The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) AFRICA | Africa | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2016 | Seq No: 6 | ARCHIVED on 10-Oct-2019 | ISR38255 | Implementing Agencies: Republic of Mozambique, Ministry of Health, Ministry of Health, Kingdom of Lesotho, Ministry of Health, Republic of Zambia, Ministry of Health, Republic of Malawi, Ministry of Finance, Ministry of Finance Key Dates Key Project Dates Bank Approval Date: 26-May-2016 Effectiveness Date: 05-Dec-2016 Planned Mid Term Review Date: 22-Apr-2019 Actual Mid-Term Review Date: 22-Apr-2019 Original Closing Date: 31-Dec-2021 Revised Closing Date: 31-Dec-2021 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) A. Proposed Development Objective(s) The overall objectives of the project are to: (i) improve coverage and quality of TB controland occupational lung disease services in targeted geographic areas of the participating countries; and (ii) strengthen regionalcapacity to manage the burden of TB and occupational diseases. Has the Project Development Objective been changed since Board Approval of the Project Objective? Yes Board Approved Revised Project Development Objective (If project is formally restructured) A. Proposed Development Objective(s) The overall objectives of the project are to: (i) improve coverage and quality of TB control and occupational lung disease services in targeted geographic areas of the participating countries; and (ii) strengthen regional capacity to manage the burden of TB and occupational diseases. Components Table Name Innovative Prevention, Detection and Treatment of TB:(Cost $45.49 M) Regional Capacity for Disease Surveillance, and Diagnostics and Management of TB and Occupational Lung Diseases:(Cost $43.19 M) Regional Learning and Innovation, and Project Management:(Cost $33.32 M) Overall Ratings Name Previous Rating Current Rating 10/10/2019 Page 1 of 10 The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) Progress towards achievement of PDO ►Moderately Satisfactory ►Satisfactory Overall Implementation Progress (IP) ►Moderately Satisfactory ►Satisfactory Overall Risk Rating ►Substantial ►Substantial Implementation Status and Key Decisions The Southern Africa TB and Health Systems Support Project (SATBHSSP) is making progress towards achieving its Project Development Objective (PDO) in all participating countries (Lesotho, Malawi, Mozambique, and Zambia) and regional organizations--the East, Central and Southern Africa Health Community (ECSA-HC) and the New Partnership for Africa’s Development (NEPAD). Specifically, 4 of 5 Project Development Objective (PDO) indicators are on track to achieve their end of project targets. Over the last 2.5 years, the project has supported key innovations in TB care and control and proven to be a valuable resource for countries in responding to public health threats. The Mid-Term review conducted in April through May, 2019 provided an opportunity to comprehensively review the project’s monitoring and evaluation framework against national, regional and global TB epidemiological contexts and new innovations for TB care and control. Based on this review, it was agreed that the project's Results Framework would be modified. In recognition of the synergies between the project's objectives and regional needs in strengthening core public health functions, the project's PDO will also be revised to include epidemic preparedness and response. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance ►Moderate ►Moderate ►Moderate Macroeconomic ►Moderate ►Moderate ►Moderate Sector Strategies and Policies ►Moderate ►Moderate ►Moderate Technical Design of Project or Program ►Substantial ►Moderate ►Moderate Institutional Capacity for Implementation and Sustainability ►Substantial ►Substantial ►Substantial Fiduciary ►Substantial ►Substantial ►Substantial Environment and Social ►Moderate ►Moderate ►Moderate Stakeholders ►Substantial ►Substantial ►Substantial Other ►Moderate ►Moderate ►Moderate Overall ►Substantial ►Substantial ►Substantial Results PDO Indicators by Objectives / Outcomes Improve coverage and quality of TB control and occupational lung disease services in targeted areas IN00734996 10/10/2019 Page 2 of 10 The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ►TB case notification in target geographic areas (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 85,391.00 73,808.00 92,967.00 100,758.00 Date 31-Dec-2014 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is on track to be achieved. In aggregate, the achievement level for 2018 full year was 92,967 against annual target of 95,109 (representing 97.7 percent of annual target and 92 percent of end line target). Malawi achieved 60 percent of their annual target, while Zambia achieved 80 percent, Lesotho achieved 81 percent and Mozambique over achieved by scoring 126 percent. All countries have noted the declining incidence of TB at the Comments: national level as a contributing factor for TB notification trends. IN00734998 ►TB Treatment success rate in target geographic areas (percent) – new and relapse TB cases (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 83.00 85.50 86.00 90.00 Date 31-Dec-2014 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator--at the regional level--is on track. The 2021 target for this indicator is 90 percent versus baseline of 83 percent. So far, the average treatment success rate across the four countries is 86 percent compared with the annual target of 88 percent. The highest performance is in Mozambique and Zambia with 90 percent each (surpassing national annual target), while Lesotho has the lowest rate at 76 percent (falling below national annual target, although there has been Comments: improvement from the baseline of 71%). Malawi achieved their annual targets of 88 percent. Achieving the regional targets-- over the next 2.5 years--on this indicator will require significant improvements in treatment success rate in Lesotho as well as sustained momentum in all the other three countries. IN00734999 ►Number of TB cases identified through active TB case finding (screening) among TB vulnerable populations in targeted geographic areas (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 5,239.00 8,185.00 13,780.00 22,557.00 Date 31-Dec-2014 19-Dec-2018 24-Aug-2019 31-Dec-2021 Comments: This indicator is on track. Even though the total number of TB cases identified through active case finding (screening) for 2018 full year was 13,780 versus an annual target of 17,890, the level of achievement still represents 77 percent of the annual target and 61 percent of the end line targets. The low number of cases identified is attributable to declining incidence of TB in the sub region, coupled with the design of interventions to screen presumptive cases and increase yield on sputum and specimen collected. Given declining incidence, identifying new cases takes much more effort and will require adaptation of approach to better refine screening and case finding techniques. For some countries, they are now intensifying efforts in identifying the most high-risk groups, like 10/10/2019 Page 3 of 10 The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) prisoners, to increase TB detection rates. This issue was discussed during the Regional Advisory Committee meeting of the Project and the indicator was revised during the MTR to capture all cases identified among TB vulnerable population. IN00735000 ►Number of direct beneficiaries (all diseases within health facilities including TB) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 695,903.00 308,480.00 22,347,731.00 1,109,191.00 Date 31-Dec-2014 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is on track to be achieved. Malawi, Lesotho, Zambia surpassed their annual targets. Total number of beneficiaries for these three countries was 22,347,731 versus 889,456 target for 2018. The indicator for Mozambique indicates overperformance 22 million people (more than half of Mozambique population) accessed health services, which is Comments: unlikely. Countries needs to put up systems to filter beneficiaries that are likely counted multiple times. For the restructuring, it is proposed that indicator be downgraded to an IOI; the targets for all countries will be revised. IN00735001 ►percent of which, female direct beneficiaries (Percentage, Custom Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 37.00 50.75 51.00 35.00 Strengthen regional capacity to manage the burden of TB and occupational diseases IN00734997 ►Number of project supported laboratories compliant with regionally harmonized SOPs for surveillance of MDR-TB (number) – national and sub national levels (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 58.00 30.00 30.00 100.00 Date 31-Dec-2014 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is not on track. The annual target was 72; however, only 30 have been reported to have complied with the SoPs, which is less than 50 percent of the planned target. The actual number is also less than the baseline, which raises questions about the reliability of the data (there was no tool to measure compliance at baseline). The 30 labs have been in Comments: only Malawi (which surpassed its annual target of 26). Currently the regional tool has been developed which will facilitate harmonization of assessment and reporting on this indicator. Only Malawi had applied the tool by MTR. Overall Comments PDO PDO Indicators #1, 2, 3, and 4 are on track to be achieved. Even though some of the indicators fell slightly short of their annual targets, when compared with baseline and end line targets, current achievements are laudable and--if pace maintained--will be achieved or surpassed. The only challenge is with PDO indicator #5; however, with new harmonized tools developed and finalized, the other countries (besides Malawi) will be able to start reporting. The MTR reviewed the Results Framework in-depth and a number of changes to the indicators and targets were agreed upon. These changes will be implemented through a project restructuring, expected to begin in late September 2019. 10/10/2019 Page 4 of 10 The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) Intermediate Results Indicators by Components Innovative Prevention, Detection and Treatment of TB IN00735002 of MDR-TB patients in target geographic areas benefiting from psychological and nutritional support during the treatment period ►Proportion (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 82.75 83.00 57.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 The indicator has exceeded its end of project target. This indicator may need to be reevaluated to determine if the end line Comments: target is too low, given that two countries have already achieved 100 percent. IN00735005 ►Proportion of miners eligible for compensation due to occupational diseases actually receiving it (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.00 50.60 33.00 50.00 Date 25-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is on track in both Lesotho and Zambia where compensation for ex-miners have been scaled up. Mozambique has achieved half of its annual target (10 percent versus 20 percent). There is no data for Malawi where compensation Comments: activities have not been initiated. The Government of Malawi plans to begin these activities in Year 3. IN00735007 ►Proportion of TB patients satisfied with TB services as per patient exit surveys or “drop box” feedback in target geographic areas (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 84.60 88.00 0.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is also on track--for the three countries where data is available for the current year. Malawi (95.8%), Lesotho (86%), and Mozambique (85%) exceeded their annual targets. Zambia (60% for 2018 and 80% for 2019). However, there is Comments: no baseline or end line data for this indicator since baseline survey had not been conducted across the four countries at project preparation. The baseline and end targets will be reflected in the modified RF during restructuring. IN00735009 ►Percentage of HIV patients routinely screened for TB in targeted geographic areas in the four participating countries (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 89.00 81.00 79.00 95.00 Date 31-Dec-2015 19-Dec-2018 24-Aug-2019 31-Dec-2021 10/10/2019 Page 5 of 10 The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) This indicator is not on track, especially in Mozambique and in Lesotho. Across the four countries the percentage of HIV patients routinely screened for TB is 79 percent versus an end line target of 95 percent and a baseline of 94 percent ((based on completed baseline studies). The relatively low performance is concerning and will require reassessment during restructuring. The task team believes the low rate of TB/HIV screening is attributable to the fact that HIV programs in Comments: countries have been implementing a series of strategies that have reduced drastically the number of times patients go to the health facilities. Such strategies include the CAAG and the rapid flows which only require that patients come for a consultation with the doctors once or twice a year, unless they are unstable. IN00735011 ►Proportion of health facilities with TB smear microscopy (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 25.00 42.00 42.00 41.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator--when viewed as the average proportion of health facilities across the four countries--appears to be on track (42 percent, which is higher than end line target of 41 percent); however, it is only on track (surpassed) in Zambia (with 94 percent), which is an outlier. In all other countries the indicator is below the annual target; for example, excluding, Zambia, Comments: the mean is 24.6 percent, which is below the annual target of 33.25 (across the four countries). The figures in Zambia thus skew the measure of performance. IN00735013 ►Health facilities renovated and/or equipped (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 25.00 51.00 45.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is on track, though there were delays in initiating civil works in all three countries and the challenges Comments: experienced with procurements of equipment. Malawi recorded 24, which is for the purchase of equipment. IN00735015 ►Number of countries scaling up Electronic Health Systems for TB case management or laboratory management (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 3.00 4.00 2.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is achieved. All four countries have piloted eHealth systems. Comments: IN00735016 ►Number of miners and ex-miners successfully referred for TB and occupational health services between participating countries and within participating countries (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 113,904.00 135,001.00 0.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 10/10/2019 Page 6 of 10 The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) Since there was no end line data provided on this indicator it is difficult to ascertain whether on track or not. So far three countries have c 135,001 miners and ex-miners successfully referred for TB and occupational health services. A new end line target will be provided base Comments: Regional Capacity for Disease Surveillance, and Diagnostics and Management of TB and Occupational Lung Diseases IN00735003 ►Outbreaks for infectious diseases for which cross-border investigations undertaken (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 2.00 5.00 5.00 10.00 Date 31-Dec-2015 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is halfway towards the end line target. The performance is 5 out of end line target of 10. Given the project is nearly midway, this indicator could be considered on track. However, performance was strongest in Mozambique and Comments: Zambia who surpassed and achieved their annual targets respectively. IN00735006 ►Number of target labs rated 2 stars and above in SLIPTA assessment (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 9.00 9.00 13.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is on track, with more than half of the end line target already achieved. . Comments: IN00735008 ►Proportion of mines inspected at least twice a year for compliance with national mine health regulations (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 33.00 42.00 90.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is on track. Currently the proportion of mines inspected at least twice a year for compliance is 42 percent (against an annual target of 38 percent and an end line target of 90 percent). Performance in Malawi has been strong with Comments: 76 percent, reflecting the strong collaboration between the ministries of mines, health and labor. Performance in Mozambique is weakest (3 percent). IN00735010 ►Number of health personnel receiving training (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 1,845.00 2,604.00 2,539.00 Date 31-Dec-2015 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is on track and will be surpassed. Already 2,604 health personnel have been trained in the four countries, Comments: representing 89 percent of the end line target. 10/10/2019 Page 7 of 10 The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) IN00735012 ►Number of countries with harmonized clinical protocols for occupational health in compliance with international best practices (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 4.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This data was not reported by countries. Comments: IN00735014 ►Number of countries in which new legislation or amendment to existing mine health and safety legislation are drafted (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 3.00 3.00 2.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This indicator is achieved. Currently, three countries (with exception of Mozambique) have new legislation/amendment of Comments: existing mine health and safety legislation being drafted. Regional Learning and Innovation, and Project Management IN00735004 ►Regionaloperational research studies commissioned and findings, lessons learned disseminated effectively through national and regional platforms (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 3.00 5.00 Date 26-Jan-2016 19-Dec-2018 24-Aug-2019 31-Dec-2021 This target is an annual target and will have to be revised into a cumulative target in order to better capture all studies completed during this Project. The RF in the system should have had the cumulative target to start with and this will be duly rectified during restructuring. So far only three studies have been completed against a goal of 17 by year 3. The reasons Comments: for the low performance include delays in securing ethical clearances, and delays in hiring consultants. This issue was discussed during the MTR and mitigation measures have been proposed, as well as revised targets. Overall Comments IR 10 out of 15 (representing 66 percent) intermediate outcome indicators are either on track, achieved or surpassed. With baseline surveys completed, there is now adequate information to populate the indicators for which there was no baseline information and to also update end line targets. Data on Financial Performance 10/10/2019 Page 8 of 10 The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P155658 IDA-58220 Effective USD 15.00 15.00 0.00 12.46 2.34 84% P155658 IDA-58230 Effective USD 45.00 45.00 0.00 25.19 19.12 57% P155658 IDA-58630 Effective USD 22.50 22.50 0.00 12.72 9.29 58% P155658 IDA-58640 Effective USD 7.50 7.50 0.00 5.79 1.61 78% P155658 IDA-D1170 Effective USD 9.50 9.50 0.00 9.47 0.00 100% P155658 IDA-D1180 Effective USD 22.50 22.50 0.00 11.09 10.91 50% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P155658 IDA-58220 Effective 26-May-2016 26-Jul-2016 13-Dec-2016 31-Dec-2021 31-Dec-2021 P155658 IDA-58230 Effective 26-May-2016 15-Dec-2016 23-Mar-2017 31-Dec-2021 31-Dec-2021 P155658 IDA-58630 Effective 26-May-2016 05-Sep-2016 06-Dec-2016 31-Dec-2021 31-Dec-2021 P155658 IDA-58640 Effective 26-May-2016 05-Aug-2016 05-Dec-2016 31-Dec-2021 31-Dec-2021 P155658 IDA-D1170 Effective 26-May-2016 05-Aug-2016 05-Dec-2016 31-Dec-2021 31-Dec-2021 P155658 IDA-D1180 Effective 26-May-2016 05-Sep-2016 06-Dec-2016 31-Dec-2021 31-Dec-2021 Cumulative Disbursements 10/10/2019 Page 9 of 10 The World Bank Implementation Status & Results Report AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) Restructuring History There has been no restructuring to date. Related Project(s) P161791-Southern Africa Tuberculosis and Health Systems Support Project AF 10/10/2019 Page 10 of 10