Lesotho - Maternal Newborn Health PBF Level 1 …documents.worldbank.org/curated/en/205661479480928830/... · Web view1.Modify the Project Development Objective (PDO) from "improve

Document ofThe World Bank

FOR OFFICIAL USE ONLY

Report No: RES23679

RESTRUCTURING PAPER

ON A

PROPOSED PROJECT RESTRUCTURING OF THE

HEALTH SECTOR PERFORMANCE ENHANCEMENT PROJECT(BOARD APPROVAL DATE OF THE ORIGINAL

MATERNAL AND NEWBORN HEALTH PERFORMANCE BASED FINANCING PROJECT WAS ON APRIL 11, 2013)

TO THE

KINGDOM OF LESOTHO

November 2, 2016

HEALTH, NUTRITION & POPULATIONAFRICA

This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

ABBREVIATIONS AND ACRONYMS

CERC Contingent Emergency Response ComponentCPF Country Partnership Framework DOTS Directly Observed Treatment StrategyEmONC Emergency Obstetric and Neonatal CareFM Financial ManagementFY Fiscal YearGoL Government of LesothoHMIS Health Management Information SystemHRITF Health Results Innovation Trust FundIP Implementation ProgressISR Implementation Status and ResultsM&E Monitoring and EvaluationMNH Maternal and Newborn HealthMoF Ministry of FinanceMoH Ministry of HealthMU Moderately UnsatisfactoryNSRHSC National Sexual and Reproductive Health Steering CommitteePBF Performance-Based FinancingPAU Project Accounting UnitPDO Project Development ObjectivePMTCT Prevention of Mother to Child TransmissionPPP Public Private PartnershipQMMH Queen 'Mamohato Memorial HospitalSRH Sexual and Reproductive HealthTA Technical AssistanceTWG Technical Working GroupVHW Village Health Worker

Regional Vice President: Makhtar DiopActing Country Director:

Senior Global Practice Director: Sebastien DessusTimothy Evans

Practice Manager/Manager: Magnus LindelowTask Team Leader: Kanako Yamashita-Allen

ii

lesothoHealth Sector Performance Enhancement Project

(formerly Maternal and Newborn Health Performance Based Financing Project)

CONTENTS

A. SUMMARY 2B. PROJECT STATUS 4C. PROPOSED CHANGES 5

ANNEX 1: RESULTS FRAMEWORK AND MONITORING 14

iii

DATA SHEETLesotho

Lesotho Health Sector Performance Enhancement Project (formerly Maternal & Newborn Health PBF) (P114859)

AFRICAHealth, Nutrition & Population

.

Report No: RES23679.

Basic InformationProject ID: P114859 Lending Instrument: Specific Investment Loan

Regional Vice President: Makhtar Diop Original EA Category: Partial Assessment (B)Country Director: Sebastien Dessus Current EA Category: Partial Assessment (B)

Senior Global Practice Director: Timothy Grant Evans Original Approval Date: 11-Apr-2013

Practice Manager/Manager: Magnus Lindelow Current Closing Date: 30-Jun-2017

Team Leader(s): Kanako Yamashita-Allen.

Borrower: Ministry of Finance

Responsible Agency: Ministry of Health, Ministry of Finance

.

Restructuring TypeForm Type: Full Restructuring Paper Decision Authority:

Board/AOB Decision

Restructuring Level: Level 1.

Financing ( as of 16-Jun-2016 )Key Dates

Project Ln/Cr/TF Status Approval Date Signing Date Effectiveness

DateOriginal Closing Date

Revised Closing Date

P114859 IDA-52290 Effective 11-Apr-2013 18-Apr-2013 14-Feb-2014 30-Jun-2017 30-Jun-2017

P114859 TF-14147 Effective 18-Apr-2013 18-Apr-2013 14-Feb-2014 30-Jun-2017 30-Jun-2017

Disbursements (in Millions)

Project Ln/Cr/TF Status Currency Original Revised Cancelled

Disbursed

Undisbursed

% Disburse

d

P114859 IDA-52290 Effective USD 12.00 12.00 0.00 2.36 8.69 20

P114859 TF-14147 Effective USD 4.00 4.00 0.00 0.59 3.41 15.

Policy WaiversDoes the project depart from the CAS/CPF in content or in other significant respects? Yes [ ] No [ X ]

Does the project require any policy waiver(s)? Yes [ ] No [ X ].

A. Summary of Proposed ChangesThis level one restructuring seeks to:

1. Modify the Project Development Objective (PDO) from "improve utilization and quality of maternal and newborn health (MNH) services in selected districts in Lesotho" to: "(i) increase utilization and improve the quality of primary health services in selected districts in Lesotho with a particular focus on maternal and child health, TB and HIV; (ii) improve contract management of select PPPs; and (iii) in the event of an Eligible Crisis or Emergency, provide immediate and effective response to said Eligible Crisis or Emergency." The level one restructuring will also revise the project title to: "Health Sector Performance Enhancement Project."

2. Reduce the project's geographical scope from nine to six districts (Leribe, Quthing, Mafeteng, Mohale's Hoek, Mokhotlong, and Thaba-Tseka) in order to utilize the availability of project financing to make adjustments to the current Performance-Based Financing (PBF) design, and to accommodate the inclusion of a new component on support to public private partnerships (PPPs). The project will no longer scale up to the three districts of Berea, Butha Buthe, and Qacha's Nek.

3. Revise implementation arrangements to: (i) Include the Ministry of Finance (MoF) as a second implementing agency for the new component on PPP support (Component 3); and (ii) Revise the staffing requirements of the Ministry of Health (MoH) PBF Unit. The MoH will continue as the implementing agency for Components 1 and 2, and oversee the implementation of the newly added Component 4.

4. Streamline project governance and oversight structures by delegating operational and technical functions to the existing Sexual and Reproductive Health (SRH) Technical Working Group (TWG), previously carried out by the inter-ministerial National Sexual and Reproductive Health Steering Committee (NSRHSC), which involves a wide range of development partners. Given that the NSRHSC does not meet frequently, operational functions of the NSRHSC will be delegated to the SRH TWG comprised of a sub-set of the NSRHSC. Under this new arrangement, the NSRHSC will continue to provide overall policy direction to the project, even given the broadened scope of the operation.

5. Revise the project components as follows:

(a) Component 1 would be renamed to: "Improving Health Service Delivery through PBF," and would be revised to: (i) suspend implementation of the village health worker (VHW) PBF program; (ii) adjust the PBF program at the District Hospital level to focus more on the quality of services, and provide individual bonuses to hospital staff; and (iii) revise the quantitative incentivized indicators at the health center level by revising existing and including additional HIV and TB indicators.

2

(b) Component 2 would be renamed to: "Capacity Building Support to the Ministry of Health," and the scope of activities will be expanded to provide additional capacity building support to: (i) strengthen MoH procurement capacity and streamline procedures; (ii) better align the MoH's Annual Joint Review with health sector strategic objectives, with a greater focus on program impact; and (iii) improve the integration of the Queen 'Mamohato Memorial Hospital (QMMH) network into the health system.

(c) Add a third component entitled: "Enhance PPP Management Capacity within the Government of Lesotho," to support the QMMH network PPP, including PPP management capacity building. Proposed activities include the provision of TA to strengthen oversight over the QMMH network PPP and other existing health PPPs, including PPP management capacity building.

(d) Add a no-cost fourth component, entitled: "Contingent Emergency Response Component (CERC)," in the event of the potential need to support activities related to mitigating the impact of shocks in Lesotho. The CERC is included under the project in accordance with OP10, paragraphs 12 and 13, for situations in urgent need of assistance.

6. Reallocate funds across project components and disbursement categories to: (i) increase allocations to consulting services under both the IDA credit and the Health Results Innovation Trust Fund (HRITF) grant, as well as operating costs under the IDA credit; and (ii) decrease allocations to category one (performance-based grants), under both the IDA credit and HRITF grant, training under the IDA credit, and operating costs under the HRITF grant. Funds will also be reallocated across the project components. Overall, US$1,541,888 will be reallocated to PPP and health systems related activities under Components 2 and 3. Consequently, allocations to Component 1 will be reduced from US$13.7 million to US$11.45 million, while Component 2 allocations will increase from US$2.3 million to US$3.73 million, and US$815,000 will be reallocated to the new Component 3. Finally, a goods category will be included under the IDA financing to facilitate the aforementioned activities under component 2.

7. Revise the Results Framework to include new and revised PDO level indicators and intermediate results indicators to reflect the broadened PDO and to improve the measurability of specific indicators, and the consistency of data sources. A new indicator reflecting the establishment of the MoF Central PPP Unit and MoH Contract Management Office has been added as a PDO level indicator as proxy for the activities under the new PPP component. Two intermediate outcome indicators (one on TB treatment according to the Directly Observed Treatment Strategy (DOTS) and another on the prevention of mother to child transmission (PMTCT) of HIV) have been converted to PDO level indicators to reflect the broader focus of the PDO.

8. Extend the project closing date by 24 months, from June 30, 2017 to June 30, 2019 in order to maximize the potential for the achievement of the project's broadened objectives in the areas of PBF and PPP management capacity building in the health sector.

Change in Implementing Agency Yes [ X ] No [ ]

Change in Project's Development Objectives Yes [ X ] No [ ]

Change in Results Framework Yes [ X ] No [ ]

Change in Safeguard Policies Triggered Yes [ ] No [ X ]

Change of EA category Yes [ ] No [ X ]

Other Changes to Safeguards Yes [ ] No [ X ]

Change in Legal Covenants Yes [ X ] No [ ]

3

Change in Loan Closing Date(s) Yes [ X ] No [ ]

Cancellations Proposed Yes [ ] No [ X ]

Change to Financing Plan Yes [ ] No [ X ]

Change in Disbursement Arrangements Yes [ ] No [ X ]

Reallocation between Disbursement Categories Yes [ X ] No [ ]

Change in Disbursement Estimates Yes [ X ] No [ ]

Change to Components and Cost Yes [ X ] No [ ]

Change in Institutional Arrangements Yes [ X ] No [ ]

Change in Financial Management Yes [ ] No [ X ]

Change in Procurement Yes [ X ] No [ ]

Change in Implementation Schedule Yes [ X ] No [ ]

Other Change(s) Yes [ X ] No [ ]

Appraisal Summary Change in Economic and Financial Analysis Yes [ ] No [ X ]

Appraisal Summary Change in Technical Analysis Yes [ ] No [ X ]

Appraisal Summary Change in Social Analysis Yes [ ] No [ X ]

Appraisal Summary Change in Environmental Analysis Yes [ ] No [ X ]

Appraisal Summary Change in Risk Assessment Yes [ ] No [ X ].

B. Project StatusThe Lesotho Health Sector Performance Enhancement (formerly Maternal and Newborn Health Performance-Based Financing) Project (P114859) was approved by the Board on April 11, 2013, and became effective on February 14, 2014 with an original closing date of June 30, 2017. The IDA Credit of SDR 7.8 million (US$12 million equivalent) is co-financed by a US$4 million grant from the HRITF. The current PDO is to improve the utilization and quality of maternal and newborn health services in nine districts in Lesotho. The restructured project supports the relevant health sector objective of the Country Partnership Framework (CPF) for FY16-FY20 (Report number 106720) to strengthen the health system and improve health outcomes by: (i) reducing inefficiencies in public health sector spending by linking financing to objective, transparent and well-understood measures of performance of the service provider; (ii) addressing health human resource shortages by focusing on maximizing the productivity and performance of existing health care workers through incentive-based compensation schemes; and (iii) motivating facilities and their workers to improve overall service quality, which would contribute to improving health outcomes.

The PBF program has been piloted in two districts, Leribe and Quthing, with initial plans to scale up to seven additional districts (while some activities under Component 2 have had broader implementation). However, since project effectiveness, the pace of implementation has been adversely affected by critical bottlenecks, namely financial management (FM) capacity constraints, delays in the flow of PBF incentives to health facilities in the pilot districts, and lack of dedicated personnel in the MoH PBF Unit to support key project activities. Despite the aforementioned challenges, however, following 32 months of implementation, the PBF pilot program is showing some good progress, with data for health outputs demonstrating positive trends for several incentivized indicators including institutional deliveries: four antenatal care visits, post-natal care and immunization. In addition, average health facility quality of care

4

scores in the pilot districts of Leribe and Quthing have improved from 38.3 percent in 2013 to 70.7 percent in 2015. FM and funds flow capacity constraints have been resolved, with the FM function of the project migrated to the MoH Project Accounting Unit (PAU), and the opening of the Health Center Committee administered bank accounts at the Government of Lesotho (GoL) health facilities. The PBF Unit is also in the process of recruiting additional staff members, including a Senior PBF Officer and PBF Officer, in order to resolve the current staffing constraints. Other highlights include ongoing training activities for health care workers, including advanced midwifery, neonatology, and anesthesiology training for nurses, training for VHWs, and training on procurement and contract management, monitoring and evaluation, and PBF principles to key MoH staff.

To date, a combined US$3 million or 18.5 percent of the total project funds have been disbursed under the Credit and the HRITF grant, and there are no overdue audit reports related to the project. According to the latest June 2016 Implementation Status and Results Report (ISR), the project’s PDO, overall implementation progress (IP), FM, and Project Management ratings are Moderately Unsatisfactory (MU), primarily due to the aforementioned critical bottlenecks affecting project implementation, including FM and PBF funds flow constraints, and an inadequate staffing complement at the MoH PBF Unit. Furthermore, Monitoring and Evaluation (M&E) is also rated MU due to inadequate M&E capacity within the MoH, which has impacted timely reporting, particularly with regards the results framework indicators..

C. Proposed Changes.

Change in Implementing Agency

Please describe the change and explain the reason for change:

The proposed restructuring includes the addition of a PPP management capacity enhancement support component and the MoF will be responsible for the implementation of this new component, including PPP management capacity building, jointly with the MoH. Therefore, the MoF will be included, in addition to the MoH, as a second implementing agency. However, project funds allocated to the activities under the MoF will continue to be disbursed out of the existing MoH Designated Account for the project.

Implementing Agency Name Type Action

Ministry of Health Implementing Agency No Change

Ministry of Finance Implementing Agency New.

Development Objectives/ResultsProject Development Objectives

Original PDO

The overall project development objective is to improve the utilization and quality of maternal and newborn health (MNH) services in selected districts in Lesotho.

Change in Project's Development Objectives

Explanation

The project's development objectives will be amended in order to reflect support to the QMMH network PPP and other existing health PPPs, as well as the sharpened focus of the PBF program, and potential support in the event of an eligible crisis or emergency.

Proposed New PDO

5

The overall project development objective is to: (i) increase utilization and improve the quality of primary health services in selected districts in Lesotho with a particular focus on maternal and child health, TB and HIV; (ii) improve contract management of select PPPs; and (iii) in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency.

6

Change in Results Framework

Explanation:

The Results Framework will be revised to not only reflect the now broadened PDO, with a particular focus on maternal and child health, TB and HIV, but also to improve the measurability of specific PDO and intermediate results indicators, and the consistency of data sources. A new indicator reflecting the establishment of the MoF Central PPP Unit and MoH Contract Management Office has been added to the PDO level indicators as a proxy for the activities under the new PPP component. Furthermore, supplementary progress/sub-indicators (beyond those monitored in the Results Framework), including qualitative indicators, will be tracked, in consultation with GoL, in order to monitor progress under the new PPP component. Two intermediate outcome indicators (one on TB treatment according to DOTS and another on PMTCT of HIV) have been converted to PDO level indicators to reflect the broader focus of the PDO. The proposed changes are reflected in the revised Results Framework, which is harmonized with Lesotho’s Health Management Information System (HMIS), as well as routine utilization data from the PBF invoices reporting on the incentivized quantitative and qualitative indicators under the project. Baseline and targets have also been revised keeping in mind the project’s reduced geographic scope from nine districts to six, and the two year extension to the closing date..

Change in Legal Covenants

Explanation:

The two legal covenants related to the creation and maintenance of a MoH procurement unit, and the recruitment of a procurement manager and two procurement officers, are not currently complied with as they do not reflect the current set-up of the MoH procurement unit, and will consequently be dropped. The MoH rather seeks the project’s support to strengthen and build capacity and efficiency of the MoH’s procurement systems and processes.

In addition, under the principles of a PBF operation, although the health facilities are required to maintain sound FM systems, they are not required to submit audited financial statements, as is currently stated in the project Financing and Grant Agreements, and as such, the relevant statements will be removed. Health facilities are the beneficiaries of earned incentives which are rigorously reviewed prior to release, and which they are entitled to spend in accordance with their respective business plans. Furthermore, facilities are subject to audits on a sample basis by the auditor general, and quarterly reviews by the MoH internal audit team. The MoH, however, is required to submit annual audited financial statements and maintain a sound FM arrangement as per the project legal agreements.

Ln/Cr/TF

Finance Agreement Reference

Description of Covenant Date Due Status Recurre

ntFrequency Action

IDA-52290

Finance Agreement :Section II. B. 4 of Schedule 2. | Description :Procure no later than one (1) month after the Effective Date, additional financial management software (TOMPRO) licenses, in accordance with the provisions of Section III of this Schedule 2 to the

Complied with

No Change

7

Financing Agreement | Due Date :17-Mar-2014

IDA-52290

Finance Agreement :Section I D. 1 of Schedule 2. | Description :Prepare a program of activities (including Training and Operating Costs) proposed for inclusion in the Project during the following Fiscal Year, including: (a) a detailed timetable for the sequencing and implementation of such activities; and (b) a proposed budget and financing plan for such activities. The Recipient shall furnish such program of activities to the Association as soon as available | Frequency :Yearly

Complied with

No Change

IDA-52290

Finance Agreement :Section I. A. 2 (b) of Schedule 2. | Description :(i) Maintain within the MOH, throughout the period of Project implementation, a procurement unit, with terms of reference and resources satisfactory to the Association, and supported by qualified and experienced staff in adequate numbers and | Due Date :17-Aug-2014

Partially complied with

Marked for Deletion

IDA-52290

Finance Agreement :Section I. A. 2 (b) of Schedule 2. | Description :(ii) recruit a procurement manager and two (2) procurement officers, each with terms of reference and qualifications and

Partially complied with

Marked for Deletion

8

experience satisfactory to the Association, no later than six (6) months after the Effective Date. | Due Date :17-Aug-2014

.

FinancingChange in Loan Closing Date(s)

Explanation:The Government of Lesotho has requested a 24-month extension of the current Closing Date of June 30, 2017, thereby extending the project's Closing Date to June 30, 2019.

Ln/Cr/TF Status Original

Closing DateCurrent Closing Date

Proposed Closing Date

Previous Closing Date(s)

Proposed Application Deadline Date

IDA-52290 Effective 30-Jun-2017 30-Jun-2017 30-Jun-2019 30-Jun-2017 30-Oct-2019

TF-14147 Effective 30-Jun-2017 30-Jun-2017 30-Jun-2019 30-Jun-2017 30-Oct-2019

Reallocations

Explanation:

A reallocation of funds across expenditure categories in both the HRITF grant and the IDA Credit are detailed below. Furthermore, a goods category, and a contingent emergency expenditures category under Component 4 (Part D) of the project are included under the IDA credit. Although the combined financing percentages for the IDA credit disbursement category 2 (consulting services) and category 4 (operating costs), and for the HRITF grant disbursement category 2 (consulting services) and category 3 (operating costs), which are jointly co-financed by these two operations, still add up to 100 percent, changes are being made to those individual financing percentages in the amendment and restatement of the IDA credit agreement and HRITF grant agreement individually, as outlined below:

- Increase allocations for both the HRITF grant and IDA credit to consulting services (US$1,204,098.43 for TF, and SDR 1,744,147.26 for IDA) and increase allocations to operating costs under the IDA credit (SDR 44,111.37); and- Decrease allocations for both the HRITF grant and IDA credit to category one, i.e. performance-based grants (US$700,219.73 for TF, and SDR 1,174,607.97 for IDA) and decrease allocations to operating costs under the HRITF grant (US$503,878.70) and decrease allocations to training under the IDA credit (SDR 466,542.92).

Ln/Cr/TF

Currency Cat.No.

Current Category of Expenditure

Allocation

Actual Disbursements

Pending Commitments

Allocation

Disbursement % (Type Total)

Current Proposed Current Propose

d

TF-11924-

USD 1 Cons Serv,

398,725.02

398,725.02

0.00 398,725.02

100.00 100.00

9

001

Trn, Wrks & Study Tours

Total: 398,725.02

398,725.02 0.00 398,725.

02

TF-14147-001

USD 1

Gds,SmWks,POC,NonCS,PC PT A.1

2,475,000.00

25,851.03 0.00 1,774,78

1.00 25.00 25.00

2

Cons Svcs except PT A.1

837,500.00

177,488.90 0.00 2,041,59

8.00 25.00 35.00

3

Operating Costs except PT A.1

687,500.00

116,240.87 0.00 183,621.

00 68.75 57.60

Total: 4,000,000.00

718,305.82 0.00 4,000,00

0.00

TF-15305-001

USD 1

GDS,SWK,NCS AND POC

171,134.25

171,134.25 0.00 171,134.

25 100.00 100.00

2

NCS,CS,TRG,OC ex part Vii

275,721.11

275,721.11 0.00 275,721.

11 100.00 100.00

Total: 446,855.36

1,165,161.18 0.00 446,855.

36

IDA-52290-001

XDR 1

Gds,SmWks,POC,NonCS,PC PT A.1

4,825,000.00

65,418.18 0.00 3,650,39

2.00 75.00 75.00

2

Cons Svcs except PT A.1

1,372,000.00

565,614.31 0.00 3,116,14

7.00 75.00 65.00

3Training except PT A.1

1,026,000.00

188,108.65 0.00 559,457.

00 100.00 100.00

4 Operating Costs

162,000.00

178,614.78

0.00 206,111.00

31.25 42.40

10

except PT A.1

5PPF REFINANCING

415,000.00

174,690.71 0.00 174,691.

00 0.00 0.00

6Goods except PT A.1

0.00 0.00 0.00 93,202.00 0.00 100.00

7

Emergency Expenditures under PT D

0.00 0.00 0.00 0.00 0.00 100.00

Total: 7,800,000.00

2,337,607.81 0.00 7,800,00

0.00

IDA-Q8380-001

USD 1

GDS, NCS, TRG, CS & Op. Costs

0.00 0.00 0.00 0.00 100.00 100.00

Total: 0.00 2,337,607.81 0.00 0.00

Disbursement Estimates

Change in Disbursement Estimates

Explanation:

Given the proposed extension of the Closing Date by 24 months to June 30, 2019, and the additional PPP support component, the disbursement estimates have been revised.

Fiscal Year Current (USD) Proposed (USD)

2013 630,000.00 0.00

2014 2,000,000.00 0.00

2015 4,620,000.00 397,610.70

2016 4,370,000.00 2,478,777.30

2017 4,380,000.00 5,198,656.00

2018 0.00 4,582,447.00

2019 0.00 3,342,509.00

Total 16,000,000.00 16,000,000.00.

ComponentsChange to Components and Cost

Explanation:

11

Component 1 would be renamed to: "Improving Health Service Delivery through PBF." The PBF program under Component 1 will be revised to: (i) suspend implementation of the village health worker (VHW) PBF program, given the MOH's decision to substantially change the VHW organizational set-up, and the challenges associated with the modalities of rewarding incentive payments to VHWs; (ii) adjust the PBF program at the District Hospital level to focus more on the quality of services, and provide individual bonuses to hospital staff; and (iii) revise the quantitative incentivized indicators at the health center level by revising existing and including additional HIV and TB indicators. This new title of this component thus now reflects the broader support provided under the PBF program. The project will finance the expanded scope of indicators under component 1, in conjunction with the aforementioned adjustments to the ongoing PBF program, based on the experience in the two pilot districts. Allocations to Component 1 will be reduced from US$13.7 million to US$11.45 million, given the reduced geographic scope of the PBF program.

Component 2 would be renamed to: "Capacity Building Support to the Ministry of Health." The scope of activities under Component 2 will be expanded to provide additional capacity building support to: (i) strengthen MOH procurement capacity and streamline procedures; (ii) better align the MoH Annual Joint Review with health sector strategic objectives, with a greater focus on program impact; and (iii) improve the integration of the QMMH network into the rest of health system. Medical equipment will be procured to improve MNH outcomes following the findings of the February, 2016 Emergency Obstetric and Neonatal Care (EmONC) report. This expanded scope of activities is therefore reflected in the revised title of the component, and allocations to component 2 will increase from US$2.3 million to US$3.73 million.

Component 3 would be added, entitled: "Enhance PPP Management Capacity within the Government of Lesotho." Proposed activities under this new component comprise the establishment of the MoF Central PPP unit and MoH PPP Contract Management Office, the recruitment of the full PPP management staff complement, and the provision of technical assistance (TA) to strengthen oversight over the QMMH network PPP and other existing health PPPs, including PPP management capacity building within GoL, in the amount of US$815,000. Some PPP and health systems related activities have also been included under Component 2 above.

Component 4, a zero-cost Contingent Emergency Response Component (CERC), will be added, in the event of the potential need to support activities related to mitigating the impact of the current El Niño induced drought in Lesotho. The proposed costs of the four components are presented below.

Current Component Name

Proposed Component Name

Current Cost (US$M)

Proposed Cost (US$M) Action

Component 1: Improving Maternal and Newborn Health (MNH) Service Delivery at Community, Primary and Secondary Levels through PBF

Component 1: Improving Health Service Delivery through Performance-Based Financing

13.70 11.45 Revised

Component 2: Training of health professionals and VHWs and improving Monitoring

Component 2: Capacity Building Support to the Ministry of Health

2.30 3.73 Revised

Component 3: Enhance PPP Management Capacity within the

0.82 New

12

Government of Lesotho

Component 4: Contingent Emergency Response 0.00 New

Total: 16.00 16.00.

Other Change(s)Change in Institutional Arrangements

Explanation:Changes in institutional arrangements will comprise:

(i) Addition of the MOF as an implementing agency. The MoF will be responsible for the: (a) implementation of the new component on PPP support (Component 3); (b) establishment of the MoF Central PPP unit; (c) recruitment of the full PPP management staff complement based at the MoF; and (d) implementation of technical assistance (TA) activities aimed at building PPP management capacity within the MoF to allow for the newly established unit to perform its key functions of PPP contract management, fiscal management and administration. Project funds allocated to the newly added third component will continue to be disbursed out of the existing MoH Designated Account for the project.(ii) Streamlining of project governance structures whereby operational and technical functions of the NSRHSC are delegated to the existing SRH TWG. This represents a change from the current governance arrangement, whereby the project initially relied on the existing NSRHSC, the composition of which is inter-ministerial and involves a wide range of development partners, including the UN Agencies, PEPFAR and NGOs. However, given that the NSRHSC does not meet frequently, it was agreed with the MOH that operational functions (e.g. approval of the annual work plan and budget, revision of the project implementation manual) of the NSRHSC will be delegated to the existing SRH TWG comprised of a sub-set of the members of the NSRHSC. Meanwhile the MoH opted to continue relying on the NSRHSC to provide overall policy direction to the project, even given the broadened scope of the operation; and (iii) Given the struggles of the MOH to maintain a full staffing complement within the MoH PBF Unit, as per the current Financing Agreement, the staffing requirements of the MoH PBF Unit will be revised to include a Senior PBF Officer and PBF Officer in lieu of the Operations Officer role, and the FM function of the PBF Unit will be transferred to the MoH PAU in lieu of the Accountant position at the PBF Unit.

Change in Procurement

Explanation:To facilitate the purchasing of medical equipment under Component 2 following the findings of the recent EmONC report with a view of improving MNH outcomes, a goods category is being added under the IDA financing.

Change in Implementation Schedule

Explanation:

The project is being extended by 24 months until June 30, 2019, in order to maximize the potential for the achievement of the project's broadened objectives in the areas of PBF and PPP management capacity building in the health sector. The proposed extension of the closing date will facilitate full implementation of project activities, given that the project became effective in February 2014, ten months following the original Board approval in April 2013. The project's geographical coverage has also been reduced from nine to six districts. Therefore, as the project scales up from the two pilot districts to the additional four Phase II districts, the timeline for project scale up schedule has also been amended, with two additional districts entering the PBF program in July 2016 and the remaining two in October 2016.

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Other Change(s)

Explanation:

The level one restructuring will also revise the project title to: "Health Sector Performance Enhancement Project." The proposed title change will reflect support to the QMMH network PPP, and the enhanced focus of the PBF program.

14

ANNEX 1. RESULTS FRAMEWORK & MONITORING.

Project Development ObjectivesOriginal Project Development Objective:The overall project development objective is to improve the utilization and quality of maternal and newborn health (MNH) services in selected districts in Lesotho.

Proposed Project Development Objective (from Restructuring Paper):The overall project development objective is to: (i) increase utilization and improve the quality of primary health services in selected districts in Lesotho with a particular focus on maternal and child health, TB and HIV; (ii) improve contract management of select PPPs; and (iii) in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency.

ResultsCore sector indicators are considered: Yes Results reporting level: Project Level.

Project Development Objective IndicatorsStatus Indicator Name Core Unit of Measure Baseline Actual(Current) End TargetRevised Pregnant women delivering in

PBF enrolled health facilities in target districts

Percentage Value 53.20 74.30 80.00

Date 31-Dec-2009 22-Jun-2016 30-Jun-2019

Comment Source: DHS 2009

Baseline data collected from 2009 DHS as an average of the figures from the six target districts.

Source: DHS 2014

Actual data collected from 2014 DHS as an average of the figures from the six target districts.

Ongoing routine data for this indicator will be estimated using HMIS data and PBF Quarterly Quantity invoices, while endline data will be estimated using subsequent household level survey/MICS

before project closing.

Pregnant women delivering in health facilities


Date 31-Dec-2009 22-Jun-2016 30-Jun-2017

CommentRevised Children under 1-year fully

immunized in PBF enrolled health facilities in the target districts


Date 31-Dec-2009 22-Jun-2016 30-Jun-2019



Source: DHS 2014


Ongoing routine data for this indicator will be estimated using HMIS data and PBF Quarterly Quantity invoices, while endline data will be estimated using subsequent household level survey/MICS before project closing.

Children 1 year-old who received all basic vaccinations.


Date 31-Dec-2009 22-Jun-2016 30-Jun-2017

CommentRevised Currently married women

using modern contraceptive method in target districts


Date 31-Dec-2009 22-Jun-2016 30-Jun-2019

Comment Source DHS 2009

Source: DHS 2014

Ongoing routine data for this

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indicator will be estimated using HMIS data, while endline data will be estimated using subsequent household level survey/MICS before project closing.

Currently married women using modern contraceptive method.


Date 31-Dec-2009 22-Jun-2016 30-Jun-2018

CommentNew People receiving tuberculosis

treatment in accordance with the WHO-recommended “Directly Observed Treatment Strategy” (DOTS)

Number Value 4925.00 7534.00 9500.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2019

Comment Source: HMIS

Leribe 1724Quthing 361Mafeteng 1003Mohale's Hoek 1222 Mokhotlong 318Thaba Tseka 297

Source: HMIS


Ongoing routine and endline data for this indicator will be estimated using HMIS data.

New Pregnant women living with HIV who received ARV prophylaxis or complete course of ARV to reduce the risk of MTCT in target districts

Number Value 3910.00 9757.00 13000.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2019

Comment Source: HMIS Source: HMIS Ongoing routine and endline data

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Leribe 1977Quthing 295Mafeteng 601Mohale's Hoek 478Mokhotlong 262Thaba Tseka 297


for this indicator will be estimated using HMIS data.

Revised Average Health Facility Quality of Care Score in target districts


Date 31-Dec-2015 22-Jun-2016 30-Jun-2019

Comment Source: Baseline Quality of Care Assessment

Baseline data for the six target districts collected in two phases (2013 for Leribe and Quthing and 2015 for the remaining 4 Phase II districts).

Source: Routine Quality of Care Assessment

Actual data collected from the implementation of the routine quality checklist by the MOH Quality Assurance Unit.

Ongoing routine and endline data for this indicator will be estimated using the routine Health Facility Quality of Care Assessments.

Average Health Facility Quality of Care Score.


Date 21-Jan-2013 22-Jun-2016 30-Jun-2017

Comment

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New MOF Central PPP Unit and MOH PPP Contract Management office established


Date 30-Sep-2016 30-Sep-2016 30-Jun-2019

Comment Source: Project Administrative Records

The MOF Central PPP Unit and MOH Contract Management Office are yet to be established and a full staff complement recruited.

Source: Project Administrative Records

The MOF Central PPP Unit and MOH Contract Management Office are yet to be established and a full staff complement recruited.

The MOF Central PPP Unit and MOH Contract Management Office maintain a full staff complement comprising all seven essential positions.

Intermediate Results Indicators

Status Indicator Name Core Unit of Measure Baseline Actual(Current) End TargetMarked for Deletion

Pregnant women in a lowest wealth quintile delivering in health facilities.


Date 31-Dec-2009 22-Jun-2016 30-Jun-2017

Comment This indicator is being dropped because of a lack of availability of routine household level data in between DHS/MICS surveys to accurately

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measure progress/equity and the absence of suitable substitutes from the HMIS.

Marked for Deletion

Women with at least four antenatal care visits during pregnancy


Date 31-Dec-2009 22-Jun-2016 30-Jun-2017

Comment This indicator is being dropped because of a lack of availability of district-level disaggregated household data to accurately measure routine progress across this indicator, and the absence of suitable substitutes from the HMIS.

Marked for Deletion

Births (deliveries) attended by skilled health personnel

Number Value 17453.00 77000.00

Date 31-Jan-2013 30-Jun-2017

Comment This indicator is being dropped due to the lack of reliable data from the HMIS to routinely measure

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progress across this indicator.

Revised Mothers who received postnatal care within two days of childbirth in target districts


Date 31-Dec-2009 22-Jun-2016 30-Jun-2019



Source: DHS 2014


Ongoing routine data for this indicator will be estimated using HMIS data, while endline data will be estimated using subsequent household level survey/MICS before project closing.

Mothers who received postnatal care within two days of childbirth.


Date 31-Dec-2009 22-Jun-2016 30-Jun-2017

CommentRevised Pregnant women receiving

antenatal care during a visit to a health provider

Number Value 17233.00 43534.00 60000.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2019


Leribe 5693Quthing 1668Mafeteng 2806Mohale's Hoek 2756Mokhotlong 1977

Source: HMIS

Leribe 15041Quthing 4352Mafeteng 7206Mohale's Hoek 5963 Mokhotlong 4762 Thaba Tseka

Ongoing routine and endline data for this indicator will be estimated using HMIS data.

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Thaba Tseka 2333

6210

Pregnant women receiving antenatal care during a visit to a health provider

Number Value 24324.00 54297.00 100000.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2017

CommentMarked for Deletion

Children immunized Number Value 26474.00 65175.00 98000.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2017

Comment This core indicator and its sub-type breakdown is being removed and replaced with just the "core variant" children immunized (number) indicator, due to lack of availability of HMIS EPI data specific to children immunized against DTP3.

Marked for Deletion

Children immunized - under 12 months against DTP3

Number Value 26474.00 76674.00 98000.00

Sub Type Date 30-Jan-2013 22-Jun-2016 30-Jun-2017

Breakdown Comment This sub-type breakdown indicator is

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being removed and replaced with only the "core variant" children immunized (number) indicator, due to lack of availability of HMIS EPI data specific to children immunized against DTP3.

New Children immunized Number Value 17851.00 38452.00 50000.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2019


Leribe 5611Quthing 1432Mafeteng 3187Mohale's Hoek 2465Mokhotlong 2205Thaba Tseka 2951

Source HMIS


Ongoing routine and endline data for this indicator will be estimated using HMIS data. This indicator corresponds to IRI 6 in the PAD, i.e. children receiving pentavalent vaccine (diphtheria, tetanus, whooping cough, hepatitis

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B and Haemophilus influenza type b) or DPT3, but it was agreed with MOH to define it more broadly in terms of the number of children immunized.

Marked for Deletion

Tuberculosis treatment success rate.


Date 25-Oct-2012 30-Nov-2015 30-Jun-2017

Comment This indicator is being dropped due to the lack of reliable routine data to effectively measure progress. However, a similar indicator will be included as part of the results framework for the Southern Africa TB project which will be routinely collected.

Marked for People receiving tuberculosis Number Value 8553.00 11764.00 35600.00

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Deletion treatment in accordance with the WHO-recommended “Directly Observed Treatment Strategy” (DOTS)

Date 30-Jan-2013 30-Nov-2015 30-Jun-2017

Comment This indicator is being recategorized as a PDO level indicator from an IRI given the broadened PDO with a particular focus on TB.

Marked for Deletion

Pregnant women living with HIV who received ARV prophylaxis or complete course of ARV to reduce the risk of MTCT.

Number Value 4972.00 17637.00 21000.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2017

Comment This indicator is being recategorized as a PDO level indicator from an IRI given the broadened PDO with a particular focus on HIV and MCH.

Revised Number of health facilities with PBF contracts

Number Value 0.00 51.00 75.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2019

Comment Source: PBF Unit Administrative Records

Source: PBF Unit Administrative Records

The project has currently scaled up to two additional districts

The project expects to cover MOH and CHAL health facilities in six target districts by October 2016.

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(Mafeteng and Mohale's Hoek) in addition to the two pilot districts of Leribe and Quthing

Number of health facilities with PBF contracts

Number Value 0.00 37.00 107.00

Date 22-Jun-2016 30-Jun-2017


Health facilities reporting stock-out of tracer medicines and medical supplies at the time of the health facility quality of care assessment.

Percentage Value 5.00

Date 30-Jun-2017

Comment This indicator is being dropped because it is not considered relevant to the PDO. However, stock-outs will continue to be assessed through the routine facility quality of care assessments.

Revised Health personnel receiving training

Number Value 0.00 693.00 1500.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2019

Comment Source: PBF Unit Administrative Records

Source: PBF Unit Administrative Records

This indicator encompasses IRIs 13 to 17 in the PAD, including health

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This indicator encompasses IRIs 13 to 17 in the PAD, as well as training of VHWs (IRI 18).

personnel trained in advanced midwifery and neonatology; nurse anesthetists training; drug supply management manual training; ESAMI training; procurement and financial management training, as well as training of VHWs (IRI 18).

Health personnel receiving training

Number Value 0.00 7.00 20.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2017


Health personnel receiving training

Number Value 0.00 674.00 1500.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2017

Comment This training indicator measures just training of VHWs and is being folded into the one composite training indicator above.

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Marked for Deletion

Monitoring and Evaluation officers and District Health Information Officers receiving formal M&E Training

Amount(USD) Value 0.00 12.00 12.00

Date 30-Jan-2013 22-Jun-2016 30-Jun-2017

Comment This indicator solely measures training of M&E personnel and is being folded into the one composite training indicator above. It does not appear in the original PAD and is thus marked for deletion.

Marked for Deletion

Pregnant/lactating women, adolescent girls and/or children under age five-reached by basic nutrition services

Number Value 0.00

Date 30-Jun-2017

Comment This indicator was initially included because it is an essential core indicator in order to include the sub-type breakdown that measures children under 5 treated for malnutrition. This indicator

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and its sub-type do not appear in the original PAD and are thus being dropped due to the lack of reliable data from the HMIS to routinely measure progress across this indicator, although children treated for malnutrition will be incentivized under the revised PBF quantity indicators.

Marked for Deletion

Children under age five treated for moderate or severe acute malnutrition

Number Value 0.00

Sub Type Date 30-Jun-2017

Breakdown Comment This indicator does not appear in the original PAD and is thus being dropped due to the lack of reliable data from the HMIS to routinely measure progress across

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this indicator, although children treated for malnutrition will be incentivized under the revised PBF quantity indicators.

.

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Documents

Lesotho - Maternal Newborn Health PBF Level 1 …documents.worldbank.org/curated/en/205661479480928830/... · Web view1.Modify the Project Development Objective (PDO) from "improve