The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) REPORT NO.: RES59328 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF GUINEA-BISSAU STRENGTHENING MATERNAL AND CHILD HEALTH SERVICE DELIVERY APPROVED ON MAY 31, 2018 TO REPUBLIC OF GUINEA-BISSAU HEALTH, NUTRITION & POPULATION WESTERN AND CENTRAL AFRICA Regional Vice President: Ousmane Diagana Country Director: Keiko Miwa Regional Director: Trina S. Haque Practice Manager/Manager: Gaston Sorgho Task Team Leader(s): Yemdaogo Tougma Source: World Bank Operations portal 03/13/2024 The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) ABBREVIATIONS AND ACRONYMS AWP&B Annual Work Plan and Budget CHW Community Health Workers HNP Health, Nutrition and Population IP Implementation Progress MINSAP Ministry of Public Health MTR Mid-Term Review PCU Project Coordination Unit PDO Project Development Objective PIU Project Implementation Unit IR Intermediaries Results Source: World Bank Operations portal 03/13/2024 The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) BASIC DATA Product Information Project ID Financing Instrument P163954 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 31-May-2018 26-Dec-2025 Organizations Borrower Responsible Agency Republic of Guinea-Bissau Project Development Objective (PDO) Original PDO To improve coverage of essential maternal and child health services in the Recipient’s territory. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-D3280 31-May-2018 17-Jul-2018 03-Oct-2018 26-Dec-2025 25.00 12.72 10.33 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No Source: World Bank Operations portal 03/13/2024 The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Current Project Description Project Name Guinea-Bissau Strengthening Ratings Maternal and Child Health Service Delivery P-Code P163954 Project Development Satisfactory Objective IDA Funding US$25,000,000 equivalent Implement Progress Satisfactory Board Approval May 31, 2018 Financial Management Moderately Satisfactory Signing Date July 18, 2018 Procurement Satisfactory Project Restructuring June 25, 2021 Environmental & Social Moderately Safeguards Satisfactory Effectiveness Date October 3, 2023 Monitoring & Evaluation Satisfactory Original Closing Date December 31, 2023 Disbursement 54.82% Revised Closing Date December 26, 2025 B. Project Status 1. The Guinea-Bissau Strengthening Maternal and Child Health Services Delivery (P163954) development objective is to improve coverage of essential maternal and child health services in the Recipient’s territory. The project has a total financing of US$25 million equivalent, which was approved on May 31, 2018, and became effective on October 3, 2018. The project was designed to strengthen the institutional capacity of the Ministry of Public Health (MINSAP) and develop a healthcare workforce that would help improve coverage of essential maternal and child health services in the country. 2. In 2021, after two and a half years of project implementation, the project was restructured to streamline and strengthen implementation arrangements and improve disbursement. The restructuring was due to several competing challenges ranging from World Bank mission cancellation for security reasons stemming from the legislative elections, change in cabinet positions, Project Implementation Unit (PIU) inability to recruit and fill key positions (i.e., project coordinator, procurement specialist, financial management specialist, monitoring and evaluation specialist, accountant, external auditors, etc.), management issues related to inability to establish strategic partnerships with the donor community and key MINSAP staff, in addition to inadequacy of documents submitted for non-objection to the World Bank as well as inconsistencies in applying World Bank procurement procedures. The restructuring also included an extension of the closing date from December 31, 2023, to December 26, 2025. [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) 3. Since the first restructuring, project implementation has drastically improved with the upgrading of the project’s development objective (PDO) and implementation progress (IP) ratings from moderately satisfactory to satisfactory, and disbursement now peaking at 54 percent. However, the project has suffered a setback with the resignation of the Procurement Specialist, which negatively impacted the implementation of the planned activities. A new Procurement Specialist was hired and assumed office on March 1st, 2024. C. Rationale for Restructuring 4. The project’s mid-term review (MTR) took place on September 18, 2023. One of the recommendations from the review was to revise the results framework to be aligned with the project’s outcome. Specifically, some indicators are no longer relevant. Other indicator’s baseline and end targets are overestimated and should be revised. The 2024 Annual Work Plan and Budget (AWP&B) has been approved, supported by the development of quarterly implementation action plans paving the path to a full disbursement of the project proceeds by the scheduled closing date. The Project Implementation Manual has been updated. II. DESCRIPTION OF PROPOSED CHANGES 5. The proposed changes in the result framework are described below: PDO Indicators Initial Indicators Proposed Changes Explanation PDO 1: Percentage of Number of pregnant women The unit of measurement has been pregnant women attending attending at least 4 prenatal changed from “percentage” to “number” at least 4 prenatal care care. due to challenges in acquiring accurate consultations during data to fill the denominators. Using pregnancy numerical value instead of percentage is crucial for accurately portraying the project’s accomplishments. This shift ensures capturing factual data rather than estimates. PDO 2: Percentage of Number of deliveries in the The unit of measurement has been deliveries in the health health facilities changed from “percentage” to “number” facilities due to the unreliability of the source of data for the denominator, obtained based on the national census data of 2009 PDO 3: Percentage of Number of children fully The unit of measurement has been children fully vaccinated vaccinated changed from “percentage” to “number” due to the unreliability of the source of data for the denominator. [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) PDO 4: Percentage of Number of children under The unit of measurement has been children under five with five with confirmed malaria changed from “percentage” to “number” confirmed malaria who who receive antimalaria due to the unreliability of the source of receive antimalaria treatment by CHWs data for the denominator. The indicator treatment specifies that the treatment is done by the CHWs Intermediate Result Indicators Initial Indicators Proposed Changes Explanation IR 1: MINSAP Legal Number of administrative The initial indicator was no longer relevant Framework Validated staff trained and has been replaced IR 2: Percentage of Data collection methodology. The indicator did not change. The healthcare workers that methodology to collect the data will be provide the correct based on a sample of supervised or treatment for a basic case of surveyed health workers. The review of the childhood diarrhea quality of diarrhea case management will be done based on existing materials/knowledge/tests/ and observation. IR 3: Percentage of Data collection methodology The indicator did not change. The healthcare workers that methodology to collect the data will be apply the appropriate based on a sample of supervised or EmONC treatment surveyed health workers. The review of the application of the EmONC treatment will be done based on existing materials/knowledge/tests/ and observation. IR 4: People who have End Target The end target has been revised upwards received essential health, (from 125,000 to 1,200,000) after obtaining nutrition, and population a consensus on the content of the (HNP) services indicator. IR 5: People who have End Target The end target has been revised upwards received essential health, (from 73,000 to 230,000) after obtaining a nutrition, and population consensus on the content of the indicator. (HNP) services - Female (RMS requirement IR 6: Number of children End Target The end target has been revised upwards immunized (from 65,000 to 800,000) after obtaining a consensus on the content of the indicator. [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) IR 7: Number of women and End Target The end target has been revised upwards children who have received (from 73,000 to 1,000,000) after obtaining basic nutrition services a consensus on the content of the indicator IR 8: Number of deliveries End Target The end target has been revised upwards attended by skilled health (from 50,000 to 105,000) personnel IR 9: Children 12-59 months End Target The end target has been revised upwards of age attending at least one (from 50,000 to 700,000) after obtaining a healthcare consultation consensus on the content of the indicator. IR 10: Percentage of primary Data collection methodology The indicator will be calculated based on a health care facilities (type A, sample of health centers where the B, and C) with all essential availability of essential drugs will be drugs available on the day of checked the day of the visit. the visit IR 11: Women referred to Indicator revised to “Women This is a new indicator. The wording of the antenatal care, postnatal visited by community health previous indicator has changed to better care, family planning, or workers”. End target revised. aligned with the CHW activities. The end delivery by community target has been revised downwards (from health workers (CHW) 50,000 to 20000) due to difficulties to properly incentivize CHW workers IR 12: Satisfaction of users Data collection methodology The indicator will be calculated based on with basic MCH services the level of satisfaction of MCH service provided surveyed users IR 13: Percentage of women Revised indicator The indicator has been changed to with high-risk pregnancy “number of women care for in halfway referred to health facilities by houses” to better align with project active CHWs activities and implementation arrangements. All parameters (Baseline, end target, data collection methodology and frequency, etc.) will be changed. III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Implementing Agency ✔ DDO Status ✔ [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) Project's Development Objectives ✔ PBCs ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) . [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) . Results framework COUNTRY: Guinea-Bissau Guinea-Bissau Strengthening Maternal and Child Health Service Delivery Project Development Objectives(s) To improve coverage of essential maternal and child health services in the Recipient’s territory. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline End Target To improve coverage of essential maternal and child health services in the Recipient’s territory. Pregnant women attending at least 4 prenatal care consultations 23,990.00 103,000.00 during pregnancy (Number) Rationale: The indicator has been revised to address the difficulty in obtaining reliable data to populate the denominators, which are based on uncertain demographic estimates. Consequently, this change aims at utilizing numerical values instead of percentages, which is crucial for accurately portraying the project's accomplishments. The revision also updated the baseline by using data from the 2018 Health Statistics Yearbook, which is the official source data of the government. The previous baseline used partial data from September 2018, and the new one is from December 2018, which includes all Action: This indicator has been Revised the information for the year 2018. The 2018 Health Statistics Yearbook is the most reliable data source for the baseline, as the project was approved on May 31, 2018 and became effective on October 3, 2018. Number of deliveries in the health facilities (Number) 30,197.00 105,000.00 [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline End Target Rationale: The unit of measurement has been changed from 'percentage' to 'number' due to challenges in acquiring accurate data to fill the denominators. The change aims to tackle the difficulty in obtaining reliable data for populating denominators, which rely on uncertain demographic estimates. Employing numerical values instead of percentages is crucial for accurately Action: This indicator has been Revised portraying the project's accomplishments. This shift ensures capturing factual data rather than estimates. The baseline is updated to relate to the data source, which is the Health Statistics Yearbook 2018. The health statistics yearbook includes data from January 1st to December 31st, 2018. Number of children (0-11 months) fully vaccinated (Number) 51,523.00 105,000.00 Rationale: The unit of measurement has been changed from 'percentage' to 'number' due to challenges in acquiring accurate data to fill the denominators. The change aims to tackle the difficulty in obtaining reliable data for populating denominators, which rely on uncertain demographic estimates. Employing numerical values instead of percentages is crucial for accurately Action: This indicator has been Revised portraying the project's accomplishments. This shift ensures capturing factual data rather than estimates. The baseline is updated to relate to the data source, which is the Health Statistics Yearbook 2018. The health statistics yearbook includes data from January 1st to December 31st, 2018. Number of children under-five with confirmed malaria who 0.00 4,000.00 receive antimalaria treatment by CHWs (Number) Rationale: Challenges persist in accurately documenting the project's achievements, primarily due to insufficient data. Consequently, Action: This indicator has been Revised This change aims to address the difficulty in obtaining reliable data to populate the denominators, which are based on uncertain demographic estimates. Utilizing numerical values instead of percentages is crucial for accurately portraying the project's accomplishments. [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline End Target PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Institutional Strengthening of the Ministry of Public Health MINSAP Legal Framework Validated (Yes/No) No Yes Rationale: The validation of the MINSAP legal framework is supported by other donors and is no longer under the responsibility of the Action: This indicator has been Marked for Deletion World Bank project. Number of administrative staff trained in the ministry of health 0.00 250.00 (Number) Rationale: The initial indicator was no longer relevant and has been replaced. in fact the previous indicator related to the validation of the MINSAP legal framework is supported by other donors and is no longer under the responsibility of the World Bank Action: This indicator is New project. Health workforce development Number of primary health workers trained in RMNCH 0.00 2,500.00 competencies (Number) [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Rationale: The indicator has been revised to raise the end-of-project target. Action: This indicator has been Revised The target is already achieved in 2023, and the indicator has been revised to increase its end-of-project target Percentage of healthcare workers that provide the correct 0.00 60.00 treatment for a basic case of childhood diarrhea (Percentage) Rationale: The change concerns the data source and the data collection methodology. The previous data source is the SDI, and the Action: This indicator has been Revised project does not foresee an SDI during its lifetime, and there was not a specified methodology for collecting the data. Percentage of healthcare workers that apply the appropriate 0.00 60.00 EmONC treatment (Percentage) Rationale: Action: This indicator has been Revised The indicator is revised to specify the data collection methodology Improving Essential Maternal and Child Health Services People who have received essential health, nutrition, and 228,000.00 1,200,000.00 population (HNP) services (CRI, Number) Rationale: This is a corporate indicator. The final target has been reached, and has been revised upwards (from 125,000 to 1,200,000) Action: This indicator has been Revised following a consensus on the indicator's content. People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) (CRI, 54,000.00 230,000.00 Number) [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Rationale: Action: This indicator has been Revised The final target has been reached, and has been revised upwards following a consensus on the indicator's content. Number of children immunized (CRI, Number) 51,523.00 800,000.00 Rationale: Action: This indicator has been Revised The final target has been reached, and has been revised upwards following a consensus on the indicator's content. Number of women and children who have received basic 190,000.00 1,000,000.00 nutrition services (CRI, Number) Rationale: Action: This indicator has been Revised The final target has been reached, and has been revised upwards following a consensus on the indicator's content. Number of deliveries attended by skilled health personnel 30,197.00 105,000.00 (CRI, Number) Rationale: Action: This indicator has been Revised The final target has been reached, and has been revised upwards following a consensus on the indicator's content. Children 12-59 months of age attending at least one healthcare 122,535.00 700,000.00 consultation (Number) Rationale: Action: This indicator has been Revised The final target has been reached, and has been revised upwards following a consensus on the indicator's content. [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Percentage of primary health care facilities (type A, B, and C) with all essential drugs available on the day of the visit 0.00 50.00 (Percentage) Rationale: Action: This indicator has been Revised The indicator has been revised to specify the data collection methodology, ensuring that the indicator is measurable. Number of health centers rehabilitated (Number) 0.00 11.00 Number of facilities with beneficiaries reporting illegal charges from providers for essential maternal and child health services 128.00 70.00 (Number) Rationale: Action: This indicator has been Revised The indicator is revised to specify how the data will be collected Community Health and Social Mobilization Women visited by community health workers (Number) 0.00 20,000.00 Rationale: This is a new indicator. The wording of the previous indicator has changed to better aligned with the CHW activities. The Action: This indicator has been Revised end target has been revised downwards (from 50,000 to 20000) due to difficulties to properly incentivize CHW workers Satisfaction of users with basic MCH services provided 0.00 60.00 (Percentage) Rationale: Action: This indicator has been Revised The indicator is revised to specify the data collection methodology, ensuring that the indicator is measurable [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Number of women taken care in way houses (Number) 0.00 4,000.00 Rationale: There was no indicator directly measuring CARITAS activities in the project. Considering the significance of CARITAS Action: This indicator has been Revised activities, it is necessary to introduce an indicator to measure them. IO Table SPACE [Type here] The World Bank Guinea-Bissau Strengthening Maternal and Child Health Service Delivery (P163954)