The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) REPORT NO.: RES38501 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SYSTEM STRENGTHENING FOR BETTER MATERNAL AND CHILD HEALTH RESULTS PROJECT (PDSS) APPROVED ON DECEMBER 18, 2014 TO DEMOCRATIC REPUBLIC OF CONGO HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Hafez M. H. Ghanem Country Director: Jean-Christophe Carret Regional Director: Amit Dar Practice Manager/Manager: Magnus Lindelow Task Team Leader: Hadia Nazem Samaha The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) ABBREVIATIONS AND ACRONYMS AF Additional Financing CAGF Cellule d’Appui et de Gestion Financière CERC Contingent Emergency Response Component CGPMP Cellule de Gestion des Projets et des Marches Publics DEP Département d’Etude et de Plannification DPS Directorate Provincial de la Sante EVD Ebola Virus Disease GFF Global Financing Facility HNP Health Nutrition and Population MTR Mid Term Review NHIS National Health Information System PBF Performance-based financing PDO Project Development Objective PDSS Projet du Développement du System du Santé REDISSE Regional Disease Surveillance Systems Strengthening The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) BASIC DATA Product Information Project ID Financing Instrument P147555 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 18-Dec-2014 31-Dec-2021 Organizations Borrower Responsible Agency Democratic Republic of Congo Ministry of Health,Ministry of Finance Project Development Objective (PDO) Original PDO The proposed project development objective is to improve utilization and quality of maternal and child health services in targeted areas within the Recipient's Territory. Current PDO To improve utilization and quality of maternal and child health services in targeted areas within the Recipient's Territory and, to provide an immediate and effective response to an eligible crisis or emergency OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-D4390 27-Feb-2019 06-Mar-2019 28-Aug-2019 31-Dec-2021 120.00 77.93 39.97 IDA-59980 31-Mar-2017 19-Apr-2017 13-Feb-2018 31-Dec-2021 120.00 122.21 .83 IDA-55720 18-Dec-2014 20-Jan-2015 30-May-2016 31-Dec-2021 130.00 111.13 11.20 The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) IDA-D0210 18-Dec-2014 20-Jan-2015 30-May-2016 31-Dec-2021 90.00 82.43 2.01 TF-A6945 24-Jan-2018 14-Mar-2018 14-Aug-2018 31-Aug-2018 4.53 4.53 0 TF-A5096 24-May-2017 24-May-2017 22-Nov-2017 30-Jun-2019 3.47 3.47 0 TF-A4579 19-Apr-2017 19-Apr-2017 18-Aug-2017 31-Dec-2021 40.00 24.45 15.55 TF-18375 20-Jan-2015 20-Jan-2015 30-May-2016 31-Dec-2021 6.50 4.43 2.07 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING 1. The Health System Strengthening for Better Maternal and Child Health Results Project (Projet du Développement du System du Santé (PDSS) is a US$521 million project financed from US$460 Million IDA, US$40 million Global Financing Facility (GFF) and US$21 million from multiple donors (Global Fund; United States Agency for International Development; UNICEF and others) that was approved on December 18, 2014 and became effective on May 30, 2016. The Project Development Objective is to improve utilization and quality of maternal and child health services in targeted areas within the Recipient's Territory, and to provide an immediate and effective response to an eligible crisis or emergency. 2. The health system in DRC was under major stress when PDSS was designed and approved. At the time (2014), the government spent US$1 per capita on health (among the lowest in the world), health service utilization and quality were poor, 70 percent of staff did not receive a salary, user fees at health facilities were high, and only about 30 percent of essential medicines were available at facilities. The health system was not equipped to handle stress or shocks. PDSS was designed to strengthen health sector financing, payment, regulation, decentralization, patient satisfaction and equity to establish a more resilient health system. 3. The project has four components.1 The project introduced a basic benefit package of cost-effective quality maternal, adolescent and child health services for 21.8 million Congolese. The project covers 169 districts in 11 of the 26 provinces, which is close to a third of the population. Its intervention uses performance-based financing (PBF), the largest of its kind globally, to strengthen service delivery and ensure quality and good governance. The contracting approach involves public and private health facilities, public health administration, central ministry of health departments and the provincial public purchasing bodies. Beyond PBF, the project is the main vehicle in DRC to increase policy dialogue and donor engagement around human resources for health, pharmaceuticals, governance, and health financing. The project has supported capacity 1(1) Improve Utilization and Quality of Health Services at Health Facilities through PBF; (2) Improve Governance, Purchasing and Coaching and Strengthen Health Administration Directorates and Services through PBF; (3) Strengthen Health Sector Performance – Financing and Health Policy Capacities; (4) Disease Surveillance System Strengthening and Response. The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) development and provided technical assistance for the development and implementation of key health sector policies. The project had its Mid Term Review (MTR) between July 1 an August 16, 2019. 4. To rapidly respond to the challenging implementation context in DRC, the project has secured three Additional Financings and activated the Contingent Emergency Response plan three times. Two of the Additional Financings were completed within the first 26 months of implementation to expand the project’s geographic scope and to strengthen family planning, nutrition and health workforce activities. Then, the country’s 9th and 10th Ebola Virus Disease (EVD) outbreaks hit, which urgently required funds for the response efforts. PDSS responded rapidly: to date, US$200 million has been committed for Ebola response activities through activation of the Contingent Emergency Response Component (CERC), triggering of the Pandemic Emergency Response facility, and securing the project’s third Additional Financing. Table 1 summarizes PDSS Additional Financings, and Table 2 summarizes PDSS CERC activations. Table 1: PDSS Additional Financing (AF) AF No. Approval Effective Total (US$) Credits/Grants/Trust Funds Objective Parent Nov-14 May-16 226.5M Cr-55720 130M Improve utilization and quality of Gr-D0210 90M maternal and child health services in TF-18375 6.5M targeted health zones AF1 Mar-17 Feb-18 163.5M Cr-59980 120M Expand geographic coverage and TF-A4579 40M emphasize family planning, nutrition and retirement of health workers key priority areas identified in the Global TF-A5096 3.5M Financing Facility (GFF) investment case which resulted in funding from GFF and USAID AF2 Mar-18 Aug-18 10M the Global Fund a partner of the GFF (5.47M cancelled) TF-A6945 4.53M was included to support the core objectives of the PDSS AF3 Feb-19 Aug-19 120M Gr-D4390 120M Reconstitute 80M allocated to CERC1 to components 1-3, add an additional 40M to CERC for EVD10 response Table 2: PDSS CERC Activations CERC Triggered Amount Credit/Grant/ Reallocation Objective No. Reallocated Trust Fund CERC1 Nov-18 80M Cr-59980 45 M Component 1  CERC Respond to 15M Component 2  CERC EVD9, and later 20 M Component 3  CERC to EVD10 CERC2 May-19 Cr-55720 25M Cagegory 1  CERC Respond to 50M Gr-D0210 25M Category 1  CERC EVD10 The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) CERC3 Aug-19 Respond to 30M TF-A4579 30M Category 1  CERC EVD10 5. A large amount of financing was transferred from components 1-3 to the CERC category for Ebola, and now the remaining funding for component 1 is insufficient. Component 1 finances health services through Performance Based Financing (PBF), and its financing is critical to ensure that people within the target provisions continue to receive basic health services. The first change in the restructuring is to therefore reallocate funds back into Component 1 of the project as well as adjust allocation to the CERC component for the GFF TF. 6. During the MTR, the team determined that the key performance indicators are moving in a positive direction towards the Project Development Objective (PDO) and that the project had surpassed four of six PDO indicators.2 However, the rating was downgraded during the MTR from Satisfactory to Moderately Satisfactory to reflect methodological issues identified in quarterly results reporting. Indeed, results are reported quarterly using data from the National Health Information System (NHIS). The team has noted large increases or decreases in the project indicators during the first quarter of the project, which is most likely due to the way in which the indicators are calculated, and not associated with project activities and impact. The exact calculations made to set the baselines are not recorded. The results indicators, including the baseline and setting of end line, therefore need to be re-calculated using the same NHIS data that is reported quarterly. The second change in the project restructuring is to revise the project’s results framework to ensure consistency between data sources used for target setting and quarterly monitoring. 7. Implementation progress is rated Moderately Unsatisfactory. PDSS is being implemented within a challenging context. Many of the targeted provinces are geographically remote: health centers often cannot be accessed by road, and in certain areas, can only be accessed by boat. This makes supervision of health facilities and hospitals costly and time consuming. The project did not initially finance PBF in Kinshasa. However, the government has now initiated PBF in the densely urban area using government funds. The domestic funds for PBF in Kinshasa will run out during the first quarter of 2020. The project has increased the use of management and quality tools in health facilities, frequency of supervision visits, community involvement in facility management and enforcement of financial sanctions. However, weak governance still exists at all levels. This is particularly evident in the Equateur province, where after repeated warnings, funds are not reaching intended beneficiaries, as a result the PDSS will cease funding the Equateur Province till the Government has mitigated all risks. The third change in the project restructuring is to stop financing PBF in Equateur and reallocate this financing to the remaining provinces, including Kinshasa as requested by the Government. Data for Kinshasa will be incorporated into monitoring against project targets. 8. The HNP portfolio in DRC has changed substantially since PDSS began implementation, so specific PDSS activities should be dropped so that the portfolio is streamlined, and PDSS can deliver on its PDO while effectively supporting the 10th Ebola Virus Disease response. Ebola response efforts have added additional demands and stress on PDSS and nutrition and 20.67 people per year received a new curative consultation (target 0.30), 72 percent of children were completely vaccinated (target 60 percent), and the average quality score for health facilities with PBF contracts was 62 percent (target 35 percent). A total of 5,587,652 people received nutrition and health services, which was slightly under the target of 5,653,687. While only 42 percent of pregnant women received at least 3 prenatal consultations (target 62 percent), the project baseline value in 2015 is greater than the quarter 4 value in 2018, suggesting a potential issue with the indicator calculation. The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) gender-based violence (GBV) activities did not start as planned after AF1 was approved because of the project’s focus on the Ebola outbreak. Over the life of PDSS, the HNP portfolio has grown to US$1.2 billion, and now includes specialized projects for nutrition, disease surveillance and GBV. The Human Development System Strengthening Project is ongoing. The World Bank in DRC has always worked with the Government and partners to design projects opportunistically, and according to country demand. However, with such a large portfolio, more attention is needed to ensure that PDSS complements and leverages the other projects. The fourth change in the restructuring is to reduce the technical scope of the project, by removing nutrition, GBV and disease surveillance activities, as these activities had not started under PDSS and are now covered by new projects within the HNP portfolio in DRC. The HNP portfolio now includes a Multisectoral Nutrition Project and a Regional Disease Surveillance Project. These changes will also be reflected in the project’s results framework. Table 3: Summary of World Bank Health Projects in DRC (excluding Advisory Services and Analytics) Project Human Development Multisectoral Nutrition Regional Disease DRC Gender Based System Strengthening and Health Project Surveillance Systems Violence Prevention Strengthening Phase IV and Response Project (REDISSE IV) Approval date 23 April 2014 27 May 2019 27 September 2019 30 August 2018 Effectiveness 20 January 2015 20 December 2019 30 August 2019 19 July 2019 date Closing date 31 January 2020 4 July 2024 31 July 2024 30 June 2023 Project US$ 56.08 M US$ 502 M (US$ 492 M US$ 280 M (US$ 150 M US$ 100 M amount IDA; US$ 10 M) for DRC) Project Strengthen selected Increase utilization of Strengthen national and Increase in targeted Development management systems quality nutrition-specific regional cross-sectoral Health Zones: (i) the Objective for education in and nutrition-sensitive capacity for participation in Gender- targeted geographic interventions targeting collaborative disease Based Violence (GBV) areas in the recipient’s children 0-23 months of surveillance and prevention programs; territory age and pregnant and epidemic preparedness (ii) the utilization of lactating women in in ECCAS Region; in the multi-sectoral response project areas event of an eligible services for survivors of crisis or emergency, to GBV; and (iii) in the provide immediate & event of an Eligible effective response to Crisis or Emergency, to eligible provide immediate and crisis/emergency. effective response to said Eligible Crisis or Emergency. Geographic Nationwide reform Kwilu, Kassai, Kassai Nationwide North Kivu, South Kivu, scope agenda Central, Sud Kivu Maniema, Tanganyika 9. Financial Management is rated Moderately Unsatisfactory. Contingent exchange rate losses and their impact on the budget are not adequately addressed. The project accounts show long outstanding (+8 months) sundry debtors accounts The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) worth US$ 103,592 of undocumented advances that are not adequately archived. The Project Implementation Unit (PIU) also has deficiencies and recurrent delays in archiving supporting documentation. The Cellule Administrative et de Gestion Financière (CAGF) (the Administration and Financial Management Unit) was not performing and responding to the project needs as requested. Hence, the Financial Management Specialist was chiefly responsible for the fiduciary aspects of the project which made it challenging. However, in the past three months, the PDSS team has recruited additional financial, accounting and procurement specialists. The World Bank team also conducted an in-depth fiduciary training and it is expected that by the next supervision mission, the rating will be upgraded. 10. Procurement is also rated Moderately Unsatisfactory. The Cellule Administrative et de Gestion Financière (CAGF) and Cellule de Gestion des Projets et des Marches Publics (CGPMP) have surrendered their fiduciary responsibilities for IDA projects to contracted Technical Assistants. These units devote most of their time to monitoring other donor funded activities. The final objective of the restructuring is to change the project’s institutional arrangements to improve the procurement and financial management aspects of the project. The fifth change in the restructuring is to revise the project’s institutional arrangements to improve its fiduciary and procurement performance. II. DESCRIPTION OF PROPOSED CHANGES Change 1: Reallocate funds to Component 1 The Financing Agreements for CR-55720, Gr-D0210 and TF18375 define the proportion of funds for category 1 at 60%, 36% and 4% respectively. With the activation of CERC 2 in May 2019, the funds available for category 1 for CR-55720 and GR- D0210 are almost exhausted, while there is approximately US$2 million remaining for TF018375 that cannot be used due to this distribution. The restructuring therefore lifts the distribution level and allows the project to use 100% of the remaining funds available under Cr-55720, Gr-D0210 and TF18375. To secure additional funding for component 1 activities, a total of XDR 6 million in DTS will be reallocated from Category 3 to Category 1 of Cr-59980. Category Description Initial Allocation Proposed New Amount (XDR) Reallocation (XDR) 1 PBF GRANT PART 1 AND 2 11 500 000,00 6 000 000 17 500 000,00 2(A)(I) G/NCS/CS/OC/TR/WKSHOP PART 1, 2 5 000 000,00 5 000 000,00 2(A)(II) G/NCS/CS/OC/TR/WKSHOP PART 3 1 900 000,00 1 900 000,00 2(B) RETIREMENT BENEFITS PART 3(c)(i) 1 800 000,00 1 800 000,00 3 GD, N/CS,OC, TR, WKSHOP PT 4(a) 11 000 000,00 - 6 000 000 5 000 000,00 4 EMERGENCY EXPENDITURES PART 4(b) 57 200 000,00 57 200 000,00 TOTAL 88 400 000,00 88 400 000,00 In addition, USD 12 million will be reallocated from category 2 to category 1 of TF0A4579. Category Description Initial Allocation Proposed Reallocation New allocation (USD) (USD) The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) 1 G/NCS/CS/OC/TR/WKSHOP PT 1.2/3a/3b 10,000,000 12,000,000 22,000,000 2 EMERGENCY EXPENDITURES 30,000,000 -12,000,000 18,000,000 TOTAL 40 000 000,00 40,000,000 Change 2: Revise the project’s results framework Indicators in the results framework will be revised, added or dropped accordingly. The changes are also summarized in Annex 1. Indicators to revise:  Percentage of pregnant women who had 3 prenatal visits (PDO indicator): changing to 4 prenatal visits, which is more commonly reported (in alignment with the World Health Organization recommendation of 4 visits, which has since been increased to 8).  Percentage of children fully immunized (PDO indicator): indicator definition updated to reflect national definition for fully immunized children used in the NHIS.  New and existing acceptors of modern contraceptives (intermediate indicator): Reported as two separate indicators and as a percentage: 1) new acceptors of modern contraceptives, and 2) existing users of modern contraceptives.  First time adolescent girls accepting modern contraceptives (intermediate indicator): Definition revised. Was number of new and existing adolescent acceptors – now is just number of new adolescent acceptors. Also now reported as a percentage.  Single contract signed and implemented at province level (intermediary indicator): revised to singled contract signed at province level due to challenges defining and measuring its implementation.  Number of poor people benefiting from fee exemption mechanism (intermediary indicator): Changed to percentage to be consistent with other project indicators. Numerator is number of poor people benefiting from fee exemption mechanisms. Denominator is estimated number of poor people targeted by fee exemption mechanism (5 percent of the population in targeted health zones).  Percentage of EVD samples received that have been tested (Intermediary indicator): Add suspected EVD samples Indicators to Add  Number of health service delivered to target population through PDSS support (intermediate indicator): This indicator reports the number of services delivered at health facilities and hospitals with PDSS financing. While an individual may receive more than one service, and the services vary by type, this indicator is being added to illustrate the magnitude of services provided through the project. Verified services are reported through the PBF database.  Average availability of tracer medicines at hospitals/health centers (intermediate indicator): This indicator is added to assess availability of medicines, existing indicator to track medicines is not available. Numerator: sum of availability scores for essential medicines (percentage) for all health centers/hospitals contracted under PBF. Denominator: Number of health centers/hospitals contracted under PBF. Reported through the PBF database. The baseline value, estimated at 69 percent, is overestimated. The team expects a decrease over time in this indicator and then an increase. This indicator will become more reliable as the project matures due to better governance and more experience using the metric. The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555)  Average performance score of Provincial Health Directorates (DPS) under Single Contract (intermediate indicator): This indicator measures the performance of the DPS. Numerator is the sum of performance scores for all DPS under the single contract. Denominator is the number of DPS under performance contract.  Percentage of births attended by a skilled health professional (intermediate indicator): This is a key indicator to assess utilization of maternal health services. Numerator is the number of deliveries attended by a skilled health professional during the quarter. Denominator is the number of women who gave birth during the quarter. Indicators to Drop  Percentage of children under 24 months participating in growth monitoring and promotion activities at community level (intermediary indicator): Nutrition and growth monitoring activities at community level removed from project scope.  Exclusive breastfeeding for children under 6 months (intermediary indicator): data not available, indicator not relevant to project scope.  Average quality of nutritional services (intermediary indicator): Nutrition activities removed from project scope.  Average number of days with stock out of tracer drugs in targeted health facilities on the day of the visit (intermediary indicator): data not available, new indicator to track medicines availability added in its place. Considerations for Kinshasa and Equateur  Kinshasa has higher utilization that the other provinces given its substantially more urban nature. Tracking data from Kinshasa will therefore increase utilization. Since support in the province started later than the other provinces, the utilization indicators for Kinshasa will be tracked separately than the other provinces within internal project documents. Data for Kinshasa will be combined with overall project tracking in Q4 2018, prior to PBF starting in Kinshasa in April 2019. Baselines for Kinshasa that are reported as percentages are set using Q4 2018 and Q1 2019 data. Baselines for indicators reported against annual numeric targets are set using annual data from 2018.  Starting in Q1 2020, support for Equateur will stop and Equateur data will be removed from overall project tracking at this point. Unlike Kinshasa, where utilization is substantially higher than the other provinces, utilization in Equateur is comparable to the average in the other provinces. Removing Equateur will therefore not have a substantial impact on progress towards the PDOs.  Annex 1 presents all project indicators in Q4 2018 with data from Kinshasa added. This value was taken into consideration when revising project targets. Change 3: Discontinue PDSS activities and financing in Equateur and expand activities in Kinshasa After repeated warnings, governance in Equateur has not improved. Project funds could therefore be used more efficiently and effectively in other provinces. PBF financed through PDSS in Equateur will therefore be stopped, and the funds will be used to strengthen PBF in the remaining provinces. The government has invested nearly US$ 1 million to initiate PBF in Kinshasa, the most densely province of the country. PDSS will finance PBF in Kinshasa for the remaining duration of the project. All safeguard documents for the project will be developed for Kinshasa. Change 4: Reduce the technical scope of the project, as it relates to nutrition, GBV and disease surveillance The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) Nutrition and GBV activities under component 1 will be removed. Nutrition and GBV activities were originally included in AF1 but have not yet started due to the project’s focus on the Ebola response. Disbursement for disease surveillance activities under component 4.1 will stop, and the remaining funds will be reallocated to Category 1. Due to the EVD 9 and 10 outbreaks, the project did not start financing any of these activities. Furthemore, removing these activities will avoid duplication of efforts between PDSS and the three new projects (Multisectoral Health and Nutrition Project; GBV Prevention and Response; REDISSE IV) and will help streamline PDSS work in the second half of implementation. Change 5: Revise the project’s institutional arrangements The PIU will be moved from under the Département d’Etude et de Plannification (DEP) to the Secretary General level to ensure better oversight of the many implementing actors and to achieve greater accountability of those actors. The Secretary General is responsible for health system administration. The Secretary general is placed under the Minister of Health but reports to the Minister of Public Service. As head of health system administration, the Secretary General ensures that health policy documents, national directives and health standards are applied in the sector according to the country's policies. The Secretary General monitors all projects anchored in the General Secretariat and ensures the smooth running of all the reforms affecting health system administration on behalf of the Minister of Health. The Secretary General chairs the Technical Coordination Committee of the National Steering Committee, which is responsible for validating sectoral documents that are submitted by commissions, departments or specialized programs. In addition to shifting the PIU from the Dep to the Secretary General, fiduciary responsibilities for project implementation aspects will be removed from CAGF and CGPMP and integrated into the PIU’s mandate. These revised institutional arrangements will stand until the Directorate of Administration and Finance (DAF) is fully functional. The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) Annex 1: Summary of Revisions to Project Baseline and End line data Indicator PAD Targets Revised Targets Baseline End line Baseline Q4 2018 value End line 2014 2021 2015 with Kinshasa 2021 Added PDO Indicators Pregnant women having at least 4 antenatal care 57% 65% 36% 44% 55% visits before delivery (%) People who have received essential health, 0 7,1500,000 5,208,170 7,819,376 nutrition, and population (HNP) services (# - annual) Female (# - annual) 0 5,812,950 Removed Children Immunized (# - annual) 0 1,250,000 434,750 752,583 1,063,706 Women/Children receiving Basic Nutrition 0 4,200,000 4,352,206 5,505,670 Services (# - annual) (First growth monitoring visit) Deliveries by skilled personnel (# - annual) 0 1,700,000 421,214 9,830,076 1,250,000 Average score of the quality checklist at the health 20% 60% 21% 60% 60% centers (%) Children Fully Immunized (%) 54% 65% 62% 71% 70% New curative consultations per capita per year .25 .50 0.38 0.41 0.50 Eligible individuals vaccinated during EVD (# - 0 120,000 No change cumulative) Intermediate Indicators Component 1: Improve Utilization and Quality of Health Services at Health Facilities through PBF Health service delivered to target population New indicator 0 18,099,673 20,000,000 through PDSS support (# – annual) New acceptors of modern contraceptives (%) New indicator 5% 9% 15% Existing users of modern contraceptives (%) New indicator 2% 5% 15% Contraceptive prevalence (new and existing) (%) New indicator 6% 13% 15% First time adolescent girls acceptant of modern New Indicator 0% 1% 3% contraceptives (%) Pregnant women counseled and tested for HIV (%) 17.5% 40% 15% 10% 25% Births assisted by skilled personnel (%) New Indicator 52% 87% 85% Component 2: Improve Governance, Purchasing and Coaching and Strengthen Health Administration Directorates and Services through PBF Average availability of tracer medicines at New Indicator 69% 64% 70% hospitals/health centers (%) Health personnel receiving training (# - cumulative) 0 10,000 No change Single contract signed at province level (# – annual) 2 11 2 9 11 Average performance score of Provincial Health New indicator 72% 75% 77% Directorates (DPS) under Single Contract (%) Component 3: Strengthen Health Sector Performance – Financing and Health Policy Capacities Civil servants eligible for retirement in the Ministry 0 4000 No change of Health that have received their retirement indemnities/packages and retired from active service (# - cumulative) The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) Poor people benefiting from fee exemption New Indicator 0% 17% 20% mechanisms (%) (used to be #) Component 4: Disease Surveillance System Strengthening and Response EVD contacts lost to follow up (%) 0 0 No change Suspected EVD samples received that have been 0 100 No change tested (%) Suspected and confirmed EVD cases for whom safe 0 100 No change and dignified burials have been carried out (%) III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Reallocation between Disbursement Categories ✔ Institutional Arrangements ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) Improve Utilization and Quality Improve Utilization and Quality of Health Services at Health 182.00 Revised of Health Services at Health 200.00 Facilities through PBF Facilities through PBF Improve Governance, Purchasing Improve Governance, and Coaching and Strengthen Purchasing and Coaching and Health Administration 92.70 Strengthen Health 92.70 Directorates and Services Administration Directorates through PBF and Services through PBF Strengthen Health Sector Strengthen Health Sector Performance – Financing and 110.30 Performance – Financing and 110.30 Health Policy Capacities Health Policy Capacities Disease Surveillance System Disease Surveillance System 135.00 Revised 117.00 Strengthening and Response Strengthening and Response TOTAL 520.00 520.00 OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-59980-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: PBF GRANT PART 1 AND 2 11,500,000.00 8,840,401.89 17,500,000.00 100.00 100.00 iLap Category Sequence No: 2(A)(I) Current Expenditure Category: G/NCS/CS/OC/TR/WKSHOP PART 1, 2 The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) 5,000,000.00 2,364,516.88 5,000,000.00 100.00 100.00 iLap Category Sequence No: 2(A)(II) Current Expenditure Category: G/NCS/CS/OC/TR/WKSHOP PART 3 1,900,000.00 1,610,969.05 1,900,000.00 100.00 100.00 iLap Category Sequence No: 2(B) Current Expenditure Category: RETIREMENT BENEFITS PART 3(c)(i) 1,800,000.00 0.00 1,800,000.00 100.00 100.00 iLap Category Sequence No: 3 Current Expenditure Category: GD, N/CS,OC, TR, WKSHOP PT 4(a) 11,000,000.00 4,635,835.97 5,000,000.00 100.00 100.00 iLap Category Sequence No: 4 Current Expenditure Category: EMERGENCY EXPENDITURES PART 4(b) 57,200,000.00 55,789,682.78 57,200,000.00 100.00 100.00 Total 88,400,000.00 73,241,406.57 88,400,000.00 TF-A4579-001 | Currency: USD iLap Category Sequence No: 1 Current Expenditure Category: G/NCS/CS/OC/TR/WKSHOP PT 1.2/3a/3b 10,000,000.00 13,829,876.65 22,000,000.00 100.00 100.00 iLap Category Sequence No: 2 Current Expenditure Category: EMERGENCY EXPENDITURE 30,000,000.00 2,574,564.77 18,000,000.00 100.00 100.00 Total 40,000,000.00 16,404,441.42 40,000,000.00 . The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) . Results framework COUNTRY: Congo, Democratic Republic of Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) Project Development Objectives(s) To improve utilization and quality of maternal and child health services in targeted areas within the Recipient's Territory and, to provide an immediate and effective response to an eligible crisis or emergency Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline End Target Improve the utilization and quality of maternal and child health services in targeted areas. Women having at least 4 antenatal care visits before delivery (%) 36.00 55.00 (Percentage) Action: This indicator has been Revised People who have received essential health, nutrition, and 5,208,170.00 7,819,376.00 population (HNP) services (CRI, Number) Action: This indicator has been Revised People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) (CRI, 0.00 5,812,950.00 Number) Action: This indicator has been Marked for Deletion Number of children immunized (CRI, Number) 434,750.00 1,063,706.00 Action: This indicator has been Revised Number of women and children who have received basic 4,352,206.00 5,505,670.00 nutrition services (CRI, Number) The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline End Target Action: This indicator has been Revised Number of deliveries attended by skilled health personnel 421,214.00 1,250,000.00 (CRI, Number) Action: This indicator has been Revised Average score of the quality checklist at the health centers (%) 21.00 60.00 (Percentage) Action: This indicator has been Revised Children Fully Immunized (%) (Percentage) 62.00 70.00 Action: This indicator has been Revised New curative consultations per capita per year (Text) 0.38 0.50 Action: This indicator has been Revised Provide an immediate and effective response to an eligible crisis or emergency Eligible individuals vaccinated during EVD (# - cumulative) 0.00 120,000.00 (Number) Action: This indicator has been Revised PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target Improve Utilization and Quality of Health Services at Health Facilities through PBF New acceptors of modern contraceptives (%) (Percentage) 5.00 15.00 Action: This indicator has been Revised The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target First time adolescent girls acceptant of modern contraceptives 0.00 3.00 (%) (Percentage) Action: This indicator has been Revised Average quality of nutritional services (Percentage) 0.00 55.00 Action: This indicator has been Marked for Deletion Pregnant women counseled and tested for HIV (%) (Percentage) 15.00 25.00 Action: This indicator has been Revised Number of Direct Beneficiaries (Number) 0.00 25,000,000.00 Action: This indicator has been Marked for Deletion Number of women (Number) 0.00 15,000,000.00 Action: This indicator has been Marked for Deletion Percentage of families participating in parental education 0.00 50.00 sessions at community level (Percentage) Action: This indicator has been Marked for Deletion Exclusive breastfeeding for children under 6 months (Percentage) 0.00 66.00 Action: This indicator has been Marked for Deletion Percentage of children under 24 months participating in the Growth Monitoring and Promotion activities at community level 26.90 45.00 (Percentage) Action: This indicator has been Marked for Deletion Existing users of modern contraceptives (%) (Percentage) 2.00 15.00 Action: This indicator is New The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target Contraceptive prevalence (new and existing female users %) 6.00 15.00 (Percentage) Action: This indicator is New Births attended by skilled professional (%) (Percentage) 52.00 85.00 Action: This indicator is New Health service delivered to target population through PDSS 0.00 20,000,000.00 support (# – annual) (Number) Action: This indicator is New Improve Governance, Purchasing and Coaching and Strengthen Health Administration Directorates and Services through PBF Average number of days with stock out of tracer drugs in >30 days >15 days targeted health facilities on the day of the visit (Text) Action: This indicator has been Marked for Deletion Health personnel receiving training (# - cumulative) (Number) 0.00 10,000.00 Action: This indicator has been Revised Health facilities receiving Client Tracer and Satisfaction Survey 0.00 70.00 feedback (Percentage) Action: This indicator has been Marked for Deletion Average availability of tracer medicines at hospitals/health 69.00 70.00 centers (%) (Percentage) Action: This indicator is New Single contract signed at province level (# – annual) (Number) 2.00 11.00 Action: This indicator is New Average performance score of Provincial Health Directorates 72.00 77.00 under Single Contract (%) (Percentage) The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target Action: This indicator is New Strengthen Health Sector Performance – Financing and Health Policy Capacities Civil servants eligible for retirement in the Ministry of Health that have received their retirement indemnities/packages (# - 0.00 4,000.00 cumulative) (Number) Action: This indicator has been Revised Poor people benefiting from fee exemption mechanisms (%) 0.00 20.00 (Percentage) Action: This indicator has been Revised Disease Surveillance System Strengthening and Response Single contract signed and implemented at province level 2.00 11.00 (Number) Action: This indicator has been Marked for Deletion Contacts of suspected or confirmed EVD cases lost to follow up 0.00 0.00 (%) (Percentage) Action: This indicator has been Revised Suspected EVD samples received that have been tested (%) 0.00 100.00 (Percentage) Action: This indicator has been Revised Suspected and confirmed EVD cases for whom safe and dignified 0.00 100.00 burials have been carried out (%) (Percentage) Action: This indicator has been Revised IO Table SPACE The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) Note to Task Teams: End of system generated content, document is editable from here. 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