The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) REPORT NO.: RES34663 DOCUMENT OF THE WORLD BANK 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 REPUBLIC DEMOCRATIC OF CONGO HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Hafez M. H. Ghanem Country Director: Jean-Christophe Carret Senior Global Practice Director: Timothy Grant Evans Practice Manager/Manager: Trina S. Haque Task Team Leader: Hadia Nazem Samaha The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) I. 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 Ministry of Health,Democratic Republic of Republic Democratic of Congo Congo,Ministry Of Finances 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. Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-59980 31-Mar-2017 19-Apr-2017 13-Feb-2018 31-Dec-2021 120.00 60.00 63.14 IDA-55720 18-Dec-2014 20-Jan-2015 30-May-2016 31-Dec-2021 130.00 51.59 71.07 IDA-D0210 18-Dec-2014 20-Jan-2015 30-May-2016 31-Dec-2021 90.00 40.00 44.93 TF-A6945 24-Jan-2018 14-Mar-2018 14-Aug-2018 31-Aug-2018 10.00 5.08 4.92 TF-A5096 24-May-2017 24-May-2017 22-Nov-2017 30-Jun-2019 3.50 3.49 .01 TF-A4579 19-Apr-2017 19-Apr-2017 18-Aug-2017 31-Dec-2021 40.00 2.27 37.73 TF-18375 20-Jan-2015 20-Jan-2015 30-May-2016 31-Dec-2021 6.50 1.94 4.56 The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No II. SUMMARY OF PROJECT STATUS AND PROPOSED CHANGES The project was approved on December 18, 2014 and became effective on May 30, 2016 with a closing date of December 31, 2021. The project was designed to improve utilization and quality of maternal and child health services in targeted areas within the Recipient’s Territory. It is supported with two sources of funding: IDA and Trust Fund. The proposed restructuring is for Credit 59980-ZR. The project continues to perform in a satisfactory manner. Progress towards achievement of the Project Development Objective (PDO) and overall Implementation Progress (IP) have been rated Satisfactory in the last Implementation Status & Results Report (ISR). Preliminary results show an improvement in service utilization in health facilities where the performance-based financing has been implemented. There is an increase in utilization of health service given the negotiated lower fees and subsides provided. In addition, quality of care has also improved from an average score of 20 percent at the beginning of the project to 65 percent, a full 13 points increase compare to the target of 52 percent. Out of the 5 PDO indicators, two have surpassed and good progress has been made for the remaining as well. Furthermore, projects components have been positively progressing in the 11 provinces targeted by the project. The situation of the Emergency: On May 8, 2018, World Health Organization (WHO) was notified by the Ministry of Health of the Democratic Republic of Congo of two lab-confirmed cases of Ebola Virus Disease (EVD) occurring in Bikoro health zone, Equateur province. Cases have also been found in nearby Iboko and Mbandaka. As of May 22, 2018, 58 EVD cases have been reported of which 30 confirmed, 14 probable and 14 suspected cases. Twenty-seven deaths have also been recorded giving a case fatality rate of 46.5 percent (27/58). Most of these cases have been in the remote Bikoro health zone, though over the past week 10 confirmed case have been identified in Mbandaka, a city of 1.2 million, which has implications for its spread as this makes the situation to become more serious and worrisome since the disease is now affecting an urban area in proximity to the Congo river, which has significant regional traffic across porous borders. Nine neighboring countries, including Congo-Brazzaville and Central African Republic, have been advised that they are at high risk of spread and are being supported with equipment and personnel. As a result of the notification of the 9th Ebola Outbreak, the Government of DRC requested that the Contingency Emergency Response Component (CERC) be triggered. As such on May 25th 2018, the World Bank approved the triggering of the CERC resulting in reallocating $80 million from Categories 1 and 2 to category 4 (CERC). While the 9th Ebola Outbreak was contained and declared over on July 24th, 2018, unfortunately on August 1st, the Government declared a 10th Ebola Virus Disease (EVD) outbreak in the health zone (ZS) of Mabalako, North-Kivu province, a strategic response plan was rapidly developed and implemented by the Ministry of Health, in collaboration with all technical and financial partners. The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) As of November 15, 2018, 344 cases have been reported (including 202 deaths) in ten Health zones: Malalako, Beni, Oicha , Masereka, Butembo / Katwa, Kalunguta, Mandima, Tchomia, Komanda and Musienene. The risk of transmission at the national level is very high because the affected provinces are connected to the rest of the country by air, river and road. The risk of transmission at the regional level is also high. Indeed, the epidemic affects border areas with Uganda and neighboring Rwanda, where there is a high cross-border migration flow for reasons of trade, access to health care, family and humanitarian visits. The overall security situation gradually deteriorated during the epidemic period with clashes between rebels and Congolese armed forces, street demonstrations by residents and the observation of so-called “dead cities”. The security dimension, however, has not been comprehensively approached, thus impeding the implementation of response activities such as contact tracing, alert investigations, and secure burials. The pockets of community resistance often associated with urban delinquency continue to be reported, particularly in the Beni and Butembo SZs. Attacks on the staff responsible for the response have been noted several times. A regular evaluation of the causes of these incidents is necessary in order to be able to provide targeted and specific control measures and improve relations with the communities. Important public health challenges are noted in the affected areas, characterized in particular by a low percentage of regular contacts, lost contacts, unsolved transmission chains, late arrival of patients to ETCs, low notification of community alerts and deaths. These challenges are due to multiple causes, including those mentioned above. It should be noted, however, the low commitment of traditional healers who are passing many confirmed cases of EVD. The Ebola outbreak in the DRC has several characteristics that areof particular concern: the risk of more rapid spread given that Ebola has now spread to an urban area; that there are several outbreaks in remote and hard to reach areas; that health care staff have been infected, which may be a risk for further amplification. There are huge logistical challenges given the poor infrastructure and remote location of most cases currently reported; these factors affect surveillance, case detection and confirmation, contact tracing, and access to vaccines and therapeutics. The proposed restructuring is to reallocate fund from Component 1 (Cat. 1) and Components 2 and 3 (Cat. 2) to the Contingent Emergency Response Component (CERC, Component 4/category 4) in the amount of SDR 57.2 million (US$80 million equivalent) to finance activities in the areas of: (a) coordinating the response; (b) enhanced surveillance of the epidemic; (c) laboratory confirmation of the infection; (d) case management and follow-up of contacts; (e) control and prevention of infection, (f) funerals organized in safety and dignity; (g) immunization; (h) social mobilization and community involvement, (i) logistics (j) risk communication, (k) immunization, (l) commitment of technical and financial partners; (m) research; and (n) resource mobilization. There is no outstanding audit report and the scope of activities proposed under the CERC would be fully in line with the project design. III. DETAILED CHANGES The World Bank Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Current Current Actuals + Proposed Disbursement % Ln/Cr/TF Expenditure Allocation Committed Allocation (Type Total) Category Current Proposed IDA-59980- PBF GRANT 43,500,000.00 11,489,328.53 11,500,000.00 100.00 100.00 001 PART 1 AND 2 Currency: G/NCS/CS/OC/T XDR R/WKSHOP 21,000,000.00 0.00 5,000,000.00 100.00 100.00 PART 1, 2 G/NCS/CS/OC/T R/WKSHOP 1,900,000.00 1,192,685.23 1,900,000.00 100.00 100.00 PART 3 RETIREMENT BENEFITS PART 11,000,000.00 0.00 1,800,000.00 100.00 100 3(c)(i) GD, N/CS,OC, TR, WKSHOP PT 11,000,000.00 0.00 11,000,000.00 100.00 100 4(a) EMERGENCY EXPENDITURES 0.00 0.00 57,200,000.00 100.00 100.00 PART 4(b) Total 88,400,000.00 12,682,013.76 88,400,000.00