RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SECTOR SERVICES DEVELOPMENT PROJECT. IDA GRANT No. H393-CG

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SECTOR SERVICES DEVELOPMENT PROJECT IDA GRANT No. H393-CG Board Approval on 29 May 2008 TO THE REPUBLIC OF CONGO Restructured February 28, 2012 Report No:

2 ABBREVIATIONS AND ACRONYMS AFD French Development Cooperation Agency IP Indigenous People (Agence française de développement) CHW Community health worker IPP Indigenous people s plan CNLP National Center to Fight Malaria (Centre IPT Intermittent preventive treatment National de Lutte contre le Paludisme) CNLS National Center to Fight AIDS (Centre LLINS Long-lasting insecticidal nets National de Lutte contre le SIDA) COMEG Congolese Company of Essential Generic M&E Monitoring and Evaluation Medicines CSI Integrated Health Center MDGs Millennium Development Goals Health District (Circonscription Socio MFEB Ministry of Finance, Economy and Budget CSS Sanitaire) DAF Directorate of Administration and Finance (Direction des Affaires administratives et financières) MHSAS F Ministry of Health. Social Affaires and the Family (Ministère de la Santé, des Affaires Sociales et de la Famille DDS Regional Health Directorate (Direction Départementale de la Santé) MSP Ministry of Health and Population (as of October 24, 2011) (Ministère de la Santé et de la Population) DEP Research and Planning Directorate (Direction MTR Midterm review de l'etude et de la Planification) DGAF Director General of Administration and NGO Non Governmental Organization Finance DGS Director General of Health NHA National Health Accounts DHS Demographic and Health Survey PNLP National Malaria Control Program DLM Directorate of Disease Control PHC Primary Health Care DPT Diptheria, pertussis, tetanus PIU Project Implementation Unit DOE Directorate of Organization and Evaluation PLVSS HIV/AIDS Control and Health Project (Projet de Lutte contre le VIH/SIDA et de Santé) EPI Expanded Program of Immunization PSE Package of Essential Health Service FS Health facility formation sanitaire) PSDSS HSSDP (Projet sectoriel de développement des services de la santé GFATM Global Fund to fight AIDS, Tuberculosis and RBF Result Based Financing Malaria GoC Government of Congo SBA Skilled birth attendant HBV Hepatitis B virus SGS General Secretary of Health HIV/AID Human Immunodeficiency Virus - Acquired SNIS National health information system S Immunodeficiency Syndrome HMIS Health Management Information System UNFPA United Nations Fund for Population Activities HSSDP Health sector services development project UNICEF United Nations Children's Fund IDA International Development Association WB World Bank Vice President: Obiageli Ezekwezili Country Director: Eustache Ouayoro Sector Director: Ritva Reinikka Acting Sector Manager: Jean J. De St Antoine Task Team Leader: Jean-Jacque Frère

3 REPUBLIC OF CONGO HEALTH SECTOR SERVICES DEVELOPMENT PROJECT Table of Contents A. SUMMARY... 1 B. PROJECT STATUS... 3 C. PROPOSED CHANGES... 5 D. APPRAISAL SUMMARY Annex 1 - Results Framework and Monitoring Annex 2: RBF Indicators Package of Essential Services... 19

4 REPUBLIC OF CONGO HEALTH SECTOR SERVICES DEVELOPMENT PROJECT RESTRUCTURING PAPER A. SUMMARY 1. The Financing Agreement (FA) providing an SDR 24.3 million ($40 million equivalent) IDA grant for this project was signed on July 18, 2008 and became effective on February 2, At the time of the February 2010 implementation support mission less than 3 percent of the IDA grant had been disbursed. The mission agreed with the Government on a number of actions to accelerate project implementation. These actions and their current status are presented in the table below. Actions Introduce a system of Performance based financing Intensify supervision of project implementation in the provinces Control of malaria: purchase 200,000 Long lasting insecticidal bed nets Review the results framework and the associated indicators Organize a Demographic and Health Survey (DHS) Survey technical capacity of health facilities Strengthen project coordination and recruit additional support staff Implement biomedical waste plan; carry out Indigenous Peoples component. Current status of actions Workshop was organized; two contracts have been signed to conduct a pilot project in three provinces 5 ambulances, 16 4x4 vehicles and 40 motorcycles purchased; travel cost defined; supervision schedules with checklists established 440,000 bed nets have been distributed in six provinces In progress Contract signed and under execution A survey of health facilities was carried out in 2010 Project coordinator appointed in February 2011 and additional support staff recruited National IP policy enacted, but IP component was not carried out. Instead, a diagnostic assessment of their health needs is proposed under the restructured project. The biomedical waste plan which was too ambitious at the time was partially implemented and will be fully implemented for the primary health centers covered under the RBF component as well as for those health centers which will be rehabilitated under the restructured project. 1

5 2. This action plan was based on lessons learned from the first three years of project implementation. The most important lessons were that: (i) the design was too complex for the context with the large number of indicators being a sign of the complexity; (ii) there were too many small activities and those were not defined in operational terms (e.g. leadership strengthening ), thus a need now to focus on fewer high impact priorities; (iii) not enough attention was paid to M&E; and (iv) there was too much focus on workshops, training, and process measures that had little impact on the health system and the health status of the population. 3. Project implementation improved considerably in the 18 months following the 2010 action plan and as a result disbursements improved as shown in the disbursement graph below. Figure 1: Disbursements Over Time (SDRs Millions) estimate based on half year Q Q Q Q Q4 In spite of the progress being made, only half of the US$40 million equivalent (SDR 24.3 million) IDA grant has been disbursed and committed six months prior to the closing date and an important time lag remains. Progress towards achieving the PDOs is modest although the most recent ISR (January 2012) has upgraded the DO rating to MS from MU. The IP rating was upgraded from MU to MS in October. Increasing access to a package of priority health services (Component 4) was the main financing reason of the project but remained the weakest performing activity and had the lowest disbursement percentage of all four components (see component-specific disbursements below in Section C). 4. MTR Conclusions: Options discussed with the Government at the MTR in June 2011 included canceling part of the grant or formally restructuring the project together with a time extension of the closing date. The first option was strongly resisted by the Government. 2

6 However, the Minister of Health and the Country Director agreed on a series of actions that, if accomplished by October 2011 would lead the Bank to consider a restructuring of the Project and an extension of Closing Date. These actions included: (i) distribution of the Long Lasting Insecticidal Nets (LLINS); (ii) engaging consultants to design a results-based financing (RBF) pilot scheme; (iii) improving the functioning of the project management unit; (iv) decentralization of project activities and involvement of regional directors; and (v) a greater focus in the MOH action plan on activities directly related to mother and child health. Given the considerable progress that has been made on these actions, a restructuring procedure has been initiated. 5. The proposed redesign and restructuring focuses on: (i) high impact services to improve health status, implement the RBF pilot scheme, and ensure continued compliance with safeguards (biomedical waste concerns) and implementation of a suitable component to address the needs of indigenous people; (ii) supporting activities: rehabilitate and complete equipping health facilities, strengthening the cold chain; and (iii) putting in place a robust framework for monitoring progress and evaluating outcomes including relevant national surveys. The restructuring would extend the original closing date of May 29, 2012 by 19 months to December 31, B. PROJECT STATUS 6. Project implementation has consistently been behind schedule. Disbursement improved recently (47% in November 2011 versus 3% prior to the February 2010 supervision mission) as some important activities mentioned in the table above were launched. Long Lasting Insecticidetreated bed nets have been procured and distributed, the contract for the Demographic and Health Survey (DHS) has been signed and field work is underway, the contracts for recruiting a health services purchasing agent and a monitoring agency to implement a pilot Results-Based Financing (RBF) scheme have been signed and work has been initiated, additional staff for the coordination unit has been recruited (internal auditor, financial controller) using updated Bank procurement guidelines for consultants. The RBF contracts are valid only until May 31, 2012 (coinciding with the original closing date of the project). A seven month pilot RBF would not deliver the anticipated benefits; a period of two years is generally acknowledged as a reasonable period to show improvements in health status as result of this innovative and evidence-based financing approach. The effectiveness of the use of bed nets cannot be ascertained in a short time frame. The number of indicators currently listed in the results framework (45) is unrealistic given the status of the health information system. A revised results framework with measurable indicators needs to be developed. 7. Financial management. The FA required, as a condition of effectiveness that the Recipient assign two Internal auditors from Inspection Générale des Finances to the Ministry of Health to carry out auditing functions and ensure adequate control of the flow of funds going from central to departmental levels. This measure was complied with at the time of effectiveness and two internal auditors were assigned to carry out these functions. However, they resigned subsequently: as a result, two consultants have been recruited and assigned to the project coordination unit to replace the auditors who left. These recent hires would remediate the reported internal auditing weakness that was the reason for the MS rating. Unaudited Interim Financial Reports (IFRs) for the PDSS are submitted on time, reviewed and found to be 3

7 satisfactory; the IFRs are submitted to the Bank within two months after the end of each quarter. In the future, the IFRs should rather be submitted within 45 days as for all other projects in line with FM guidelines. The external auditors issued an unqualified audit report for the year ended June, 2009 and 2010 and the management letter from the external auditors did not raise any major issues. While the external audit reports are currently required to be furnished semiannually to the Association, following this restructuration it is proposed that these may be furnished annually. The implementing entity is compliant with the Bank s financial management requirements; and there are no overdue audit reports and interim financial reports from this entity. The FM system was rated as moderately satisfactory during the last supervision mission conducted in June 2011 mainly due to lack of staffing at the internal audit unit; however, that issue has since been remedied as noted above. 8. Safeguards. The FA requires the Recipient to implement the Project in accordance with the provisions of the Environmental and Social Management Framework (ESMF). The ESMF was developed during project preparation and was found acceptable to the Association; it includes institutional, monitoring, and budgetary responsibility. However, the national biomedical waste management plan (BWMP) for health facilities, which was included in the ESMF was too ambitious and thus was only partially implemented at the time. However, it will now be fully implemented as part of the restructured project in all the primary health care (PHC) facilities supported by the RBF as well in those facilities being rehabilitated. The Government has begun the procurement of approved incinerators for those PHC facilities and rehabilitated centers and their installation would be completed during the proposed extension period. The proposed restructuring includes safe disposal of medical waste in health centers and the corresponding training of staff. 9. The project includes support for indigenous people (IP), and an entire project sub-component was devoted to analyzing the constraints to culturally appropriate health care, particularly for IPs, and to encouraging their utilization of and participation in the health care system. The proposed activities were non-specific and overly ambitious and included building the capacity of the IP to participate in articulating their special needs, building local ownership and community participation in delivery of services, rehabilitating health facilities, establishing outreach services and strengthening prevention programs, health education and behavior change communication. While the Government approved a national policy on IP, the capacity to implement the action plan as proposed was vastly overestimated. A number of smaller scale activities, however, have been carried out, and IPs were always included in national campaigns such as vaccination and the distribution of long lasting insecticidal bed nets. The proposed restructuring includes a diagnostic assessment of the health status and health needs of this vulnerable population and development of a targeted and realistic health plan to improve their health. 10. The original design of the project anticipated the possibility that construction or extension of health facilities might entail social impact related to displacement of people and loss of socioeconomic activities. Therefore, during Project preparation a Resettlement Policy Framework (RPF) was prepared and adopted, covering any persons who might be resettled under the Project. The RPF defines objectives, principles and procedures to determine the land acquisitions and required compensation that might be required to carry out such facility construction. However there has not been a need to apply the RPF, as no new construction has 4

8 taken place and existing facilities have not been extended. The proposed restructuring will renovate and rehabilitate 21 health centers that will not involve any resettlement or displacement of people, since all activities will be carried out within the existing structures. C. PROPOSED CHANGES 11. Project Development Objectives. No change in PDO. PDO as defined in the FA: to strengthen the Recipient s health system in order to enable it to combat the major communicable diseases effectively and improve access to quality services for women, children and other vulnerable groups. Revised Results Indicators: The Results Framework in the PAD proposed a list of 45 indicators with very few having a credible baseline value. The list consisted of 8 PDO outcome indicators and 37 component-specific intermediate and output indicators. The results framework in the PAD is overly complex with unrealistic indicators that are difficult to measure and rely on a weak information system. The MTR therefore proposed to revise the RF and define indicators with a baseline and a target value that would be measurable and would be logically linked to the proposed activities. The reworked RF shown in Annex 1 retains a few of the original indicators and adds several core indicators for health projects. For simplicity, Annex 1 focuses only on the core indicators that are being retained and the new indicators to be added. 12. Restructuring of Components Components as in the PAD Component 1: Strengthening leadership capacities of MSASF in managing a functioning and decentralized health system. This component will strengthen management and leadership capacities at all levels within the government s decentralization program, including monitoring and evaluation. Component 2: Development and implementation of an efficient and effective system for managing human resources for health % disbursed as of 11/30/ % ($4.0/10.20) 62.5% ($0.5/0.8) Restructured Components This component was very ambitious with limited design details and has had little impact on the health system and on provision of essential services.. The indicators in the M&E sub-component were unrealistic and difficult to measure. Some activities are now incorporated in new components 1 (strengthening decentralization) and 3 (M&E). A new organizational structure for the renamed MSP was approved by presidential decree in October 2011 with the intention to strengthen its managerial and leadership capabilities. The Subcomponent on application of an appropriate financial management system and medium term expenditure Mostly completed as data have been collected. Data analysis is underway. Completed and remaining activity merged into new component 2 5

9 Component 3: Rehabilitation and equipment of health facilities Component 4: Improvement of access to a package of quality essential health services (PSE). 191% ($4.4/2.3) 30% ($7.1/23.9) Would become Component 2 to provide support to new Component 1and include rehabilitating and equipping of PHC centers covered by RBF, and safe disposal of biomedical waste in these facilities. This component was the main reason for financing the project yet has had the lowest disbursement percentage. Will now be narrowed and becomes Component 1 focusing on the essence of the PDO: strengthening the health system and implementing high impact activities (malaria and maternal and child health the latter delivered through a pilot RBF scheme - and includes prevention of mother to child transmission of the HIV virus. The IP subcomponent activities will be restricted to IP health needs assessment under component 2. The subcomponent on improving the efficient procurement and management of essential medicines and medical supplies has been dropped. Application of an appropriate financial management system and medium term expenditure framework, in order to enhance the financing of the sector, and provision of goods, including software, required for the purpose. 13. Restructured Components The following components or sub-components from the original project have been dropped: i) component 1 (Strengthening of Leadership Capacities for Decentralized Health Sector Management), (a) the project helped the client to get an organizational framework for the health sector and strengthening of MSASF s managerial capabilities by hiring consultants and training; (b) create human resources management and finances resources management and (c) the M&E is in the new component 3 in the restructuring project; ii) component 2 (Improvement of Effective Health Sector Human Resources Management) was dropped because it is financed by the AFD (French Development Agency) conforming to the Memorandum understanding signed with the MoH; iii) from component 4 the subcomponent 4.2, 4.3 ( Empower communities in their roles as co-managers of health services) and 4.4 (promotes equitable access to quality health services for all) were dropped. The restructured Project now includes the following components and activities: 6

10 Component 1: Access to a package of high priority health services US$3.025 million This component addresses three health problems that account for the largest share of the burden of disease in the Republic of Congo: malaria, maternal and child mortality, interrupting the transmission of mother to child of the HIV virus. It also includes a pilot program to finance health services based on results. Subcomponent Malaria control: Malaria is the leading cause of mortality and morbidity in the Republic of Congo especially for children. Prevention activities are focusing on the use of long lasting insecticidal bed nets and treatment uses artemisinin-based combination therapy (ACT). Preventive activities are already included and financed under this project. Treatment with ACT is available in the country and ACTs are procured and financed by the Government. Long lasting insecticidal bed nets have been distributed in six provinces (Likouala, Sangha, Cuvette, Cuvette Ouest, Plateaux and Pool). The utilization rate in the pilot province of Pool (utilization defined as bed nets being hung up and ready for use) was recorded by the WHO verification team at 67%. Surveys proposed under Component 3 will verify the utilization rate six and twelve months after the delivery of the bed nets to households. If bed net use is found to be below expected levels to be effective the National Center to fight Malaria (CNLP) would then organize media campaigns to raise awareness and increase usage. Subcomponent Results Based Financing (RBF) This financing approach has been applied successfully in several African countries and has shown that an RBF scheme produces better results in terms of outcomes and outputs, quality of care and equity in the provision of health services as compared to the traditional input approach based on financing inputs (buildings, equipment, medical supplies, drugs, etc.) This pilot subcomponent would be implemented in three departments (Plateaux, Niari, Pool) at a cost of $6.2 million over two years. Two contracts have been signed for the purpose, following Bank procurement guidelines, one with a monitoring agent, the other with a purchasing agent, and these agents have initiated the design of the RBF component. The details of the RBF approach are set out in the procedures manual now being developed by the agents. The RBF approach would involve the provision of a package of essential health services by health facilities. In addition, the agents would provide training to staff to improve their maternal and child services and immunization services to increase the vaccination rates. It is anticipated that the contracts with agents engaged for the RBF would be extended so that they would continue to manage this process once the restructuring is approved by Bank management. A feasibility study for a RBF project was carried out in June 2010 by two consultants at the request of the Government and financed out of the Financing. Cost of the first contract for the purchasing agent is derived from extrapolating the operational items of the 18 month estimated budget included in the feasibility study to 24 months thereby adding $0.9 million to the $4.5 million estimated budget for 18 months. The cost of the second contract for the independent monitoring agent would be $800,000. Annex 2 shows a preliminary list of indicators proposed by the NGO monitoring agent in their proposal with targets to measure progress towards delivery of essential health services. External Monitoring Agent: $0.8 million for 23 months Health services purchasing agent including consulting fees, reimbursable expenses, equipment and financing of operational support and internal monitoring from health 7

11 districts and provincial health departments: $.625 million for 24 months Payments to health services facilities in reimbursement for services provided: $1.6 million for 24 months Individual health facilities would be awarded sub-grants for the delivery of agreed basic packages of health services and would be paid amounts in reimbursement for services rendered based on the quantity and quality of services they provide as independently verified. A unit price for each service will be developed and defined in the procedures manual to ensure, inter alia, that the price does not exceed the reasonable cost (not otherwise financed) for the service and reflects the quality of the service as well as the remoteness of the facility. Adoption by the Recipient of the procedures manual approved by the Association for this component would be required before any sub-grant could be awarded. The unit price would be reviewed and updated each year as necessary to ensure continued compliance with these requirements. An example of how the reimbursements would be made is shown in table 1 below and summarized as follows: If a health facility fully immunizes 100 children in a quarter, it could be paid up to US$500 (100 X $5 per child fully vaccinated, at the initial unit price for a fully vaccinated child). The total amount paid for this service would be adjusted for the remoteness or difficulty of the facility (equity bonus) to reflect the additional cost of providing the service under such circumstances. In the example below, this particular facility would be paid 50% more because of the difficulties it faces. The total would also be adjusted by a quality score based on a checklist administered at the facility every quarter. This facility would be paid 60% of what it would otherwise be entitled to due to the quality correction. The reimbursements paid ($900 in this example) would be transferred to the bank account of the facility and could be used, under the terms of the sub-grant agreement between the Government (acting through the agent) and the health facility concerned, for: (i) health facility operational costs (about 50%), such as drugs and consumables, outreach expenses, health facility maintenance and repair, etc.; (ii) performance bonus for the overtime work performed by health workers (up to 50%) according to defined criteria; and (iii) savings for specific expenditures that will enhance the facility s provision quality services this health facility is saving up to buy a motorcycle to facilitate community outreach. Simplified Example of Performance Based Financing in a Health Facility Service Number Provided Unit Price Total Earned Last Quarter Child fully vaccinated 100 $5 $500 Skilled birth attendance 15 $20 $300 Curative care <5 years of age 400 $0.5 $200 Total $1,000 Remoteness (Equity) Cost +50% $1,500 Quality correction 60% $900 Use of Reimbursements Drugs and consumables $300 Outreach expenditures for transportation $50 Repairs to the health facility ceiling $50 Bonuses to staff in the facility $400 Savings for motorcycle $100 8

12 Component 2: Support to provision of priority health services: $5.045 million This component would provide the tools enabling the effective delivery of the high impact health services defined in the first component: renovating and equipping physical facilities, retraining health workers, e.g. midwives from rural areas, and implementing the biomedical waste management program in the health centers rehabilitated under the project and covered by the RBF zones. Rehabilitation of 21 health centers at a cost of $4.5 million. Contracts have already been prepared following Bank procurement procedures and are ready for signature. Construction work consists of renovating and rehabilitating existing buildings, within the building s existing footprint, and for which there will be no resettlement of people. Construction supervision and quantity survey work will be the responsibility of the Government Department of Public Works. The rehabilitation of eleven other health centers is close to being completed. A total of 32 health center would therefore be rehabilitated. Additional procurement of biomedical equipment, pharmaceuticals, vaccines, and cold chain elements at a cost of $300,000. Develop and carry out a biomedical waste management program originally included in old Component 4. Cost, as specified in the PAD, is $ The restructured project will provide for safe disposal of medical waste in the PHC facilities covered by the RBF component, and the facilities to be rehabilitated under the Project (the Government assumes responsibility for biomedical waste disposal in provincial and national hospitals, not covered by the project). More details are provided below in the safeguards section. Finalize the analysis of the data collected under the Human Resources management component from the old component 2 which include the health workforce census as well as the health facilities masterplan. Strengthen the capacities of MHP; no new activities would be included, but this subcomponent would simply capture the activities already completed under the original component 1, which include the reorganization of the Ministry leading to a new organigram as well as the creation of the directorates for human resources, financial management, and project administration and management. Component 3: Monitoring and Evaluation and Project Management: $3.230 million This is a new component that recognizes the need to strengthen the Government s ability to track performance of its health sector, make adjustments, when needed, and determine whether activities undertaken are resulting in the anticipated health benefits. It continues the technical assistance to MSP in implementing the project. As part of M&E under the proposed restructuring there would be an assessment of the utilization of bed nets in two phases: first at 6 months and then at 12 months after distribution of the bed nets which took place in November This assessment will be carried out by a team of graduate students of the Université Marian Ngouabi at Brazzaville supervised by their instructors. The same team using the same assessment instrument would be used for the two phases to minimize changes in the research procedures and to maximize comparability between the two phases. The Directorate of Organization and Evaluation (DOE) of the MSP will be responsible for making the necessary implementation arrangements under implementation arrangements between the MSP and the University, and a dated covenant to ensure the conclusion of timely arrangements by May 31, 2012 for these assessments would 9

13 be included in the restructuring. The cost of each assessment is estimated at $200,000. The RBF pilot requires close monitoring in order to draw conclusions, make recommendations and prepare for extending the pilot on a larger scale. To that effect the proposed restructuring would include a limited household survey. The survey would be carried out two years after the current DHS with over-sampling in the RBF pilot districts and matched comparison districts. This would facilitate an evaluation of the impact of the RBF pilot project. A before/after and experimental/control group design would be used. For the before/after design, the before measures will be derived from the 2011 DHS and the after measures from the smaller household survey expected to be carried out at the end of The latter would use a reduced version of the DHS questionnaire. For the experimental/control group design, the three RBF departments will be the experimental group and a sample of matched non-rbf departments will be the control group. A comparison of the results in the two groups will provide a robust evaluation of the impact of the RBF experiment. The cost of the survey is estimated at $330,000. Data from the expenditure part of the household survey will contribute to the NHA program under development. Similarly, evaluating the impact of the RBF pilot would require a modest health facility survey expected to be carried out nation-wide in 2013 with over-sampling in the RBF pilot and comparison districts at an estimated cost of $300,000. This would build on the facility survey conducted in 2009, financed by the project. Both the limited household survey and the health facility survey will be contracted out under one single contract. The contract would be awarded in accordance with the Bank s procurement/consultant Guidelines. Assess the health status nationwide of the indigenous population (IP) and preparing a health plan to address their health needs concerns (OP 4.10). The methodology to be used will combine using available statistics from health centers and using an anthropological approach by visiting the IP in selected camps/villages and finding out what they consider disease and how they rate their health. This assessment would be be carried out by an international consultant recruited following Bank Consultant Guidelines in cooperation with local partners and supervised by the Bank at a cost of $100,000. In addition to these monitoring and evaluation activities the proposed restructuring would include the following activities in the project: a) Continue ongoing support to National Health Information system (Système National d Informations Sanitaires) and strengthening epidemiological surveillance. This support consists of the following activities: training of two data collection clerks in each province already approved by the Bank, quarterly supervision missions by provincial managers, quarterly M & E workshops in all 12 provinces, training of data entry clerks; field visits to verify validity of reports submitted with observed results, one national workshop to review M&E results coupled with training sessions; ($300,000) and b) Initiate a national program of operational research. This activity would establish an OR capability in the DOE of MSP by first developing and distributing a national research strategy. Workshops would then be organized to train staff in research methods with didactic support from the university, an international research organization or an academic institution. The training would include designing a research or demonstration 10

14 project to be carried out in at least three provinces. Training would also dissemination of the surveys defined above. ($200,000). c) Epidemiological surveillance will be conducted ($200,000). Project Management. Technical assistance provided to implement the project has consisted of employing six international consultants and two national consultants. The international consultant in human resources resigned and will not be replaced. At the time of effectiveness two internal auditors were assigned to carry out auditing and financial control functions. However they resigned subsequently and two consultants have now been recruited and assigned to the project coordination unit to replace the auditors who left. These two national consultants have been added to remediate the weaknesses in carrying out internal auditing functions and to ensure adequate control of the flow of funds going from central to departmental levels, i.e. an internal auditor and a financial controller, bringing the total to nine consultants. However not all positions are needed until the end of the project and contracts need therefore not be extended for the duration of the proposed extension period. Some positions can be phased out earlier. The cost of extending the contracts of the long term experts and consultants has been estimated at $900,000 for salaries and $500,000 for operating expenses or a total of $1.6 million. 14. Safeguards: The proposed restructuring includes a diagnostic assessment of the health status and health needs of indigenous population and developing a targeted and realistic health plan to improve their health under Component 2. This assessment is scheduled to be carried out by not later than December 31, 2012 under Component 3. This activity will be managed by the Recipient, and an international consultant will be recruited by the Recipient to work with local counterparts. Environmental and Social Management Framework (ESMF). The ESMF was developed during project preparation and found acceptable to the Association.. However, the national biomedical waste management plan (BWMP) for health facilities, which was part of the ESMF but was found to be too ambitious and will be implemented in the PHCs covered by RBF and those being rehabilitated under the restructured project (while the Government has implementation responsibility for provincial and national hospitals and health centers not covered by the Project). The proposed restructuring includes safe disposal of medical waste of the PHCs included in the RBF and those rehabilitated under the Project, and the corresponding training of staff and is included in Component 2 at a cost of $185,000. The diagnosis of biomedical waste management in the health facilities (PAD Annex 10 Safeguard Policy Issues) identified weaknesses in the establishment and use of incinerators, the lack of adequate plans and/or internal management procedures (technical guidelines), the inadequacy of collection, storage and sorting of biomedical waste from household waste, and the lack of adequate and regularly-supplied individual protection equipment as well as inadequate staff skills and behaviors in the biomedical waste management due partly to limited attention by nursing and support staff to waste handling, which sometimes leads to accidents. The restructured project will comprise technical assistance to implement the waste management plan at the health centers included in the RBF and those to be upgraded, under component 2, and will 11

15 include provision of personal protection equipment, training of health staff, and distribution of information and awareness materials at the health centers. It has been determined that the rehabilitation work on the 21 health centers will not cause resettlement of people as the buildings already exist and will not be expanded, but will simply be upgraded and renovated within their existing footprint. Consequently, RAPs will be not needed for this rehabilitation. In view of the above, the safeguards frameworks will not be redisclosed for this restructuring. Project Cost including Disbursements, Commitments and Extension Cost by Component (USD) A. Disbursements as of November 30, 2011 (component-specific disbursement in Section C above) B. Commitments as of November 30, 2011 $16,000,000 $4,600,000 C. Commitments for the period December $7,800,000 1, 2011 to current closing date of May 31, 2012 Balance for extension period $11,600,000 D. Cost of Extension from June 1, 2012 to April 30, 2014 Component Component 1 Malaria control o Bed nets o Media campaign RBF Pilot RFB Monitoring Cost Completed $25,000 $3 million* ($800,000)** Component 2 Rehabilitation of health centers Biomedical equipment Biomedical waste management Vaccines Subtotal $3,025,000 $4.5 million $300,000 $245,000 GOC + GAVI Subtotal $5,045,000 Component 3 Survey use of bed net $200,000 Household survey $330,000 Health Facilities survey $300,000 Indigenous population survey $100,000 Support to SNIS $300,000 Epidemiological surveillance $200,000 Operational Research Program $200,000 Project Management: long term $1.6 million consultants, supervision Subtotal $3,230,000 Non Allocated 300,000 12

16 Total Extension Grand Total *$2.4 million (Euros 1,851,875) already included in C. **Already included in C. US$11,600,000 US$40,000,000 Category (1) Goods, works, services and Operating Costs for each Approved Annual Work Plan for all Parts of the Project (excluding Part A(2) thereof) (2) Goods, services, Training and Operating Costs required for each PBHS provided under a PBHS Subproject and to be financed out of a PBHS Sub-grant under Part A (2) of the Project and paid at the Unit Price for said PBHS Disbursement Category Table Amount of the Financing Allocated (expressed in USD) Amount of the Financing Allocated (expressed in SDR) Percentage of Expenditures to be Financed (inclusive of Taxes) 37,000,000 27,477, % 3,000,000 1,822, % of amounts paid by the Recipient under the PBHS Subgrant TOTAL 40,000,000 24,300,000 D. APPRAISAL SUMMARY Closing Date: The closing date is proposed to be extended to December 31, 2013 in order to complete the two year pilot RBF. Evidence from other African demonstrates that a two year implementation period is needed to show results from a pilot RBF operation that allow drawing conclusions, making recommendations and preparing for extending the pilot on a larger scale even nationally in some countries. Implementation schedule: The extension period proposed is 19 months from June 1, 2012 to December 31,

17 Geographic Coverage. The pilot RBF project will be implemented in three provinces: Pool, Plateaux, and Niari. Distribution of long lasting insecticidal bed nets to combat malaria has been done in six provinces under the project. The Global Fund (GFATM) is presently in the process of distributing bed nets in the other five provinces and in Brazzaville thereby achieving national coverage. The proposed surveys will be nationwide. Implementation Arrangements: The Minister of Health remains the Coordinator of the project. The MOH staff member who was previously the Head of the Secretariat was appointed Deputy Coordinator (Coordinateur Délégué) on February 22, 2011 by Ministerial Decree. He reports to the Minister and his functions are to coordinate and facilitate the implementation of the project by the technical departments of the Ministry of Health and Population (formerly the Ministry of Health, Social Affairs and Family) and to coordinate the work of the five international experts and the four local long term staff. The requirement that the Recipient furnish annual proposed budgets for the health sector to the Association for comment has been dropped under the restructuring. Procurement: The approved 2011 Procurement Plan is no longer valid due to the restructuring and adjustment of Project activities. A new procurement plan for the extension period has been approved by the project coordinating unit that reflects the proposed changes in components and their associated costs.. In addition, the new Procurement/Consultant Guidelines will apply to the restructured Project. Introduction and application of Results Based Financing (RBF). This financing approach was applied in Rwanda in 2001, in the DRC in 2004, in Burundi in 2006 and subsequently in a number of African countries (Tanzania, Zambia Central African Republic, and Cameroon). These countries have shown that an RBF scheme produces better results in terms of outcomes and outputs, quaity of care and equity in the provision of health services as compared to the traditional input approach based on financing inputs (buildings, equipment, medical supplies, drugs, etc.). A number of factors account for the increasing acceptance by countries of this methodology: The population sees an improvement in the quality of services provided by a more highly motivated staff; Health staff are motivated because their remuneration increases and they are able to take more initiative which increases their sense of responsibility and accountability; Governments quickly notice an improvement in the delivery of social services; and Development partners see their contribution to meeting the MDGs and other social objectives. 14

18 E. PROCESSING SCHEDULE December 2011: Finalize restructuring paper and circulate within task team- Done December 2011: Receive letter from Government requesting restructuring and time extension Early January 2012: Circulate restructuring paper within the Bank - Done End February: submit restructuring paper to Country Director for approval and sign off. 15

19 HEALTH SECTOR SERVICES DEVELOPMENT PROJECT Annex 1 - Results Framework and Monitoring The restructured results framework contains 19 indicators to evaluate progress believed to be measurable and most have a baseline value based on official records. Seven indicators are Core Sector Indicators from the Results Platform for projects that have Health (JA) among their sector codes (May 25, 2011 version) and three indicators have been retained from the PAD. Impact and Outcome Indicators New or retained from PAD Baseline End Project Target Data Collection and Reporting Frequency and Responsibi lity PDO: to strengthen the Recipient s health system in order to enable it to combat the major communicable diseases effectively and improve access to quality services for women, children and other vulnerable groups. Project Outcome Indicators 1. % children under five years of age who slept under an ITN the previous night 2. number of outpatient consultations for children under five years of age 3. % Children fully immunized for Penta3 (DTP, Hep. B, Hemovirus) Core indicator in PAD New Core indicator 0% in 2008; 67% (range: 93% 59%). WHO verification report in 2011 Not being measured. 65% from MSP/EPI records Maintain coverage 0.2 visits per capita per year 70% Household surveys in June and December 2012 to determine % MSP/DGS MSP/DGS 4Children receiving a dose of vitamin A (%) 5Percent births attended by skilled health personnel HIV/AIDS Control in RBF Departments Pilot Project Core indicator new Core indicator in PAD 66% 70% MSP/DGS 86% (range 64% to 100%) from official Government 2011 report 90% MSP/DGS 16

20 3. 6. Number of persons tested Pregnant women receiving ART TBD TBD TBD TBD Baseline and targets will be defined 4. Number of persons under treatment TBD TBD by the contractor during initiation phase of pilot December 2011 February Long-lasting insecticide-treated malaria nets distributed (number) 2. Health facilities renovated and equipped (number) 3. Survey use of bed nets - 2 surveys in 6 departments 4. Survey Household health (mini DHS) Output Indicators Core MSP/PNLP indicator new Core MSP/DOE indicator New 67% TBD by surveys New Final report November Health Facility Survey New Final report November Survey health status indigenous population OP Payments made to PBF pilot health facilities in 3 departments 8. Develop a national strategy for operational research and carry out 3 research studies New No survey done Final report April 2012 MSP/DOE and ROC University June and December 2012 MSP/DOE and Consulting firm November 2013 MSP/DOE and consulting firm November 2013 Consultant June 2012 New 0 90% Quarterly by contracted Monitoring firm New New activity Report December 2013 MSP/DOE with TA December

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22 HEALTH SECTOR SERVICES DEVELOPMENT PROJECT Annex 2: RBF Indicators Package of Essential Services This list of examples of indicators was included in the proposal of the firm under contract to carry out the pilot RBF. This is a preliminary indicative list to be finalized at the beginning of contract execution. Not all the proposed indicators will be used in all health centers. Indicators selected will reflect the technical capacity of the health center. Baseline data and achievable targets for all indicators will be developed by the contractor during the initiation phase. Service Target New curative care patients 1/person/year New outpatient visits 10% of new patients Number of hospital days 1 occupied bed/1,000 pop. Minor surgery 5% of new patients Fully immunized children 95% Fully immunized women (VAT5) Emergency hospital referrals STI patients treated 5% of new patients Number of HIV tests Positive HIV referred to hospital Pregnant women with prophylactic ARV ARV treatments Assisted deliveries 80% New Family Planning patients 21% Number IUD inserted 2%/year Prenatal visits (DPT3 + VAT2) 80%