The World Bank Health Services Improvement Project (P145335) REPORT NO.: RES29742 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SERVICES IMPROVEMENT PROJECT APPROVED ON MARCH 21, 2014 TO MINISTRY OF FINANCE (REPUBLIC OF ZAMBIA) HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Hafez M.H. Ghanem Country Director: Paul Noumba Um Senior Global Practice Director: Timothy Grant Evans Practice Manager/Manager: Magnus Lindelow Task Team Leader: Musonda Rosemary Sunkutu, John Bosco Makumba The World Bank Health Services Improvement Project (P145335) ABBREVIATIONS AND ACRONYMS ANC Antenatal Care AWP Annual Work Plan CERC Contingent Emergency Response CHMIS Community Health Management Information System. CPAP Continuous positive airway pressure CRI Corporate Result Indicator c-RBF Community-Results Based Financing DA Designated Accounts DHIS District Health Information Systems DHMT District Health Management Team DL Disbursement Letter DLI Disbursement Linked Indicator DLR Disbursement Linked Results DPH Directorate Public Health ENC Essential Newborn Care eZICS Electronic Zambia Inventory Control System eLMIS Electronic logistics Management information System FA Financing Agreement FM Financial Management FY Fiscal Year GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GMP Growth Monitoring and Promotion GNC General Nursing Council HMIS Health Management Information System HNP Health Nutrition and Population. HRITF Health Results Innovation Trust Fund IBRD International Bank for Reconstruction and Development IDA International Development Association IFMIS Integrated Financial Management Information Systems The World Bank Health Services Improvement Project (P145335) IFR Integrated Financial Reporting iHRIS Integrated human resource information system IP Implementation Progress IPF Investment Project Financing IPT intermittent Presumptive Treatment IRI intermediate Result indicator IRS Indoor Residual Spraying ISR Implementation Status Report IVA Independent Verification Agency JMT Joint Management Team LEEP Loop electrosurgical excision procedure MACEPA Malaria Control and Elimination Partnership in Africa MCDMCH Ministry of Community Development Mother and Child Health MIS Malaria Indicator Survey MNCH Maternal Newborn and Child Health MoH Ministry of Health MTR Mid Term Review MS Moderately Satisfactory MSL Medical Stores Limited MU Moderately Unsatisfactory NFNC National Food and Nutrition Commission NHC Neighborhood Health Committee NHSP National Health Strategic Plan NMEC National Malaria Elimination Centre PAD Project Appraisal Document NPF New Procurement Framework PDO Project Development Objective PEF Pandemic Emergency Financing Facility PHC Primary Health Care PIM Project Implementation Manual MPI US Presidential Malaria initiative The World Bank Health Services Improvement Project (P145335) RBF Results Based Financing RF Results Framework RMNCAH Reproductive Maternal Neonatal Child and Adolescent Health SNDP Seventh National Development Plan SDR Special Drawing Rights SMT Senior Management Team VIA Visual Inspection with Acetic Acid WBG World Bank Group ZNCR Zambia National Cancer Registry ZHSIP Zambia Health Services Improvement project ZNPHI Zambia National Public Health Institute BASIC DATA Product Information Project ID Financing Instrument P145335 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 21-Mar-2014 30-Jun-2019 Organizations Borrower Responsible Agency Ministry of Finance (Republic of Zambia) Ministry of Health The World Bank Health Services Improvement Project (P145335) Project Development Objective (PDO) Original PDO The project development objective is "to improve health delivery systems and utilization of maternal, newborn and child health and nutrition services in project areas." OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-53940 21-Mar-2014 11-Feb-2015 31-Mar-2015 30-Jun-2019 52.00 35.59 11.66 TF-16639 11-Feb-2015 11-Feb-2015 31-Mar-2015 30-Jun-2019 15.00 10.66 4.34 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Project Status 1. The Zambia Health Services Improvement Project (ZHSIP) was approved by the Board in March 2014 and became effective in March 2015 due to delays in Government of Zambia’s internal approval. In addition to the delayed effectiveness, project implementation faced various challenges, including: i. weak and complex coordination between the two implementing agencies; the Ministry of Health (MoH) and the Ministry of Community Development Mother and Child Health (MCDMCH) and among national, provincial and districts levels and other implementing agencies; ii. poor performance by the Senior Management Team (SMT), a new project oversight structure within MoH, (i.e., the SMT has not met to review project progress); iii. delayed recruitment of project staff as well as the Independent Verification Agency (IVA); iv. high staff turnover at all levels of system because of the ongoing and extensive restructuring of MoH; v. delayed flow of funds from the main account (Control 99 account) at Central Bank of Zambia to the MoH operational account; vi. delays in procurement of goods and services; vii. delays in achieving DLIs due to low awareness and understanding of the DLI approach by key implementers; and viii. unsuitability of the DLI-approach for some activities under the project, such as capacity building and innovative pilots for which input-based financing would have been more appropriate. 2. All these challenges led to slow project implementation and low disbursement rate in the first two years. The project was therefore downgraded to “Problem Status” in 2016. The World Bank Health Services Improvement Project (P145335) 3. However, after a slow start, the project gained momentum in Year 3 and has continued to make good progress in all components since then. Key findings from the mid-term review (MTR) in May 2018 included the followings: i. project design and PDO are still relevant; ii. four out of five PDO indicators either have been achieved or are on track to reach the end targets; iii. implementation progress is satisfactory; iv. progress on the nutrition-related PDO indicator (% children under-2 years who received growth monitoring and promotion (GMP)1 is lagging, and v. the disbursement rate at MTR was 45%, which is low for a project with more than three years of implementation. 4. The pace of disbursement has improved since MTR in May 2018; the disbursement rate has reached at 70% as of May 28, 2019. However, it is considered low after having completed four years of implementation. 5. Currently, there are no outstanding project audit reports. The audit for the fiscal year ended on December 31, 2017 undertaken by the Office of the Auditor General. The accompanying management letter were submitted to the World Bank before the deadline of June 30, 2018 and the audit was issued with an unqualified report. The audit report for Trust Fund No. TF17307 managed by both MOH and MCDMCH which had been outstanding since 2015 was submitted and cleared by the Bank by December 31, 2018. B. Rationale for Restructuring 6. As part of MTR, the Government of Zambia and the World Bank agreed on a set of actions to accelerate project implementation and disbursements. Both parties also agreed that additional financing will be considered if disbursement rate reaches at least 75% by June 30, 2019. To reflect the set of actions agreed at MTR, project restructuring is proposed to: i. extend the project closing date by one year (from June 30, 2019 to June 30, 2020); ii. update institutional arrangements and funds flow to accommodate (a) the reorganized MoH as the sole project implementing agency and (b) the reintegration of MNCH and nutrition activities into the MoH mandates; iii. revise the results framework by (a) aligning it with the district health management information system (DHIS-2), the National Health Strategic Plan (NHSP) 2017-2021 and the Seventh National Development Plan (SNDP) 2017- 2021; (b) adding the Corporate Results Indicators (CRIs); and (c) adding new intermediate indicators to monitor better the project focus on health systems strengthening; iv. revise Component 1 by: (a) dropping 6 DLRs which are no longer relevant and converting their allocations into input-based financing to better support project activities; (b) adding 6 DLRs for FY 2020; and (c) adding Sub- component 1.4 “Support for scaling up of selected high impact interventions in MNCH and nutrition for FY2020.” v. add a fourth component – the Contingent Emergency Response Component (CERC); vi. reallocate funds among components and categories; vii. revise overall disbursement estimates; viii. migrate from quarterly Statement of Expenditure (SOE) Reporting to six monthly IFR based reporting with disbursements to Designated Accounts based on approved expenditure forecast; 1Unfortunately, GMP was not done comprehensively with only weight being measured. The under-five card has been revised to add measurements for height for age and both weight for age and height for age will be measured for the remaining period of project implementation The World Bank Health Services Improvement Project (P145335) ix. migrate the project’s procurement to the new World Bank Procurement Regulations for IPF Borrowers and the relevant anticorruption guidelines2. II. DESCRIPTION OF PROPOSED CHANGES A. Provided below are the detailed proposed changes: 7. Change in Project Closing Date: The project closing date will be extended by one year from June 30, 2019 to June 30, 2020 to allow the government to complete project activities and achieve the DLIs. 8. Changes in Institutional Arrangements and Flow of Funds: The continued restructuring of the MoH has led to significant changes in the MoH organizational structure and staffing at all levels including financial and procurement systems. Various departments and positions have been created, merged or abolished at all levels. This has led to the following revisions to the project implementation arrangements: i. The Senior Management Team (SMT) of the MoH has been assigned to oversee project implementation. The SMT will meet monthly to review the implementation progress of ZHSIP and other WBG supported projects. ii. The programmatic management of maternal, neonatal, child health and nutrition has been migrated from MCDMCH to the Department of Public Health under MoH. iii. The project funds will be managed by the Accounting and Internal Audit Departments of MoH. 9. The detailed changes in the institutional arrangements and flow of funds will be updated in the Project Implementation Manual (PIM). 10. Changes in the Results Framework (RF). The proposed revisions to the project’s RF are as follows: i. revising the original five PDO indicators to align them with those in the DHIS-2-, National Health Strategic Plan 2017-2021 and the Seventh National Development Plan 2017-2021 (Table 1). ii. revising yearly and end target values for all PDO indicators and IRIs (Annex 1) iii. revising the intermediate result indicators (IRIs) by: a. changing the HNP CRIs from PDO indicators to IRIs in the ZHSIP RF (Table2); b. dropping 4 IRIs because they are no longer relevant (Table 3); c. introducing 11 IRIs to better monitor the project focus on health systems strengthening and increasing the coverage of services in targeted rural areas (Table 4). 2“Procurement in Investment Project Financing Goods, Works, Non-Consulting and Consulting Services” of July 2016 Revised November 2017 and August 2018, The World Bank Health Services Improvement Project (P145335) Table 1. Revised Original PDO Indicators Original PDO Indicators Revised PDO indicators Deliveries by skilled health providers (percentage) Deliveries by skilled health providers in the project areas Heath centers with essential medicines and Health facilities (health post, health centres and district commodities in stock (percentage) hospitals) with all tracer drugs, vaccines, and nutritional commodities in stock nationally Health centers offering integrated Management of Health centres (health post, health centres and district Childhood Illnesses (percentage) hospitals) offering integrated management of childhood Illnesses (IMCI) based on new standard guidelines in the project areas Under -2 children received monthly growth Under-2 children received monthly growth monitoring and monitoring and promotion (percentage) promotion3 (GMP) based on new standard guidelines in the project areas Children 0-11 months fully immunized Fully immunized children at 12 months of age in the project (percentage) areas Table 2. HNP CRIs to be changed from PDO indicators to IRIs in the ZHSIP Results Framework CRI Type 1. People who have received essential health, nutrition, and population (HNP) Composite services in project areas 2. People who have received essential health, nutrition, and population (HNP) Composite -Female services - Female (RMS requirement) 3. Number of children immunized in project areas Breakdown 4. Number of women and children who have received basic nutrition services in Breakdown project areas 5. Number of deliveries attended by skilled health personnel in project areas Breakdown Table 3. IRIs to be dropped Indicator Reason for dropping indicator 1. Trained health providers in MNCH and The indicator is beyond the control of the project. nutrition deployed to facilities in the project Achievement of the indicator is based on macroeconomic performance of the country. 2. Health facilities using electronic inventory Indicator no longer relevant. Dropped based on Government control and logistics management system in decision to implement and scale up the electronic Logistics the project areas. Management Information (eLMIS) throughout the country instead of scaling up the electronic Zambia Inventory Control System (eZICS) pilot. 3. Direct project beneficiaries The indicator replaced with the CRI indicator 4. Female Beneficiaries The indicator replaced with the CRI indicator 3 Includes weight, height, mid arm circumference and a nutrition promotion indicator The World Bank Health Services Improvement Project (P145335) Table 4: New IRIs added to the Results Framework New Intermediate Result Indicators Data Source 1. Nurses and midwives trained in MNCH and nutrition competencies Integrated Electronic Human based on enhanced preservice & in-service training and continuous Resource Information System professional development (CPD) in project areas (Cumulative) (iHRIS) 2. Rural health facilities (health post, health centres and district iHRIS/ District Health hospitals) with at least one qualified health worker in the project Management Team (DHMT) areas Records 3. Health facilities (health post, health centres and district hospitals) DHMT records conducting GMP based on new standard guidelines in the project areas 4. Outreach sites in targeted provinces conducting GMP based on DHMT records new standard guidelines in the project areas. 5. Health facilities (health centres and district hospitals) conducting DHMT records cervical cancer screening in project areas 6. Women attending ANC within the first three months of Pregnancy DHIS-2/ DHMT records in the project areas 7. Lactating women accessing post-natal care within six days in the DHIS-2/ DHMT records project areas 8. Neighborhood health committees (NHCs) implementing the RBF DHMT records approach in the project areas 9. NHCs implementing community health management information DHMT Records system (CHMIS) in targeted in the project areas 10. Number of structures protected by indoor residual spraying in National Malaria Elimination project areas. Centre (NMEC) records 11. Number of health care providers and tutors Trained in essential iHRIS/DHMT Records newborn care (ENC) competency-based training. 11. Revise some of the DLRs by dropping 6DLRs to be disbursed on actuals as input -based financing: Six DLRs (2.4, 2.5, 6.2, 6.3, 6.4 and 6.5) will be dropped because they are no longer relevant: i. DLR#2.4 and 2.5: all the relevant health workers who need the 3-month in-service induction training have been trained. The new cohorts of health workers entering the work force no longer need such a training as it has been incorporated in the pre-service curricula. ii. DLR# 6.2, 6.3, 6.4 and 6.5: The Ministry of Health has decided to implement the eLMIS throughout the country instead of scaling up the eZICS pilot. It is proposed under this restructuring to convert the allocation of the these DLRs into input financing to support completion and evaluation of pilot to generate evidence for future reference and decision making and scaling up health services. 12. A total of SDR 2,900,000 in allocation for these six DLRs will therefore be reallocated to a new category six that will disburse on actuals to support scaling up of selected high impact interventions in MNCH and nutrition. The high impact interventions will include both direct and indirect causes of maternal morbidity and mortality, and the major causes of morbidity and mortality in under five children. Strengthening of the community platform will continue to be supported under Sub-component 1.3 and Component 2. The World Bank Health Services Improvement Project (P145335) Table 5: DLRs to be dropped and allocations to be disbursed on actuals as input-based financing 13. Add 4DLRs to be achieved in the project extension period under Categoty1(a)- DLI based disbursement financing: For the four remaining DLIs (4, 7, 8 and 9 that are still applicable for the project extension period, there is a total undisbursed amount of SDR 3,142,500 due to underachievement of results in the past. Four corresponding new DLRs will therefore be added under the 4 DLIs for the one-year project extension period (calendar year 2019 and 2020) as follows: i. For DLI# 4, the undisbursed amount is SDR 1,250,000  Add DLR #4.7: Percentage point increase from the baseline in the number of PHC facilities in targeted provinces stocked with all tracer drugs by June 30, 2020.  Disbursement formula: SDR 62,000 SDR for every 1 percentage point increase from the baseline in the number of PHC facilities in targeted provinces stocked with all tracer drugs by June 30, 2020. ii. For DLI# 7, the undisbursed amount is SDR 385,000  Add DLR 7.7: Percentage point increase from the baseline in the number of women registered during the first trimester of their pregnancy in targeted provinces by June 30, 2020.  Disbursement formula: 18,900 SDR for every 1 percentage point increase from the baseline in the number of women registered during the first trimester of their pregnancy in targeted provinces by June 30, 2020. iii. For DLI# 8, the undisbursed amount is SDR 620,000.  Adding DLR 8.7: Percentage point increase from the baseline in number of mothers who received post-natal care within 6 days of delivery in targeted provinces by June 30, 2020.  Disbursement formula: 32,000 SDR for every 1 percentage point increase from the baseline in the number of mothers who received post-natal care within 6 days of delivery in targeted provinces by June 30, 2020. iv. For DLI#9, the undisbursed amount is SDR 887,500  Adding DLR 9.7: Percentage of Outreach Centers in targeted provinces conducting GMP following the revised national GMP standards and guidelines by June 30, 2020.  Disbursement formula: 48,000 SDR for every 1 percentage point of Outreach Centers in targeted provinces conducting GMP following the revised national GMP standards and guidelines by June 30, 2020. The World Bank Health Services Improvement Project (P145335) 14. Addition of Sub-component 1.4 for scaling up selected high impact interventions to reduce maternal and neonatal mortality. Under the proposed sub-component, the project will support: i. Malaria Elimination Program. The Government has identified malaria control and eventual elimination as one of its main public health priorities. Targeted indoors residual spraying (IRS) is one of the key interventions for malaria in Zambia. While the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the US Presidential Malaria initiative (PMI), and the Malaria Control and Elimination Partnership in Africa (MACEPA) are key supporters for IRS in the country, their combined resources cannot support the spraying of 3,473,750 eligible structures during the 2019 IRS campaign. Therefore, in response to a Government’s formal request, the project will support (a) the training of IRS operators and (b) the operating costs for the 2019 IRS campaign in 9 out of 10 provinces4; (c) and monitoring and evaluation of IRS campaign. A total of 2.4 million households and 10.4 million people are expected to be protected during the 2019 IRS campaign with the Project’s support. This is expected to improve the impact on maternal mortality and child mortality throughout the country. There will be no change or additional environmental safeguards requirements for IRS since these have already been put in place with the support of PMI and GFATM in the previous years and will continue to be applicable for this campaign. ii. Scaling up neonatal care at PHC level. The project will support the implementation of the National Newborn Health Scale-Up Plan 2016–2020, inter alia: (a) development of standard operating procedures for neonatal care in health facilities and community; (b) provision of low-dose, high-frequency training in neonatal care for health workers ; (c) provision of required equipment such as continuous positive airway pressure (CPAP) for delivery sites; (d) implementation and scale up of Kangaroo mother care at delivery facilities; (e) strengthening the referral system; and (f) strengthening perinatal audits and surveillance. iii. Scaling up cervical cancer screening at PHC level. In Zambia, cervical cancer is the most common cancer in adult population. It accounts for over 30% of new cancer cases. Over 3 million females aged 15 years and older are at risk of developing cancer of the cervix. In the past, the project supported the evaluation of HPV vaccination for school girls. For the remaining duration, the project will support the scaling up of cervical cancer screening in selected health facilities in the targeted provinces as part of the implementation of the National Cancer Control Strategic Plan. Activities financed by the project will include: (a) Support procurement of Visual Inspection with Acetic Acid (VIA), Cryotherapy and Loop electrosurgical excision procedure (LEEP); (b) Other equipment including appropriate beds for cervical cancer examination. (c) continuous professional development (CPD) training for service providers in cervical cancer screening; (d) strengthening the referral mechanisms of clients and specimens using currently available transport systems; and (e) monitoring and evaluation, including support for the Zambia National Cancer Registry (ZNCR); supporting to strengthen monitoring and evaluation system for cervical cancer including support to strengthening of the ZNCR. 15. These new activities will not require additional safeguards instruments. Satisfactory implementation of current instruments under the parent project, namely national plan of action and strategies for implementation of the national plan of the HCWMP should incorporate the infectious waste and occupational health and safety aspects needed for this component. 4 The IRS campaign in Eastern Province will be funded by PMI The World Bank Health Services Improvement Project (P145335) 16. Changes in Disbursement Categories and Reallocations Among Disbursement Categories: Creation of category six under part A of the project for a total of SDR 3,900,000 to be disbursed on actuals to support service delivery scale up as stated above. This category will comprise: (i) reallocation of SDR 1,000,000 from Category 4; (ii) a total SDR 2,900,000 from DLI#2 (SDR 1.1million) and from DLI#6 (SDR 1.8million) for the DLRs that are no longer relevant (Table 5). Table 6. Change in expenditure category under IDA Credit 53940 Expenditure category Original amount of the Revised amount of the Credit allocated (SDR Credit allocated (SDR million) million) (1) DLI Based Financing under Part A of the project 17.9 15.0 (2) Goods, works non- consulting services, consultant services Training and Operating Costs required for Sub-Projects and to be 7.9 7.9 financed out of Subproject Grants under Part B of the Project (3) Goods, non-consulting services, consultant services, Training and Operating Costs Under Part C of the Project (except under Part 6.8 6.8 C.7 of the Project) (4) Consultants services under Part C.7 of the Projects 1.3 0.3 (5) Emergency Expenditures under Part D of the Project 0.0 0.0 (6) Goods, non-consulting services, consultant services, Training 0.0 3.9 and Operating Costs Under Part A of the Project. TOTAL AMOUNT 33.9 33.9 Table 7. Change in the amount allocated for TF 16639 by expenditure category Expenditure category Original amount Revised amount allocated (US$ allocated (US$ million) million) (1) Goods, works non- consulting services, consultant services Training and Operating Costs required for Sub-Projects and to be 12 14.5 financed out of Subproject Grants under Part B of the Project (2) Consultants services under Part C.7 of the Projects 3 0.5 Total Financing 15 15 17. Change in Components: In addition to the new Sub component 1.4 as discussed above, a zero-cost Contingent Emergency Response Component (CERC) will be added as a fourth component to support rapid response to epidemics control and preparedness as per the Government’s request to the Bank to access the Pandemic Emergency Financing Facility (PEF). The World Bank Health Services Improvement Project (P145335) 18. Change in Component Costs and Reallocation of Funds: The proposal is to reallocate a total of US$3.9 million from Component 3 as follows: (i) US$1.4 million5 will be allocated to sub- component 1 under Part A of the project for input-based activities to support scaling up selected service delivery interventions as stated above; and (ii) US$2.5 million to Component 2 to support scaling up RBF activities, especially strengthening of the base community service delivery platform which is critical to the delivery of nutrition interventions. Table 8. Project costs and financing by component Original Component Allocation(US$million) Proposed Component reallocation (US$millions) Original Project IDA HRITF % IDA Total Finnacing IDA HRITF % IDA Project Component Component Financing Financing Financing after Financing Financing Financing Cost Reallocation Component 1: Strengthen capacity for 27.5 27.5 0 100% 28.9 28.9 0 100% primary and community level MNCH and services nutrition2 Component : Strengthen utilization of primary and community level MNCH 24 12 12 50% 26.5 12 14.5 45% and nutrition services with results based financing approaches Component 3: Strengthen project 15.5 12.5 3 81% 11.6 11.1 0.5 96% management and policy analysis Component 4: Contingent Emergency N/A N/A N/A 100% N/A N/A N/A 100% Response Component (CERC) Total Financing 67 52 15 78% 67 52 15 78% 19. Change to Designated Accounts and Financial Management Arrangements: The current authorized limits of Designated Accounts be removed as the project moves to IFR based disbursement. The frequency of reporting of eligible expenditures will be changed from monthly to quarterly. Funds will be disbursed to the Designated Accounts based on quarterly Interim Final Reports (IFRs) with the project’s estimated expenditures for the next six months. Such changes are justified because (i) the project currently submits its withdrawal applications regularly and the quarterly IFRs on time; and (ii) the Government needs enough funds at their disposal for inputs-based financing activities as well as accelerated project implementation. 20. Changes in Procurement Arrangements: All procurement responsibilities will be transferred to the MoH as it is now the sole project implementing agency. Project procurement will also migrate to the new World Bank procurement guidelines to take advantage of the various flexibilities and innovative approaches under the New Procurement Framework (NPF) and applicable regulations. To facilitate this change, the Financing and Grant Agreements will be amended to enable migration from the Guidelines: “Procurement of Goods, Works and Non-Consulting Services under IBRD Loans and IDA Credits and Grants by World Bank Borrowers” dated January 2011 and Guidelines: “Selection and Employment of Consultants under IBRD Loans and IDA Credits and Grants by World Bank Borrowers” dated January 2011 to the NPF: “Procurement Regulations for Investment Project Financing (IPF) for Borrowers – Goods, Works, Non- Consulting and Consulting Services” of July 2016 including relevant anticorruption guidelines. This notwithstanding, applicable Government Procurement Rules and Regulations will continue to be in force for procurement activities utilizing funds gained through DLIs subject to any relevant modifications acceptable to the Bank. Procurement details, including 5 The proposed reallocated amounts are based on a rate of USD1.397170 to 1 SDR. The World Bank Health Services Improvement Project (P145335) appropriate clarity of accountability over procurement, record keeping, and frequency and scope of prior and post review will be detailed in the procurement module in the revised PIM, and in the procurement plans. B. Appraisal Summary 21. This section focuses on the appraisal for the addition of Sub-component 1.4 for input financing to support selected high impact interventions in MNCH and the CERC component. Addition of Sub-component 1.4 22. Malaria Elimination Program. Malaria is endemic throughout Zambia and continues to be a significant public health problem. The goal is to eliminate local malaria infection and disease in Zambia by 2021. Despite major achievements in malaria control, the disease remains a significant cause of morbidity and mortality in Zambia, with more than 16 million people at risk, over 5 million cases per year and one in five children under five infected with malaria. Among 2,000 reported malaria deaths annually, the majority are among under-five children and pregnant women. According to the 2018 malaria indicator survey (MIS), the national malaria parasite prevalence dropped to 9% among children under age five years in 2018 compared with 19 percent in 2015. However, in the target project provinces under the ZHSIP, the malaria parasite prevalence continues to be above 9% of the national average. Table 9. Malaria Prevalence rate in children <5 years by province SN Province Malaria Prevalence rate in children <5years 1. Central 1.7 2. Eastern 7.7 3. Copperbelt 8.7 4. Luapula 30.4 5. Lusaka 0.1 6. Muchinga 23.0 7. Northern 11.0 8. North-Western 13.2 9. Southern 0.0 10. Western 10.4 23. Given the high burden of malaria in Zambia, especially among children under five and pregnant women, project support for malaria control, which is one of the “best buys” in global health, is justified. IRS is cost effective and one of the key pillars of malaria control in SSA recommended by WHO. 24. Zambia National Malaria Control Center has a good track record of conducting annual IRS campaigns since 2003 with the support of the US Presidential Malaria Initiative, the World Bank and the GFATM. The proposed sub-component 1.4 will further strengthen the country’s capacity in IRS by supporting the training of spray operators as well as finance the operating cost of the 2019 IRS campaign. In 2017 spray season, the National Malaria Elimination programme (NMEP) covered 1,915,821 structures (82% of targeted 2,331,898 structures); this represented 58% of the total eligible structures countrywide (3,281,046). A total population of 7,800,704 was protected by IRS representing 55% of the total targeted population in 2017. In 2018 spray campaign, a total of 1,798,395 structures were sprayed (92 % of 1,958,905 targeted structures) representing 55% of the total eligible structures countrywide (3,281,046); 7,451,289 people were protected by IRS representing 52.5% of the total population in 2018. In 2019, the NMEP plans to spray a total of 3,376,196 eligible structures countrywide. The World Bank Health Services Improvement Project (P145335) 25. Prior to every IRS campaign, the program conducts annual needs assessments to ensure that adequate supplies and consumables are available for a successful and quality spray campaign. Key to these assessments is to quantify needs for insecticides, spray pumps and personal protective equipment among others. Environmental safe-guards are key during the campaigns in this regard the following actions are undertaken:  All districts implementing IRS have sock pits for managing liquid waste of non-DDT insecticides.  DDT has been reintroduced for IRS and will be used in 59 districts. In this regard DDT evaporation bays have been constructed in these districts to manage liquid waste derived from DDT use.  Prior to the reintroduction of DDT, a Strategic Environmental Assessment was conducted by the Zambia Environmental Management Agency (ZEMA) to ensure that all districts met the minimum standards for using DDT as per Stockholm Convention  During all the annual trainings prior to implementation a module on environmental compliance is delivered to all participating in the programme.  Monitoring of environmental compliance before, during and after all spray campaigns is undertaken by ZEMA 26. Support the scaling up neonatal care at PHC level. Zambia’s neonatal mortality rate remains high at 24 deaths per 1,000 live births and accounts for about 30% of under-five deaths. Zambia’s 2018-2021 RMNCAH&N Roadmap aims to reduce this rate to 5 per 1,000 live births by 2021. The causes of neonatal mortality include birth asphyxia and neonatal sepsis, which reflect poor quality of neonatal care. The project will support the scale up of key interventions to improve quality of neonatal care identified in the 2018-2021 RMNCAH&N Roadmap, through funding training, key commodities and equipment as well as non-salary operating costs in selected districts in project areas. 27. Support scaling up cervical cancer screening in maternal health services at PHC level. In Zambia, cervical cancer is the most common cancer among females. Women with cervical cancer present themselves too late to health facilities and therefore mortality rate due to this type of cancer remains high. In the 15 and 44 age group, the age standardized incidence and mortality rates are 58 and 36 per 100,000 women respectively. Like many other countries in LMICs, Zambia has faced challenges in implementing cervical cancer prevention programmes. Integrating cervical cancer prevention and treatment with the existing programmes such as HIV, adolescent and maternal health services will help reaching out to more women. As per the, National Cancer Control Strategic Plan, the plan to screen and treat cervical cancers involves three levels with different technologies: (i) Provincial level hospitals- VIA, Cryotherapy and LEEP (ii) District hospitals - VIA, Cryotherapy, +/- LEEP (iii) Health centers – VIA and Cryotherapy 28. The project will focus on supporting the scale up of cervical screening using above technologies at the provincial, district and health centers in selected districts in project areas. Addition of the CERC component 29. Zambia has suffered several major national disasters and disease outbreaks in the past (including cholera), and such threats remain. The country has developed the National Action Plan for Health Security 2017-2021 and is in the process of developing a National Integrated Emergency Response, Mitigation and Adaptation Plan to handle future public health emergencies. Integrating a CERC into the project will allow the country to rapidly access a portion of its undisbursed International Development Association (IDA) balances to address immediate financing needs in the event of a crisis and/or emergency. It will strengthen the level of country preparedness and eliminate the need for time-consuming restructuring in the immediate aftermath of a crisis, when the government is in urgent need of quick liquidity. The World Bank Health Services Improvement Project (P145335) 30. The availability of such immediate financing is critically important in: (i) supporting the client in the initial response; (ii) helping to coordinate the early recovery phase from an emergency; and (iii) bridging the gap to longer-term recovery and reconstruction phases. CERC can be used for other immediate and emerging risks, such as natural and man- made disasters, conflicts, epidemics and economic shocks. 31. The MoH will prepare a Contingent Emergency Response Implementation Plan (CERIP) for each eligible crisis or emergency. The CERIP will provide the implementation arrangements for the emergency response, including: (i) institutional arrangements; (ii) specific activities for the response; (iii) financial management arrangements; (iv) procurement methods and procedures; (v) documentation required for the withdrawal application; and (vi) relevant safeguards instruments. The PIM will be updated to include the CERC Component. III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Technical Analysis ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ Cancellations Proposed ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ The World Bank Health Services Improvement Project (P145335) Legal Covenants ✔ APA Reliance ✔ Economic and Financial 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) Component 1: Strengthening Component 1: Strengthening capacity for primary and capacity for primary and 27.50 27.50 community level MNCH and community level MNCH and nutrition services nutrition services Component 2: Strengthening Component 2: Strengthening utilization of primary and utilization of primary and community level MNCH and community level MNCH and 24.00 24.00 nutrition services through nutrition services through results results based financing ap based financing ap proaches proaches Component 3: Strengthening Component 3: Strengthening project management and policy 15.50 project management and 15.50 analysis policy analysis Component 4: Contingent 0.00 New Emergency Response 0.00 Component (CERC) TOTAL 67.00 67.00 OPS_DETAILEDCHANGES_LOANCLOSING_TABLE LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications IDA-53940 Effective 30-Jun-2019 30-Jun-2020 30-Oct-2020 TF-16639 Effective 30-Jun-2019 30-Jun-2020 30-Oct-2020 The World Bank Health Services Improvement Project (P145335) OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-53940-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: DLI BASED FINANCING Part A 17,900,000.00 11,740,262.97 18,900,000.00 100.00 100.00 iLap Category Sequence No: 2 Current Expenditure Category: GD WK CON NON-C TRN OP sb prj PrB 7,900,000.00 6,711,605.52 7,900,000.00 50.00 50.00 iLap Category Sequence No: 3 Current Expenditure Category: GD CON N-CON TRN OP Prt C excptC7 6,800,000.00 4,950,570.44 6,800,000.00 100.00 100.00 iLap Category Sequence No: 4 Current Expenditure Category: CONSULTANTS SERVICES Part C.7 1,300,000.00 98,448.00 300,000.00 40.00 40.00 Total 33,900,000.00 23,500,886.93 33,900,000.00 TF-16639-001 | Currency: USD iLap Category Sequence No: 1 Current Expenditure Category: GD WK CON NON-C TRN OP sb prj PrB 12,000,000.00 9,451,992.34 14,500,000.00 50.00 50.00 iLap Category Sequence No: 2 Current Expenditure Category: CONSULTANTS SERVICES Part C.7 3,000,000.00 204,593.11 500,000.00 60.00 60.00 Total 15,000,000.00 9,656,585.45 15,000,000.00 The World Bank Health Services Improvement Project (P145335) OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 2014 0.00 0.00 2015 10,100,000.00 2,000,000.00 2016 13,580,000.00 4,589,013.14 2017 12,835,000.00 9,889,160.87 2018 11,305,000.00 14,267,659.16 2019 3,180,000.00 13,169,069.71 2020 1,000,000.00 2,905,405.12 The World Bank Health Services Improvement Project (P145335) . Results framework COUNTRY: Zambia Health Services Improvement Project Project Development Objectives(s) The project development objective is "to improve health delivery systems and utilization of maternal, newborn and child health and nutrition services in project areas." Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Improve health delivery systems for MNCH and nutrition services Deliveries attended by skilled DLI 2 27.00 31.00 33.00 39.00 45.00 57.00 health providers (Percentage) Health Centers with essential medicines and commodities in 33.30 38.30 43.30 51.00 52.50 53.00 stock (percent) (Percentage) Health Centers offering integrated Management of 0.00 0.00 13.00 213.00 51.00 64.00 Childhood Illnesses (Percentage) Improve utilization of MNCH and nutrition services Under-2 children received monthly growth monitoring 0.00 0.00 55.00 65.00 75.00 82.80 and promotion (Percentage) The World Bank Health Services Improvement Project (P145335) RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Children 0-11 months fully 80.00 80.00 82.00 84.00 86.00 90.00 immunized (Percentage) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Component 1: Strengthening capacity for primary and community level MNCH and nutrition services Health workers trained in MNCH and nutrition DLI 1 0.00 400.00 800.00 1,200.00 1,600.00 2,000.00 competencies (Number) Percentage of trained health workers deployed to facilities 0.00 70.00 75.00 80.00 82.50 85.00 in the five provinces. (Percentage) Health facilities (health centers and district hospitals) using electronic inventory control 0.00 94.00 151.00 376.00 565.00 734.00 and logistics management system (Number) Regional hubs and staging posts equipped in target areas 0.00 1.00 2.00 4.00 5.00 6.00 (Number) Component 2: Strengthening utilization of primary and community level MNCH and nutrition services through results based financing ap proaches The World Bank Health Services Improvement Project (P145335) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Health facilities (health centers and district hospitals) 70.00 92.00 149.00 275.00 365.00 545.00 implementing the RBF approach (Number) Protocols and guidelines at community and primary care 0.00 1.00 2.00 3.00 4.00 4.00 levels updated and disseminated (Number) Direct project beneficiaries 0.00 0.00 1,300,000.00 1,850,000.00 2,950,000.00 3,300,000.00 (Number) Female beneficiaries 0.00 20.00 35.00 45.00 50.00 55.00 (Percentage) People who have received essential health, nutrition, and 931,505.00 1,887,451.00 2,051,232.00 2,213,033.00 4,027,370.00 4,544,409.00 population (HNP) services (CRI, Number) Rationale: This is a composite CRIs Indicator that has been updated as follows:  Targets for this CRIs have been revised  Actuals achieved since project effectiveness has been revised based on the DHIS-2 as shown below: Action: This indicator has been o Baseline 12/2013 – 931,505 Revised o 12/2014 – 961,720 o 12/2015 – 1,035,865 o 12/2016 – 1,136,029 o 12/2017 – 1,065,387 o 12/2018 – 3,548,820 The World Bank Health Services Improvement Project (P145335) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4  Target for the number of people who received essential health, nutrition and population services in the project areas – Female (Composite breakdown) target is at 80% (universal Access) of the composite CRI.  The composite actual add up to the three breakdown CRIs (children immunized, deliveries by skilled attendants, Women and children receiving basic nutrition).  The data for all CRIs was complete only for the year 2018. People who have received essential health, nutrition, and population (HNP) 851,721.00 1,321,216.00 1,435,862.00 1,549,123.00 2,819,159.00 3,181,086.00 services - Female (RMS requirement) (CRI, Number) Rationale: This is a composite breakdown - female CRIs requirement has been updated as follows:  Targets for this CRI have been revised to 80% (universal coverage) of the composite  Actuals achieved since project effectiveness has been revised based on the DHIS-2 o Baseline 12/2013 – 851,721 Action: This indicator has o 12/2014 – 883,421 been Revised o 12/2015 – 948,917 o 12/2016 – 1,044,312 o 12/2017 – 967,796 o 12/2018 – 2,185,483 Number of children 156,439.00 211,935.00 217,927.00 223,058.00 229,291.00 236,699.00 immunized (CRI, Number) The World Bank Health Services Improvement Project (P145335) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Rationale: CRI Breakdown - figures based on corrected and revised ISR. Baseline 2013 - 156,439 12/2014 - 153,524 Action: This indicator has 12/2015 - 170,487 been Revised 12/2016 - 179,837 12/2017 - 190,968 12/2018 - 223,058 Number of women and children who have received 683,030.00 1,400,000.00 1,550,000.00 1,700,000.00 3,500,000.00 4,000,000.00 basic nutrition services (CRI, Number) Rationale: CRI Breakdown - figures based on corrected and revised ISR Baseline 2013 - 683,030 12/2014 - 684,112 Action: This indicator has 12/2015 - 741,110 been Revised 12/2016 - 834,456 12/2017 - 727,204 12/2018 - 3,149,239 Number of deliveries attended by skilled health 92,036.00 275,516.00 283,305.00 289,975.00 298,079.00 307,709.00 personnel (CRI, Number) The World Bank Health Services Improvement Project (P145335) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Rationale: CRI Breakdown - figures based on corrected and revised ISR. Baseline 2013 - 92,036 12/2014 - 124,080 Action: This indicator has 12/2015 - 124,268 been Revised 12/2016 - 121,736 12/2017 - 147,215 12/2018 - 188,223 Component 3: Strengthening project management and policy analysis Health policy analysis conducted and results 0.00 0.00 1.00 2.00 3.00 3.00 disseminated (Number) Districts with community information system integrated 0.00 0.00 10.00 25.00 35.00 39.00 DHIS-2 (Number) IO Table SPACE Disbursement Linked Indicators Matrix DLI IN00720009 ACTION DLI 1 Health workers trained in MNCH and nutrition competencies Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Number 300,000.00 666.67 Period Value Allocated Amount (USD) Formula The World Bank Health Services Improvement Project (P145335) Baseline 0.00 March 31, 2016 to October 300,000.00 300,000.00 300,000.00 31, 2018 DLI IN00720054 ACTION DLI 2 Deliveries attended by skilled health providers Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Percentage 2,600,000.00 57.69 Period Value Allocated Amount (USD) Formula Baseline 27.00 March 31, 2016 to October 33.00 2,600,000.00 1,500,000.00 31, 2018 Verification Protocol Table: Disbursement Linked Indicators DLI_TBL_VERIFICATION DLI 1 Health workers trained in MNCH and nutrition competencies Description Number of health workers trained in MNCH and nutrition competencies in the targeted provinces. MoH Reports and project data and supervision records Data source/ Agency The external verification firm will be responsible for gathering evidence while the MoH will deliver this evidence to the Verification Entity World Bank in a timely manner The MOH generates a report of achievement of the stated disbursement linked Results (DLR) Procedure The World Bank Health Services Improvement Project (P145335) DLI_TBL_VERIFICATION DLI 2 Deliveries attended by skilled health providers Numerator: Number of deliveries conducted by skilled personnel (medical doctors and registered midwife) in health Description facilities in project areas. Denominator: Expected deliveries in project areas. MoH/MCDMCH Reports and Project data and supervision reports Data source/ Agency The external verification firm will be responsible for gathering and vetting the requisite evidence, while Verification Entity the MCDMCH/MoH will provide this evidence to the World Bank in a satisfactory format. MMOH/MCDMCH generates reports on DLI achievements that are submitted to the IVA for verification Procedure . The World Bank Health Services Improvement Project (P145335) Annex 1: DLI/DLR Schedule of Achievements and Disbursements as at June 17, 2019 DLRs to Continue with DLI DLR to Convert to Input DLI# DLR Disbursement Calculation Status of DLI Oustanding (SDR) Based Financing Finnacing DLI #1: Capacity to implement comprehensive DLR # 1.1 300,000 Fully Achieved - - - pre-service training program on MNCH and nutrition for nurses and midwives DLR # 1.2 900,000 Fully Achieved - - - strengthened DLR # 1.3 800,000 Fully Achieved - - - Sub-total 2,000,000 DLI #2: The number of vacancies for nurses DLR # 2.1 400,000 Fully Achieved - - - and midwifes in primary health facilities in DLR # 2.2 500,000 Fully Achieved - - - Targeted Provinces filled by newly recruited DLR # 2.3 500,000 Fully Achieved - - - nurses and midwifes who have completed the DLR # 2.4 100,000 Partial Achievement 400,000 - 400,000 three (3) month induction in-service training DLR # 2.5 0 Not Achived 700,000 - 700,000 on MNCH and nutrition increases Sub-total 1,500,000 DLI # 3: The number of nurses and midwives in DLR # 3.1 250,000 Fully Achieved - - - primary health facilities in Targeted Provinces DLR # 3.2 550,000 Fully Achieved - - - who have completed the continuing DLR # 3.3 400,000 Fully Achieved - - - professional development training in MNCH DLR # 3.4 400,000 Fully Achieved - - - and nutrition increases DLR # 3.5 400,000 Fully Achieved - - - Sub-total 2,000,000 DLI #4: The number of primary health DLR # 4.1 300,000 Fully Achieved - - - facilities in Targeted Provinces stocked with DLR # 4.2 400,000 Fully Achieved - - - all tracer drugs increases DLR # 4.3 100,000 Fully Achieved - - - DLR # 4.4 125,000 Not Achieved 375,000 375,000 - DLR # 4.5 125,000 Not Achieved 375,000 375,000 - DLR # 4.6 0 Not Achieved 500,000 500,000 - DLR # 4.7 1,250,000 Sub-total 2,300,000 DLI #5: Regional essential commodities DLR # 5.1 200,000 Fully Achieved - - - storage and distribution hubs established in DLR # 5.2 900,000 Fully Achieved - - - Targeted Provinces DLR # 5.3 900,000 Fully Achieved - - - Sub-total 2,000,000 The World Bank Health Services Improvement Project (P145335) Proposed Disbursement DLRs to Continue with DLI DLR to Convert to Input DLI# DLR Status of DLI Oustanding (SDR) Calculation Based Financing Finnacing DLI #6: The electronic Zambia Inventory DLR # 6.1 200,000 Fully Achieved - - - Control System (eZICS) is piloted and DLR # 6.2 0 Not Achieved 300,000 - 300,000 implemented in Targeted Provinces DLR # 6.3 0 Not Achieved 600,000 - 600,000 DLR # 6.4 0 Not Achieved 600,000 - 600,000 DLR # 6.5 0 Not Achieved 300,000 - 300,000 Sub-total 200,000 DLI #7: The number of women registered DLR # 7.1 130,000 Fully Achieved - - - during the first trimester of their pregnancy in DLR # 7.2 200,000 Fully Achieved - - - targeted Provinces increases DLR # 7.3 227,500 Partial achievement 122,500 122,500 - DLR # 7.4 87,500 Partial achievement 262,500 262,500 - DLR # 7.5 200,000 Fully Achieved - - - DLR # 7.6 70,000 Fully Achieved - - - DLR # 7.7 385,000 Sub-total 1,300,000 DLI #8: The number of mothers who delivered DLR # 8.1 200,000 Fully Achieved - - - at health facilities in Targeted Provinces and DLR # 8.2 400,000 Fully Achieved - - - who received post-natal care increases DLR # 8.3 500,000 Fully Achieved - - - DLR # 8.4 125,000 Not Achieved 375,000 375,000 DLR # 8.5 75,000 Not Achieved 225,000 225,000 - DLR # 8.6 80,000 Partial achievement 20,000 20,000 - DLR # 8.7 620,000 Sub-total 2,000,000 DLI #9: The number of Outreach Centers in DLR # 9.1 200,000 Fully Achieved - - - Targeted Provinces conducting GMP DLR # 9.2 350,000 Fully Achieved - - - monitoring following national standards and DLR # 9.3 100,000 Partial achievement 300,000 300,000 guidelines increases DLR # 9.4 100,000 Partial achievement 300,000 300,000 DLR # 9.5 62,500 Partial achievement 187,500 187,500 DLR # 9.6 0 Not Achieved 100,000 100,000 DLR # 9.7 887,500 Sub-total 1,700,000 Total SDR 15,000,000 6,042,500 3,142,500 2,900,000