification. The verification is then reviewed and assessed by a Verification Entity committee of External experts. Certificates of completed training, in possession with the midwives and other front line providers. Supervision of training is undertaken by Township and State/Region Health Departments as well as the Central programs for maternal and child Procedure health. A sample of supervision and training documents are then reviewed and verified by an Independent Verification Agency. The World Bank Essential Health Services Access Project (P149960)