The World Bank Implementation Status & Results Report Health System Support Project ("KIRA") (P156012) Health System Support Project ("KIRA") (P156012) AFRICA | Burundi | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2017 | Seq No: 4 | ARCHIVED on 17-Dec-2018 | ISR34876 | Implementing Agencies: Ministry of Health, MINISTRY OF FINANCE Key Dates Key Project Dates Bank Approval Date: 24-Feb-2017 Effectiveness Date: 20-Jun-2017 Planned Mid Term Review Date: -- Actual Mid-Term Review Date: -- Original Closing Date: 30-Jun-2021 Revised Closing Date: 30-Jun-2021 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) To increase the use of quality Reproductive, Maternal, Neonatal, Child and Adolescent Health services, and, in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency. Has the Project Development Objective been changed since Board Approval of the Project Objective? No Components Table Name Use of Performance-based Payments to Support the Recipient's Free Health Care (FHC) Program:(Cost $40.60 M) Implementation Support for the FHC program-related activities:(Cost $8.40 M) Strengthening of Newly Integrated FHC Program Service Providers through financing of minor investments/renovations works for CHWs and nursing training schools:(Cost $1.00 M) Contingency Emergency Response Component (CERC) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Satisfactory Satisfactory Overall Risk Rating Substantial Substantial Implementation Status and Key Decisions The implementation of the project has reached cruising speed on all its components. Indeed, health facilities are paid regularly for their performance and the KIRA project has helped pay the bill of FOSA for an amount of 17 542 577 407 Burundi Francs ( 9,820,897.08$US) from July 2017 to June 2018. As for the payment of the performance of community health worker groups (through the community PBF), the following activities were carried out: (i) Development of the procedures manual Community PBF and its tools (January-February 2018); (ii) Translation into Kirundi and pre-test of the 12/17/2018 Page 1 of 7 The World Bank Implementation Status & Results Report Health System Support Project ("KIRA") (P156012) Community PBF Manual and its tools (April-July 2018); (iii) Training of trainers on the community PBF in the provinces of Makamba, Mwaro, Kayanza, Muyinga, Kirundo, Gitega (September-October 2018); (iv) Training of community health workers (CHWs) and health promotion technicians (or nurses supervising CHWs) on the Community PBF and its tools (October-November 2018); (v) Supervision of the development of GASC Action Plans and the contract negotiation process; (vi) Effective start of the community PBF on 01/12/2018 in the provinces of Makamba, Mwaro, Kayanza, Muyinga, Kirundo, Gitega: the first verification will take place in January 2019 and the first payments are expected in February 2019. With regard to the PBF in nurses schools the preparation process is over and the first round of quarterly assessment has started for the first quarter of 2018 and the payment of 8 paramedical schools started with the first quarter of 2018: these schools were paid for the services of the 1st and 2nd quarter of 2018 for an amount of 298,291,660 Fbu. The contracting of the central level delivery units has not yet started and is waiting for the recruitment of an entity to evaluate their performance, except the Reproductive health program which is contracted by CORDAID using funds from KFW. While verification activities for quantity continue to be undertaken by the usual CPVV team, it was decided to recruit additional contractors who will be dedicated to quality assessment to avoid complacency. The recruitment process of the latter has completed and quality evaluations are conducted successfully . It appeared that the rigorous way this evaluation was done resulted in a significant decrease of quality score (from 76% to 67% in average) of all assessed health centers along with the loss of related bonuses. This was perceived as a wakeup call and managers of affected health centers undertook corrective measures that resulted in a significant improvement of quality score.. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance High High High Macroeconomic Substantial Substantial Substantial Sector Strategies and Policies Moderate Substantial Substantial Technical Design of Project or Program Substantial Substantial Substantial Institutional Capacity for Implementation and Sustainability Substantial Substantial Substantial Fiduciary Substantial Substantial Substantial Environment and Social Moderate Moderate Moderate Stakeholders Moderate Moderate Moderate Other High High High Overall Substantial Substantial Substantial Results PDO Indicators by Objectives / Outcomes Increase the use of quality Reproductive, Maternal, Neonatal, Child and Adolescent Health services IN00651406 ►People who have received essential health, nutrition, and population (HNP) services (Number, Corporate) Baseline Actual (Previous) Actual (Current) End Target 12/17/2018 Page 2 of 7 The World Bank Implementation Status & Results Report Health System Support Project ("KIRA") (P156012) Value 0.00 -- 8,240,485.00 18,000,000.00 Date 30-Jun-2016 -- 30-Nov-2018 30-Jun-2021 This indicator is a CRI indicator and replaces the original indicator (from PAD) which had the same label Comments: but for which definitions were not aligned with CRI guidelines. IN00651407 Number of children immunized (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 2,818,010.00 8,000,000.00 Date 01-Feb-2017 -- 06-Dec-2018 30-Jun-2021 IN00651408 Number of women and children who have received basic nutrition services (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 4,710,925.00 8,800,000.00 Date 01-Feb-2017 -- 06-Dec-2018 30-Jun-2021 IN00651409 Number of deliveries attended by skilled health personnel (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 711,550.00 1,200,000.00 Date 01-Feb-2017 -- 06-Dec-2018 30-Jun-2021 IN00601666 ►Percentage of pregnant women who received four antenatal care visits within the first 28 gestational weeks (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 32.35 -- 40.50 51.00 Date 01-Jan-2016 -- 31-Oct-2018 30-Jun-2021 IN00601668 ►National quality average score of district hospital (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 80.00 -- 80.10 85.00 Date 01-Jan-2016 -- 30-Sep-2018 30-Jun-2021 IN00601669 ►Contraceptive prevalence rate for modern methods (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 38.00 -- 35.30 45.00 Date 01-Jan-2016 -- 29-Dec-2017 30-Jun-2021 IN00601670 ►Contraceptive prevalence rate among adolescents (Percentage, Custom) 12/17/2018 Page 3 of 7 The World Bank Implementation Status & Results Report Health System Support Project ("KIRA") (P156012) Baseline Actual (Previous) Actual (Current) End Target Value 1.50 -- 2.50 12.00 Date 01-Jan-2016 -- 29-Dec-2017 30-Jun-2021 Overall Comments PDO  The results framework was modified to apply the last guidance on CRI. The indicator on “People who have received essential Health, Nutrition, and Population (HNP) services” which was in the original results framework was deleted and replaced by the newest CRI indicator with disaggregated targets for Immunization, nutrition services and assisted deliveries. All baselines were set to zero as per the guidelines and targets set for the end of the project, as cumulative numbers from year 2. For the purpose of the ISR, 2 years were cumulated for the actual value to reflect 2017 and 2018 achievements.  Concern in the progress of PDO indicators include: o PDO indicator on contraceptive prevalence which has declined since baseline o PDO indicator of contraceptive rate for adolescents is off-track Intermediate Results Indicators by Components Use of Performance-based Payments to Support the Recipient's Free Health Care (FHC) Program IN00601667 ►Number visits to a health facility for Children under five years of age (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 2.20 -- 2.07 2.50 Date 01-Dec-2016 -- 30-Aug-2018 30-Jun-2021 IN00601671 ►Pregnant women receiving antenatal care during a visit to a health provider (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 165,504.00 -- 278,060.00 903,254.00 Date 01-Jan-2016 -- 29-Dec-2017 30-Jun-2021 IN00601672 ►Number of years-protection couples for modern methods (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 553,679.00 -- 1,680,188.60 3,066,611.00 Date 01-Jan-2016 -- 29-Dec-2017 30-Jun-2021 IN00601673 ►Coverage of births attended by qualified personnel (Percentage, Custom) 12/17/2018 Page 4 of 7 The World Bank Implementation Status & Results Report Health System Support Project ("KIRA") (P156012) Baseline Actual (Previous) Actual (Current) End Target Value 77.30 -- 83.26 85.00 Date 01-Jan-2016 -- 31-Oct-2018 30-Jun-2021 IN00601674 ►Number of pregnant women on ARV protocol for the prevention of mother-child transmission (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 3,885.00 -- 12,846.00 22,430.00 Date 01-Jan-2016 -- 31-Oct-2018 30-Jun-2021 IN00601675 ►Percentage of Health Centers with Heads at level A2 (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 62.00 -- 62.00 83.00 Date 31-Dec-2013 -- 31-Dec-2013 30-Jun-2021 This indicator is not relevant as it is not monitored anymore (by SARA survey) Comments: IN00601676 ►Satisfaction rate of beneficiaries on health care delivered by health centers (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 57.43 -- 21.30 75.00 Date 30-Dec-2016 -- 29-Nov-2018 30-Jun-2021 IN00601677 ►Percentage of public health facilities that offer FHC and use RBF (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 97.00 -- 98.00 99.00 Date 01-Jan-2016 -- 29-Nov-2018 30-Jun-2021 IN00601678 ►Number of new Family Planning acceptors referred by Community Health Workers and who arrived at the health center (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 38,678.00 499,137.00 Date 01-Jan-2016 -- 06-Dec-2018 30-Jun-2021 IN00601679 ►Number of pregnant women referred for early antenatal care ANC1 (TRIM1) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 42,220.00 210,745.00 Date 01-Jan-2016 -- 06-Dec-2018 30-Jun-2021 12/17/2018 Page 5 of 7 The World Bank Implementation Status & Results Report Health System Support Project ("KIRA") (P156012) IN00601680 ►Total number of children aged 6-59 months tested and referred by community health workers for malnutrition (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 141,796.00 1,352,334.00 Date 30-Dec-2016 29-Dec-2017 06-Dec-2018 30-Jun-2021 Overall Comments IR  The IRI on “Percentage of Health Centers with Heads at level A2” should be considered for deletion as this indicator is not measured in current facility surveys being conducted in Burundi (SARA). The latest figure dates back from 2013 and will likely not be updated during the project.  Concern in the progress of IRI include: o IRI on antenatal care visit is off-track and annual achievement in 2017 was below the achievement of the previous year o IRI on Satisfaction rate of beneficiaries on health care delivered by health centers has dropped by 37% points since baseline.  IRIs on community health workers (last 3 ones) are taking off slowly but this is related to the fact that community RBF had not started in the period under study.  Surveys/studies: o The study to evaluate costs of service delivery has been delayed by a year and has not started yet, despite TORs being ready. It is expected that it will start in early 2019 as an increase in fees in needed to ensure quality of services provided o The second SARA survey is planned for the second half of 2019 o The household survey is planned for the second half of 2019 Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P156012 IDA-D1660 Effective USD 50.00 50.00 0.00 16.90 34.93 33% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P156012 IDA-D1660 Effective 24-Feb-2017 23-Mar-2017 20-Jun-2017 30-Jun-2021 30-Jun-2021 Cumulative Disbursements 12/17/2018 Page 6 of 7 The World Bank Implementation Status & Results Report Health System Support Project ("KIRA") (P156012) Restructuring History There has been no restructuring to date. Related Project(s) P166576-Burundi Health System Support-Additional Financing 12/17/2018 Page 7 of 7