The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) REPORT NO.: RES38120 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SYSTEMS STRENGTHENING AND EBOLA PREPAREDNESS PROJECT APPROVED ON NOVEMBER 25, 2014 TO THE REPUBLIC OF CÔTE D'IVOIRE HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Hafez M. H. Ghanem Country Director: Coralie Gevers Regional Director: Amit Dar Practice Manager/Manager: Gaston Sorgho Task Team Leader: Montserrat Meiro-Lorenzo, Emre Ozaltin i The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) ABBREVIATIONS AND ACRONYMS CMU Couverture Maladie Universelle (Governments' pre-paid health insurance program) CRIs Corporate results indicators DTP Diphtheria, tetanus toxoid and pertussis HMIS Health Management Information System HNP Health, Nutrition and Population IRI Intermediate results indicators ISR Implementation Status Report M&E Monitoring and evaluation PBF Performance-based financing PDO Project Development Objective PRPSS Health Systems Strengthening and Ebola Preparedness Project RASS Rapport Annuel sur la Situation Sanitaire RBF Results-based financing RMNCH Reproductive, maternal, neonatal and child health ii The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) 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 P147740 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 25-Nov-2014 31-Jan-2020 Organizations Borrower Responsible Agency Government of Côte d'Ivoire Ministry of Health and the fight against HIV/AIDS Project Development Objective (PDO) Original PDO To strengthen the health system and improve the utilization and quality of health and nutrition services in selected regions. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-55570 25-Nov-2014 17-Dec-2014 16-Mar-2015 31-Jan-2020 35.00 25.01 7.94 IDA-D0030 25-Nov-2014 17-Dec-2014 16-Mar-2015 31-Jan-2020 35.00 30.01 3.03 iii The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No Note to Task Teams: End of system generated content, document is editable from here. I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Project summary 1. The Health Systems Strengthening and Ebola Preparedness Project (PRPSS) is a USD 77 million operation, including USD 35 million IDA credit, USD 35 million IDA grant and 7 million in counterpart financing from the Government of the Republic of Cote d’Ivoire. PRPSS was approved in November 2014; became effective in March 2015 and has an original project closing date of January 31, 2020. 2. The PDO is to strengthen the health system and improve the utilization and quality of health and nutrition services in selected regions. Through the PRPSS, the government aims to: (i) pilot performance-based financing (PBF) as an approach to increase the volume and quality of health services provided to the population, with a focus on improving the effectiveness of the “Targeted Free Care” and other reproductive, maternal, neonatal and child health (RMNCH) interventions (including nutrition), and addressing the link to the governments pre-paid health insurance program (Couverture Maladie Universelle; CMU); (ii) rehabilitate and equip health centers to support the provision of quality services; (iii) support the further development of a robust health management information system (HMIS) and health system management; (iv) provide technical assistance to develop the CMU approach and assist in CMU implementation by covering the poor. 3. The May 2019 supervision mission conducted a complete review of the implementation and results of the PRPSS in the view to monitor progress and take decisions on course corrections to reinforce the achievement of the PDO in its final year. This review provides the basis for the proposed restructuring and proposes a reallocation of funds between disbursement categories and a revision to the results framework. iv The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) B. Project status 4. Progress towards achievement of the PDO and Implementation Progress rating has been satisfactory in the last two Implementation Status Reports (ISRs) dated November 26, 2018 and June 26, 2019. Overall project implementation is on track and the five PDO level indicators have shown a positive trend towards meeting the end targets. For example: (i) deliveries in health facilities by trained health personnel is at 152,439 (target is 191,209); number of severely malnourished children detected and treated is at 12,316 (target is 16,220); vaccination coverage (diphtheria, tetanus, pertussis; DTP) is at 98 percent (target is 99 percent); average quality score for facilities covered by PBF has improved by 32.4 percent (target is 35 percent); and per capita utilization of services is at 0.53 (target is 0.56). Moreover, of the 13 intermediate level indicators, eight have already achieved their targets and the project currently accounts for 4,8 million (target is 7,4 million) direct project beneficiaries, 61 percent of whom are women (target is 60 percent). 5. The paragraphs below provide a summary of progress by component: a) Component 1: Performance-based Financing (Total amount: USD 38.5 million, of which USD 31.5 million IDA). Substantial progress has been made on the implementation of the PBF pilot. The Government has adopted a National Strategy on PBF and critical reforms for the implementation of the PBF. 275 of the 403 (68 percent) health facilities targeted in 14 health districts are under performance contracts, as well as 6 of 8 (75 percent) Regional Directors of Health and 14 of 19 (74 percent) Departmental Directorates in the Ministry of Health. PBF incentives have successfully been paid to health facilities and regulators. b) Component 2: Strengthening the Health System for improved Performance (Total amount USD38.5 million IDA). This component covers: (i) technical assistance along with analytical work1 to support the implementation of the CMU scheme. This has contributed to the enrollment of 201, 354 indigents in the Nation Health Insurance program (target is 150,000). (ii) The rehabilitation and/or equipping of health facilities, 138 of which has already been rehabilitated;(iii) the strengthening of the HMIS system, including the production of annual health reports (Rapport Annuel sur la Situation Sanitaire; RASS – 2015, 2016, 2017) and integration of health data from para-public health facilities in the HMIS. (iv) The strengthening of the Government’s institutional capacities in emergency preparedness, with a particular focus on communicable diseases (e.g. Ebola preparedness), which increased the availability of equipment/supplies at the National 1Four analytical studies have been completed including: Studies on (1) The cost of health services in health facilities; (2) Resource mobilization for the CMU; (3) The contributive capacity of the population in Cote D’Ivoire; (4) The overall cost, financing and implementation of CMU in Cote d’Ivoire. 5 The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) Institute for Public Hygiene by 80 percent (target is 75 percent); and (v) overall project management including support to the Project Implementing Unit (PIU). 6. To date, the project has disbursed USD 54.87 million of the USD 70 Million IDA funds, representing an 83% disbursement rate (Table 1). Moreover, there has been rapid disbursement under Category 2 (support for the implementation of PBF) with 94.4 percent of funds disbursed. The assessment of the disbursement plan suggests that all funds will be depleted from Category 2 before the closure of the project. The project has no overdue audit reports. Table 1: Level of disbursement for the Health System Strengthening and Ebola Preparedness Project (P147740) Total project disbursement USD 54.87 (83%) IDA-credit (disbursed/undisbursed) USD 24.91 / USD 8.21 (75%) IDA-Grant (disbursed/undisbursed) USD 29.96 / USD 3.14 (91%) C. Rationale for restructuring 7. The restructuring proposes the following revisions to improve the implementation and results of PRPSS: a) Reallocate funds between disbursement categories to ensure that there are enough funds to support the implementation of PBF until the closure date; b) Revise the results framework to improve the relevance of the monitoring and evaluation (M&E) to track changes supported by the project and include corporate result indicators. II. DESCRIPTION OF PROPOSED CHANGES In line with findings from the May 2019 mission, this restructuring paper proposes the below changes:  Reallocation of funds between disbursement categories 8. The restructuring proposes the following changes to amend the disbursement table for the Credit (Table 2) and Grant (Table 3) in the PRPSS Financing agreement: a) Reallocation of 1,652,404 XDR (1,341,000,000 XOF) (conversion rate XDR to XOF on July 29, 2019 is 1 XDR = 811.544672 XOF) from Category 1 to Category 2 to support the implementation of PBF, including the verification and counter-verification related activities and M&E of PBF related services. 6 The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) b) Reallocation of 700,000 XDR (568,081,270 XOF) from Category 5 to Category 3, as the “Refund of Preparation Advance” was never used and can be allocated to support activities under Category 3. Considering that 700,000 XDR of credit will be reallocated to Category 3, the proportion of credit for this category increases from 57 to 59 percent, while the percentage of grant for this category declines from 43 percent to 41 percent. Table 2: Proposed changes in allocation of the amount of Credit to each category Category Original amount of allocated Revised amount allocated (Amount expressed in XDR) (Amount expressed in XDR) (1) Performance-based payments under part A.1 7,900,000 7,040,750 of the project (2) Goods, non-consulting services, consultants’ services, Training and Operating Costs under 4,300,000 5,159,250 part A.2 of the Project (3) Goods, works, non-consulting services, consultant’s services, Training and Operating 10,800,000 11,500,000 Costs under part B of the Project except Part B.5 of the Project (4) Goods under part B.5 of the Project 0 0 (5) Refund of Preparation Advance 700,000 0 Total amount 23,700,000 23,700,000 Table 3: Proposed changes in allocation of the amount of Grant to each category Category Original amount allocated Revised amount allocated (Amount expressed in XDR) (Amount expressed in XDR) (1) Performance-based payments under part A.1 of the project 5,700,000 4,906,846 (2) Goods, non-consulting services, consultants’ services, Training and Operating Costs under 3,200,000 3,993,154 part A.2 of the Project (3) Goods, works, non-consulting services, consultant’s services, Training and Operating 8,000,000 8,000,000 Costs under part B of the Project except Part B.5 of the Project (4) Goods under part B.5 of the Project 6,800,000 6,800,000 Total amount 23,700,000 23,700,000  Revision of results framework 9. The restructuring proposes the following revisions to the results framework: a) Revision of Intermediate results indicators (IRI): 7 The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) i. Revision of two IRIs: (A) “Children under 5 who received vitamin A supplementation” – When initially conceived, the definition of this indicator focused on routine vitamin A supplements delivered at health facilities. However, the original end target was calculated using data from vitamin A campaigns, which significantly overestimated the end target. The proposed new end target will be calculated using data from routine vitamin A distribution at health facilities; (B) “Health facilities constructed, renovated, and/or equipped” – The experience gained during implementation has shown that health facilities targeted for rehabilitation were more dilapidated than was anticipated, and the unit cost of this activity was under-estimated at the onset of the project. This led to an over-estimation of the end target. Moreover, given the significant rehabilitation costs per unit and the fact that other partners in the sector have allocated funds to equip the rehabilitated health facilities, no equipment has been, or will be, purchased for the renovated health facilities through this project. Therefore, we propose a revision to the title of this indicator as follows, “Health facilities constructed or renovated”, and a revision of the end target from 560 to 97 health facilities constructed/renovated. ii. Deletion of one IRI: “proportion of indigents among the total RBF beneficiaries” – it has not been possible to update this indicator since the beginning of the project because of delays in the implementation of an electronic medical system that records the indigent population who benefits from RBF services. b) Introduction of the HNP specific corporate results indicators (CRIs): (A) As per the latest OPCS guideline, four CRIs have been included in the results framework as intermediate level indicators. They are: (1) people who have received essential health, nutrition, and population (HNP) services; (2) number of children immunized; (3) number of women and children who have received basic nutrition services; (4) number of deliveries attended by skilled health personnel. One specific gender-based indicator have also been included in the results framework: females who received essential health, nutrition and population services. Note to Task Teams: The following sections are system generated and can only be edited online in the Portal. III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Reallocation between Disbursement Categories ✔ 8 The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-55570-001 | Currency: XDR ix The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) iLap Category Sequence No: 1 Current Expenditure Category: Performance-Based Pymt Prt A.1 7,900,000.00 2,870,581.76 7,040,750.00 80.00 80.00 iLap Category Sequence No: 2 Current Expenditure Category: Gds,NC, Cs, Trn, Opc Prt A.2 4,300,000.00 3,809,993.28 5,159,250.00 85.00 85.00 iLap Category Sequence No: 3 Current Expenditure Category: Gds,NC, Cs, Trn, Opc Prt B excl B.5 10,800,000.00 8,737,854.09 11,500,000.00 100.00 100.00 iLap Category Sequence No: 4 Current Expenditure Category: DISB - GOODS Prt B.5 0.00 0.00 0.00 100.00 100.00 iLap Category Sequence No: 5 Current Expenditure Category: PPF REFINANCING 700,000.00 0.00 0.00 Total 23,700,000.00 15,418,429.13 23,700,000.00 IDA-D0030-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: Performance-Based Pymt Prt A.1 5,700,000.00 2,656,829.18 4,906,846.00 80.00 80.00 iLap Category Sequence No: 2 Current Expenditure Category: Gds,NC, Cs, Trn, Opc Prt A.2 3,200,000.00 3,350,901.89 3,993,154.00 85.00 85.00 iLap Category Sequence No: 3 Current Expenditure Category: Gds,NC, Cs, Trn, Opc Prt B excl B.5 8,000,000.00 6,481,034.51 8,000,000.00 100.00 100.00 iLap Category Sequence No: 4 Current Expenditure Category: DISB - GOODS Prt B.5 x The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) 6,800,000.00 5,719,814.95 6,800,000.00 100.00 100.00 Total 23,700,000.00 18,208,580.53 23,700,000.00 . xi The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) . Results framework COUNTRY: Cote d'Ivoire Health Systems Strengthening and Ebola Preparedness Project Project Development Objectives(s) To strengthen the health system and improve the utilization and quality of health and nutrition services in selected regions. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 PDO Indicators Deliveries in health facilities by trained health personnel 0.00 11,266.00 40,407.00 82,853.00 134,452.00 191,209.00 (Number) Severely malnourished children 0.00 556.00 2,904.00 6,826.00 11,300.00 16,220.00 detected and treated (Number) Vaccination coverage: DTC 97.00 97.20 97.60 98.00 98.50 99.00 (Percentage) Average quality score improvement for facilities 0.00 5.00 15.00 20.00 25.00 35.00 covered by RBF (Number) Per capita utilization of 0.35 0.39 0.44 0.48 0.52 0.56 services (Number) PDO Table SPACE xii The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Intermediate Results Indicators Women using modern family- 13.80 14.00 14.40 14.80 15.20 15.60 planning methods (Percentage) Children under 5 who received Vitamin A supplementation 0.00 0.00 0.00 100,000.00 300,000.00 300,000.00 (Number) Action: This indicator has been Revised Pregnant women receiving antenatal care during a visit to 0.00 20,499.00 80,331.00 168,170.00 266,633.00 368,048.00 a health provider (number) (Number) People with access to a basic package of health, nutrition, or 0.00 446,913.00 1,598,666.00 3,298,129.00 5,315,399.00 7,433,532.00 reproductive health services (number) (Number) Health personnel receiving 0.00 600.00 1,770.00 2,950.00 4,130.00 4,720.00 training (number) (Number) Direct project beneficiaries 0.00 466,913.00 1,648,666.00 3,398,129.00 5,515,399.00 7,433,532.00 (Number) Female beneficiaries 0.00 60.00 60.00 60.00 60.00 60.00 (Percentage) Proportion of indigents among the total direct RBF 0.00 10.00 15.00 20.00 20.00 20.00 beneficiaries (Percentage) xiii The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator has been Marked for Deletion Indigents that remain enrolled 0.00 20,000.00 50,000.00 100,000.00 200,000.00 150,000.00 in health insurance (Number) Annual RASS produced No Yes Yes Yes Yes Yes (Yes/No) Health facilities constructed/ 0.00 0.00 50.00 87.00 97.00 97.00 renovated (number) (Number) Action: This indicator has been Revised Service readiness of health 0.00 5.00 15.00 20.00 25.00 30.00 facilities (Percentage) Equip./supplies available in the National Institure for Public 0.00 90.00 85.00 80.00 75.00 75.00 Hygiene (INHP) (Percentage) People who have received essential health, nutrition, and 0.00 900,381.00 population (HNP) services (CRI, Number) People who have received essential health, nutrition, and population (HNP) 0.00 540,229.00 services - Female (RMS requirement) (CRI, Number) Number of children 0.00 126,401.00 immunized (CRI, Number) xiv The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Number of women and children who have received 0.00 582,771.00 basic nutrition services (CRI, Number) Number of deliveries attended by skilled health 0.00 191,209.00 personnel (CRI, Number) IO Table SPACE xv The World Bank Health Systems Strengthening and Ebola Preparedness Project (P147740)