The World Bank Uganda Reproductive Health Voucher Project (P144102) REPORT NO.: RES29152 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF UGANDA REPRODUCTIVE HEALTH VOUCHER PROJECT APPROVED ON OCTOBER 3, 2014 TO REPUBLIC OF UGANDA HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Makhtar Diop Country Director: Diarietou Gaye Senior Global Practice Director: Timothy Grant Evans Practice Manager/Manager: Magnus Lindelow Task Team Leader: Peter Okwero, Bernard O. Olayo The World Bank Uganda Reproductive Health Voucher Project (P144102) ABBREVIATIONS AND ACRONYMS CBD Community Based Distributor EMTCT Elimination of Mother-to-Child Transmission GPOBA Global Partnership on Output-Based Aid ISR Implementation Status Report IVEA Independent Verification and Evaluation Agent MoH Ministry of Health MTR Mid Term Review PDO Project Development Objective Sida Swedish International Development Cooperation Agency UNFPA United Nations Population Fund UHSSP Uganda Health Systems Strengthening Project VMA Voucher Management Agent The World Bank Uganda Reproductive Health Voucher Project (P144102) Note to Task Teams: The following sections are system generated and can only be edited online in the Portal. BASIC DATA Product Information Project ID Financing Instrument P144102 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 03-Oct-2014 29-Dec-2017 Organizations Borrower Responsible Agency Ministry of Finance, Planning and Economic Development Republic of Uganda Project Development Objective (PDO) Original PDO The project development objective is to increase access to skilled care among poor women living in rural and disadvantaged areasduring pregnancy and delivery. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed TF-15995 18-Dec-2014 18-Dec-2014 02-Sep-2015 29-Dec-2017 13.30 3.40 9.90 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Uganda Reproductive Health Voucher Project (P144102) Note to Task Teams: End of system generated content, document is editable from here. I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING 1. The Uganda Reproductive Health Voucher Project is financed by a US$13.3 million grant from the Swedish International Development Cooperation Agency (Sida) through the Global Partnership on Output Based Aid (GPOBA). The project development objective (PDO) is to increase access to skilled care among poor women living in rural and disadvantaged areas during pregnancy and delivery. The project comprises two components: (a) package of safe delivery services to poor pregnant women; and (b) capacity building and project management. The project was designed to support 132,400 pregnant women to deliver under skilled attendance through a subsidized voucher scheme offering a package of safe delivery services consisting of: four antenatal visits, safe delivery, one postnatal visit, treatment and management of selected pregnancy-related medical conditions and complications (including caesarian sections), and emergency transport. 2. The project timeframe for implementation was reduced by about 18 months due to delays in approval and effectiveness. The delay in Bank approval of the project affected the selection process of the Voucher Management Agent (VMA) and the Independent Verification and Evaluation Agent (IVEA)1 and timely attainment of project effectiveness, which was met on September 2, 2015. The project upon effectiveness obtained co-financing of US$3 million from the Uganda Health Systems Strengthening Project (UHSSP) and US$954,436 from the United Nations Population Fund (UNFPA). 3. Overall project implementation is satisfactory. The Mid Term Review (MTR, April 2017) established the project was fully operational in 25 districts; had contracted a total of 248 service providers (110 public and 138 private); and was on track to achieve year 2 targets for all the PDO indicators. As of June 30, 2017, the project had assisted a cumulative total of 57,545 safe deliveries surpassing the year two target of 52,960 safe deliveries. The year two targets for the following indicators were also surpassed: antenatal care visits; postnatal care visits; testing for HIV; and timely reimbursement of claims. In addition, the MTR confirmed the project to be making significant contribution towards building capacity for safe delivery services, ensuring quality of care, and expanding coverage for safe delivery services. Each service provider is expected to maintain a minimum level of service standards. Critical services including (a) regular training of service providers in emergency obstetric care and neonatal care; (b) referral of mothers with complications, (c) maternal and perinatal death audits, and (d) post-partum family planning have been scaled up. Another key attribute of the project is empowerment of poor women, who are now able to choose providers of their choice. 4. The project by June 30, 2017 had received disbursements totaling US$7,354,436 (42.6 percent) from the total funding (US$17,254,436) available from the three sources, with the GPOBA grant disbursement of US$3.4 million representing 25.5 percent of the original grant amount. The low disbursement of the GPOBA/Sida grant is explained by the delay in approval and the frontloading of disbursements from UNFPA and UHSSP to ensure the project absorbs all available funding before their closing dates.2 With these two funding sources fully 1 These were the Effectiveness Conditions. 2 Closing date for UNFPA was December 31, 2016 and for UHSSP June 30, 2017 The World Bank Uganda Reproductive Health Voucher Project (P144102) disbursed, the grant disbursements are expected to increase substantially. The MTR also established that the average unit costs for the various services subsidized under the project were within the range agreed during project appraisal, and recommended maintaining the current package of services and contract rates for service delivery. 5. The VMA has a robust and an effective electronic claims processing system. The MTR noted a marked improvement in the timely processing of reimbursement of claims by service providers. The average turnaround for reimbursing service providers has reduced from 50 working days in October 2016 to 24 days as at March 31, 2017. Cases of fraudulent claims reported under the project have been limited, and where such incidences of fraud were noted, the VMA took appropriate remedial measures, including termination of the service providers from the voucher scheme. Overall, the IVEA reports confirm that: (a) the outputs as presented by the VMA reflect an accurate picture of the performance of the project; (b) the VMA has good internal controls systems in place for the management of the project; (c) the quarterly financial reports by VMA show a true and fair view of the financial results of the operations of the project; (d) most of the clients targeted were poor; and (e) there were no indications of fraud found during the review of the financial transactions or the voucher management process, indicating that the VMA was adequately identifying fraud cases at service provider level. 6. Because of the lag in the original implementation schedule arising from the initial project approval and effectiveness delays, the last Implementation Status Report (ISR) rated both Implementation Progress and Progress towards achievement of the PDO “Moderately Satisfactory”. With the project making satisfactory progress, the ratings will be upgraded to “Satisfactory” after restructuring. The restructuring is expected to compensate for the delay with project approval and effectiveness and factor the co-financing obtained into the project design by revising the results framework. In addition, the restructuring is expected to assist the VMA to implement core recommendations of the MTR, including (a) strengthening the referral system; (b) encouraging mothers to seek antenatal care early and to attend subsequent antenatal visits as well as postnatal care; (c) promote post-partum family planning; (d) conduct continuous quality assessment and provide mentoring to service providers; and (e) incentivize community-based distributors (CBDs) to follow-up with mothers and to carry out interpersonal communication beyond voucher sales. II. DESCRIPTION OF PROPOSED CHANGES 7. The following revisions are proposed to the project: i. Extension of the project closing date. The project closing date will be extended from December 29, 2017 to December 15, 2019. As already explained above, the extension will compensate for the time lost because of the delay with project approval and effectiveness. ii. Revision of the project Results Framework. The following revisions are proposed: a) Revise the project targets to accommodate the co-financing obtained from UHSSP and UNFPA under the project. The target for total deliveries assisted under the project will be increased from 132,400 to 156,400. The other proposed targets for the remaining indicators are presented in the revised Results Framework. The World Bank Uganda Reproductive Health Voucher Project (P144102) b) Revise the project indicators on account of the MTR recommendations. The proposed changes include: (a) dropping the PDO indicator - “direct project beneficiaries,” as this is no longer a World Bank core indicator; (b) replacing the indicator “number and percentage of deliveries assisted under the project” with a World Bank corporate indicator “number of deliveries attended by skilled health personnel”; and (c) adding the indicator on citizen engagement: percentage of voucher mothers satisfied with the services. Note to Task Teams: The following sections are system generated and can only be edited online in the Portal. I. SUMMARY OF CHANGES Changed Not Changed Change in Results Framework ✔ Change in Loan Closing Date(s) ✔ Change in Disbursement Estimates ✔ Change in Implementation Schedule ✔ Change in Implementing Agency ✔ Change in DDO Status ✔ Change in Project's Development Objectives ✔ Change in Components and Cost ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Change in Disbursements Arrangements ✔ Change in Systematic Operations Risk-Rating Tool ✔ (SORT) Change in Safeguard Policies Triggered ✔ Change of EA category ✔ Change in Legal Covenants ✔ Change in Institutional Arrangements ✔ Change in Financial Management ✔ Change in Procurement ✔ Other Change(s) ✔ Change in Economic and Financial Analysis ✔ The World Bank Uganda Reproductive Health Voucher Project (P144102) Change in Technical Analysis ✔ Change in Social Analysis ✔ Change in Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_RESULTS_TABLE RESULTS FRAMEWORK Project Development Objective Indicators PDO_IND_TABLE Number of deliveries attended by skilled health personnel; Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 43042.00 156400.00 Revised Date 02-Dec-2013 31-Mar-2017 13-Dec-2019 Number and percentage of vouchers distributed and redeemed for deliveries under the project; Unit of Measure: Percentage Indicator Type: Custom Supplement Baseline Actual (Current) End Target Action Value 0.00 23.00 70.00 No Change Number and percentage of women attending at least one ANC visits under the project. Unit of Measure: Percentage Indicator Type: Custom Supplement Baseline Actual (Current) End Target Action Value 0.00 34.00 90.00 No Change Direct project beneficiaries Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action The World Bank Uganda Reproductive Health Voucher Project (P144102) Value 0.00 86084.00 264000.00 Marked for Deletion Date 01-Jan-2014 31-Mar-2017 29-Dec-2017 Female beneficiaries Unit of Measure: Percentage Indicator Type: Custom Supplement Baseline Actual (Current) End Target Action Value 0.00 100.00 100.00 Marked for Deletion Intermediate Indicators IO_IND_TABLE Number and percentage of vouchers distributed and redeemed for postnatal care. Unit of Measure: Percentage Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 7.40 35.00 Revised Date 01-Oct-2013 31-Mar-2017 13-Dec-2019 Percentage of pregnant women tested for HIV; Unit of Measure: Percentage Indicator Type: Custom Supplement Baseline Actual (Current) End Target Action Value 0.00 49.00 90.00 Revised Number and percent of mothers referred; Unit of Measure: Percentage Indicator Type: Custom Supplement Baseline Actual (Current) End Target Action Value 0.00 2.10 14.00 Revised The World Bank Uganda Reproductive Health Voucher Project (P144102) Number of fresh still births Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 121.00 330.00 Revised Date 30-Dec-2012 31-Mar-2017 13-Dec-2019 Number of pregnant women with HIV who receive EMTCT Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 1521.00 7100.00 Revised Date 01-Jan-2014 31-Mar-2017 13-Dec-2019 Percentage of claims reimbursed timely Unit of Measure: Percentage Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 60.00 80.00 Revised Date 01-Jan-2014 31-Mar-2017 13-Dec-2019 Timely verification reports provided Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 4.00 8.00 Revised Date 01-Jan-2014 31-Mar-2017 13-Dec-2019 Percentage of voucher mothers satisfied with the services Unit of Measure: Percentage Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 70.00 90.00 New Date 31-Mar-2016 30-Mar-2017 13-Dec-2019 The World Bank Uganda Reproductive Health Voucher Project (P144102) OPS_DETAILEDCHANGES_LOANCLOSING_TABLE LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications TF-15995 Effective 29-Dec-2017 15-Dec-2019 15-Apr-2020 OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 2015 0.00 0.00 2016 0.00 0.50 2017 0.00 2.90 2018 0.00 4.90 2019 0.00 5.00 Note to Task Teams: End of system generated content, document is editable from here.