The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) REPORT NO.: RES56858 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SYSTEM STRENGTHENING FOR HUMAN CAPITAL DEVELOPMENT IN ESWATINI APPROVED ON JUNE 22, 2020 TO KINGDOM OF ESWATINI HEALTH, NUTRITION & POPULATION EASTERN AND SOUTHERN AFRICA Regional Vice President: Victoria Kwakwa Country Director: Marie Francoise Marie-Nelly Regional Director: Daniel Dulitzky Practice Manager/Manager: Francisca Ayodeji Akala Task Team Leaders: Yi-Kyoung Lee, Thulani Clement Matsebula The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) ABBREVIATIONS AND ACRONYMS ANC Antenatal Care CBHIS Community Based Health Information System CERP COVID-19 Emergency Response Project CHW Community Health Worker CMIS Client Management Information System COVID-19 Coronavirus Disease eLMIS Electronic Logistics Management Information System eMMS Electronic Maintenance Management System GBV Gender-based Violence HCW Health Care Worker HMIS Health Management Information System HSS4HCDP Health System Strengthening for Human Capital Development in Eswatini Project IPAG Inter-Ministerial Policy Advisory Group MoH Ministry of Health MTR Mid Term Review NCD Non-Communicable Disease PDO Project Development Objective RHM Rural Health Motivator RHMT Regional Health Management Team RMNCAH Reproductive, Maternal, Newborn, Child, and Adolescent Health SBCC Social and Behavior Change Communication SMT Senior Management Team The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) BASIC DATA Product Information Project ID Financing Instrument P168564 Investment Project Financing Environmental and Social Risk Classification (ESRC) Moderate Approval Date Current Closing Date 22-Jun-2020 30-Sep-2025 Organizations Borrower Responsible Agency Kingdom of Eswatini Project Development Objective (PDO) Original PDO The project development objective is to improve the coverage and quality of key reproductive, maternal, neonatal, child and adolescent health (RMNCAH), nutrition and NCD services (hypertension and diabetes) in Eswatini. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IBRD-91260 22-Jun-2020 04-Dec-2020 10-Dec-2020 30-Sep-2025 20.00 8.30 11.70 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING Project Status The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) 1. The objective of this Restructuring Paper is to seek approval for the proposed Level 2 restructuring of the Health System Strengthening for Human Capital Development in Eswatini Project (HSS4HCDP; P168564). This restructuring is in response to the request from the Government of the Kingdom of Eswatini dated June 16, 2023 to the World Bank to restructure the project as follows: (a) streamline the project activities by scaling down or dropping activities that cannot be implemented before the project closing date and/or that are beyond the control of the Ministry of Health (MoH) or by scaling up well performing activities that can contribute to achieving the project development objective (PDO); (b) modify the results framework to be in line with the streamlined activities; and (c) revise the institutional arrangements by dropping the inter-ministerial policy advisory group that has not been functional and by streamlining the composition of the project implementation unit. 2. The project was approved by the Board on June 22, 2020 and became effective on December 10, 2020. The PDO is to improve the coverage and quality of key reproductive, maternal, neonatal, child and adolescent health (RMNCAH), nutrition and non-communicable disease (NCD) services (hypertension and diabetes) in Eswatini. The project has four components: Component 1. Improve health service delivery to increase the coverage and quality of health services to build human capital (US$14.5 million); Component 2. Increase community demand for RMNCAH, nutrition and NCD services (US$2.0 million); Component 3. Strengthen the MoH’s stewardship capacity to manage essential health and nutrition services and project activities (US$3.5 million); and Component 4. Contingent Emergency Response (US$0.0 million). The project complements the Eswatini COVID-19 Emergency Response Project (CERP, P173883) through its focus on strengthening health systems and ensuring continuation of essential services including NCD care and treatment to help reduce the impact of the COVID-19 pandemic. The project was restructured in May 2022 to revise the results framework to better monitor implementation progress using the routine health information system in country. 3. Progress towards achievement of PDO and overall implementation progress were rated moderately satisfactory in the last implementation status report (June 2023). Since the project’s effectiveness, implementation of the planned activities has progressed slower than expected due to various challenges, some of which are not under the direct control of the MoH. Among others, the most important challenges include: (a) the COVID-19 pandemic and response measures affecting the MoH’s efforts to improve essential service delivery and strengthen health systems including those supported under the project; (b) delays in completing preparatory activities supported by other development partners; (c) staff shortages and high turnover; (d) limited availability and interest of qualified consultants and contractors; and (e) limited and irregular supply of essential commodities for service delivery including fuel. To address some of these challenges, the MoH has identified and/or started implementing mitigation measures, such as engagement of the Ministry of Public Service to fill the staff vacancies, collaboration with the United Nations and technical agencies to identify suitable technical assistance, and provision of essential commodities under the project to fill the immediate gaps. Performance of the environmental and social risk management and procurement is currently rated satisfactory, while that of financial management is rated moderately satisfactory. 4. The recent mid-term review (MTR) of the project in March 2023 confirmed that the pace of implementation has improved with some tangible outcomes of improved coverage of essential services, even though implementation of a few major activities is still behind schedule. The MoH has further scaled up training of health care workers (HCWs) to deliver high impact essential health services across the continuum of care. For example, 577 out of 811 targeted nurses/supervisors as well as 78 out of 400 targeted doctors have been trained on NCD service package. As a result, 192 clinics are offering decentralized NCD services. Also, 2,641 targeted Rural Health Motivators (RHMs) have been trained on community-based health and nutrition including NCDs. The MoH has procured and distributed equipment and commodities for NCD and nutrition services such as speculums for cervical cancer screening and ready-to-use therapeutic food for treatment of malnourished children. Also, the construction of the Operations Centre for the Central Medical The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) Stores and the offices and workshops for Biomedical Engineering Unit and Health Management Information System (HMIS) Unit is currently on schedule. The Quality Program has completed developing the continuous quality improvement plans and quality of care standards with support from the project. However, development and/or scale up of digital tools, such as electronic logistics management information system (eLMIS), electronic maintenance management system (eMMS), and community-based health information system (CBHIS), is still at the preparatory stage. B. Rationale for Restructuring 5. The MoH and the World Bank have reviewed the relevance and implementability of all the major activities during the MTR and agreed to make the following changes to accelerate the implementation pace and better achieve the PDO by the end of the project: (a) streamline the project activities by (i) scaling down or dropping activities that cannot be implemented before the project closing date, that are beyond the control of the MoH, and/or that are not the MoH’s priority; and (ii) scaling up well performing activities that can contribute to achieving the PDO; (b) modify the results framework to reflect the modified project activities; and (c) revise the institutional arrangements that are not functioning well to make the implementation more efficient. II. DESCRIPTION OF PROPOSED CHANGES 6. Changes to project activities: The proposed restructuring will scale down or drop activities that cannot be implemented before the project closing date, that are beyond the control of the MoH, that are supported by another project, and/or that are no longer the MoH’s priory. For example, the MoH is developing a National Health Emergency Response Operations Plan for All Hazards Plan and planning to provide basic public health emergency management training to 400 HCWs under the CERP instead of providing specific training on climate and health only under Component 1 of the HSS4HCDP. Also, the proposed restructuring will scale down activities related to development and/or implementation of digital applications under Component 1 (e.g., surveillance and inpatient modules of Client Management Information System [CMIS]) and Component 2 (e.g., client-based digital applications) to focus on a few health information systems to better monitor health system performance (e.g.., eLMIS, eMMS) and service delivery at the community level (e.g., CBHIS). In addition, the proposed restructuring will drop leadership/management twinning arrangements to focus on leadership/ management training based on the training needs assessment and reduce the number of regulations, policies, strategies, and guidelines to be developed/updated under Component 3. Instead, the Ministry will scale up activities that have progressed well and thus have a better chance of contributing to the achievement of the PDO and eventually health outcomes such as decentralized NCD services including cervical cancer screening and management under Component 1 and RHM training under Component 2. 7. Changes to the project cost and disbursement estimates. In line with the actual cost of activities and the proposed changes to project activities, the estimated cost per component will be revised slightly. The disbursement estimates will also be modified to reflect the delayed implementation at the beginning of the project life cycle due partly to the COVID- 19 pandemic and response measures and social unrest in the country. 8. Changes to results framework. The results framework will be modified to reflect the pace of implementation as well as the changes in the project activities. Specifically, the proposed changes include: (a) drop one indicator and rewording one indicator and its definition to better reflect the revised activities; and (b) adjusting target values to reflect the latest information and revised activities. A summary of the proposed changes is in Table 1 and the full details are in Annex – Results Framework. Table 1. Proposed changes to results framework Indicator Rationale for change Proposed change The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) PDOI3: Percentage of adolescents served  Preparatory activities and  Decrease Y3, Y4, Y5 (end) targets to 20%, or reached with quality sexual and program launch delayed 40%, and 50% reproductive health services IRI5: Percentage of women receiving  Target already achieved  Increase Y3, Y4, and Y5 targets to 85%, post-partum check-up within 14 days 88%, and 90% IRI8: Number of HCWs trained on  Target already achieved  Increase Y3, Y4, and Y5 targets to 850, RMNCAH, nutrition and/or NCD services 900, and 900 IRI9: Number of facilities using eLMIS for  Development of eLMIS  Decrease Y2, Y3, Y4, and Y5 targets to 3, supply management supported by another partner 3, 4, and 9. delayed, affecting the scale up under the project IRI13: Number of community health  Target already achieved and  Increase Y3, 4, and Y5 targets to 2,750, workers (CHWs) including rural health attrition of RHMs 3,000 and 3,000 motivators (RHMs) trained to conduct community sensitization & outreach on RMNCAH, Nutrition and NCD services IRI14. Number of people reached with  MOH unable to collect the data  Delete the indicator RMNCAH, nutrition and NCDs specific communication as part of targeted SBCC interventions IRI15: Number of client-based digital  Activity dropped  Delete the indicator applications’ users IRI16: Number of updated regulations,  Activity scaled down  Revise the indicator (definition) to policies, and strategies for MOH “Number (Cumulative number) of updated regulations, strategies, legal framework, and guidelines submitted”  Decrease Y2, Y3, Y4, and Y5 targets to 0, 4, 8, and 10 IRI17: Number of MOH management  Training needs assessment  Refine the definition to “Cumulative staff at national and regional level delayed number of MOH management staff trained (Senior Management Team and Regional Health Management Team) trained on technical and/or leadership”  Decrease Y2, Y3, Y4, and Y5 targets to 0, 0, 30, and 55 Note: PDOI- project development objective indicator; IRI- intermediate outcome indicator; Y-Year 9. Changes to the institutional arrangement: While the project has instituted the Inter-Ministerial Policy Advisory Group (IPAG) responsible for informing cabinet level decision-making and policy formulation, the IPAG has not been meeting regularly due mainly to competing priorities among representatives from the Central Agencies including the Ministry of Economic Planning and Development. Thus, the Project Implementation Unit has been relying on the guidance from the Senior Management Team (SMT) of the MoH, who meets weekly to discuss the key sector priorities including those supported by the project. In order to expedite the project implementation, the proposed restructuring will drop IPAG. The Inter-Ministerial Technical Committee will continue guiding project implementation and operationalization at a technical level and reviewing and discussing technical aspects that require coordination with the Central Agencies and other stakeholders and preparing reports and/or proposals for the guidance, information, and/or decision of the SMT, The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) instead of IPAG. Also, the composition of the Project Implementation Unit and/or terms of reference of its members will be adjusted as the implementation phase progresses to improve the implementation efficiency and sustainability. For example, Under-Secretary, Technical, MoH has been working as Project Coordinator with support from a full-time Project Officer. The Treasury Department has designated an Assistant Accountant General as the Finance Management Officer after resignation of the contracted Financial Management Specialist. These changes will be captured in the Project Operations Manual. III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Disbursement Estimates ✔ Legal Covenants ✔ Institutional Arrangements ✔ Implementation Schedule ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ PBCs ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Overall Risk Rating ✔ Financial Management ✔ Procurement ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) Component 1: Improve health Component 1: Improve health service delivery to increase the service delivery to increase the 14.50 Revised 14.00 coverage and quality of health coverage and quality of health services to build human capital services to build human capital Component 2. Increase Component 2. Increase community demand for community demand for 2.00 No Change 2.00 RMNCAH, nutrition and NCD RMNCAH, nutrition and NCD services services Component 3. Strengthen the Component 3. Strengthen the MOH’s stewardship capacity to MOH’s stewardship capacity to manage essential health and 3.50 Revised manage essential health and 4.00 nutrition services and project nutrition services and project activities activities Component 4: Contingent Component 4: Contingent 0.00 No Change 0.00 Emergency Response Emergency Response TOTAL 20.00 20.00 OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 2020 0.00 0.00 2021 3,000,000.00 1,445,909.00 2022 5,000,000.00 2,714,171.00 2023 5,000,000.00 4,140,153.00 2024 4,000,000.00 4,500,000.00 2025 2,000,000.00 4,500,000.00 The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) 2026 1,000,000.00 2,699,767.00 OPS_DETAILEDCHANGES_LEGCOV_TABLE LEGAL COVENANTS Loan/Credit/TF Description Status Action Loan Agreement. Section I.A of Schedule 2. By no later than one (1) month after the Effective Date, the Borrower shall establish and thereafter maintain, at Partially complied Marked for IBRD-91260 all times during the implementation of the Project, an with Deletion inter-ministerial policy advisory group, with a mandate, terms of reference, composition, and resources satisfactory to the Bank. Loan Agreement. Section I.A of Schedule 2. By no later than one (1) month after the Effective Date, the Borrower shall establish and thereafter maintain, at IBRD-91260 all times during the implementation of the Project, an Complied with No Change inter-ministerial technical committee, with a mandate, terms of reference, composition, and resources satisfactory to the Bank. Loan Agreement. Section I.A of Schedule 2. By no later than one (1) month after the Effective Date, the Borrower shall establish and thereafter maintain at IBRD-91260 all times during the implementation of the Project, a Complied with No Change Project implementation unit within MOH, with a mandate, terms of reference, composition, and resources satisfactory to the Bank. Loan Agreement. Section I.B of Schedule 2. By no later than one (1) month after the Effective Date, IBRD-91260 the Borrower shall adopt and thereafter carry out the Complied with No Change Project in accordance with the Project Operations . Manual. The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) . Results framework COUNTRY: Eswatini Health System Strengthening for Human Capital Development in Eswatini Project Development Objectives(s) The project development objective is to improve the coverage and quality of key reproductive, maternal, neonatal, child and adolescent health (RMNCAH), nutrition and NCD services (hypertension and diabetes) in Eswatini. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Improved coverage of key RMNCAH, nutrition and NCD services Percentage of patients diagnosed with hypertension and/or diabetes who are 58.00 76.00 80.00 85.00 90.00 90.00 managed at the PHC level (Percentage) Percentage of children under 5 years of age provided with a 32.00 35.00 40.00 45.00 50.00 55.00 basic package of nutrition specific services (Percentage) Percentage of adolescents served or reached with quality 0.00 0.00 10.00 20.00 40.00 50.00 sexual and reproductive health services (Percentage) Rationale: Action: This indicator has been - Preparatory activities and program launch delayed; Revised - Y3, Y4, Y5 (end) targets decreased to 20%, 40 %, and 50% The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Improved quality of RMNCAH, nutrition and NCD services Percentage of pregnant women receiving at least 4 8.60 10.00 20.00 30.00 40.00 50.00 ANC that meet defined quality standards (Percentage) Percentage of target health facilities that meet a minimum standard of quality as 0.00 0.00 10.00 30.00 50.00 70.00 measured by a Health Facility Quality Index (Percentage) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Improve health service delivery to increase coverage and quality of health services People who have received essential health, nutrition, and 0.00 114,072.00 156,108.00 200,029.00 246,110.00 294,360.00 population (HNP) services (CRI, Number) People who have received essential health, nutrition, and population (HNP) 0.00 66,812.00 98,423.00 131,674.00 166,494.00 202,887.00 services - Female (RMS requirement) (CRI, Number) The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Number of women and children who have received 0.00 93,336.00 113,108.00 134,029.00 156,110.00 179,360.00 basic nutrition services (CRI, Number) Number of deliveries attended by skilled health 0.00 20,736.00 43,000.00 66,000.00 90,000.00 115,000.00 personnel (CRI, Number) Percentage of women receiving post-partum check- 60.20 60.00 65.00 85.00 88.00 90.00 up within 14 days (Percentage) Rationale: Action: This indicator has been - Target already achieved; Revised - Y3, Y4, and Y5 targets increased to 85%, 88%, and 90% Number of people screened and diagnosed with 22,624.00 22,888.00 24,890.00 26,890.00 28,890.00 30,890.00 hypertension (Number) Number of people screened and diagnosed with diabetes 6,740.00 7,038.00 7,940.00 8,540.00 9,140.00 9,740.00 (Number) Number of HCWs trained on RMNCAH, nutrition and/or 0.00 80.00 178.00 850.00 900.00 900.00 NCD services (Number) Rationale: Action: This indicator has been - Target already achieved; Revised - Y3, Y4, and Y5 targets increased to 850, 900, and 900 The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Number of facilities using eLMIS for supply management 0.00 3.00 3.00 3.00 4.00 9.00 (Number) Rationale: Action: This indicator has been - Development of eLMIS supported by another partner delayed, affecting the scale up under the project; Revised - Y2, Y3, Y4, and Y5 targets decreased to 0, 3, 4, and 9 . Proportion of health facilities using CMIS for routine 54.00 66.00 70.00 75.00 80.00 80.00 reporting (Percentage) Percentage of target health facilities that received at least one comprehensive quality assessment applying the 0.00 0.00 60.00 70.00 80.00 90.00 appropriate checklist and protocol, and received adequate feedback from RHMT (Percentage) Satisfaction rates of clients with the quality of health 0.00 55.00 60.00 65.00 70.00 75.00 services (Percentage) Increase community demand for RMNCAH, nutrition and NCD services Number of community health workers (CHWs) including rural health motivators (RHMs) 0.00 12.00 800.00 2,750.00 3,000.00 3,000.00 trained to conduct community sensitization & outreach on The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 RMNCAH, Nutrition and NCD services (Number) Rationale: Action: This indicator has been - Target already achieved and attrition of RHMs; Revised - Y3, Y4, and Y5 targets increased to 2,750, 3,000, and 3,000 Number of people reached with RMNCAH, nutrition and NCDs specific communication 0.00 74,000.00 76,000.00 78,000.00 80,000.00 82,000.00 as part of targeted SBCC interventions (Number) Rationale: Action: This indicator has been - MoH unable to collect data Marked for Deletion Number of client-based digital 0.00 0.00 18,500.00 36,000.00 59,000.00 78,000.00 applications’ users (Number) Rationale: Action: This indicator has been - Activity dropped Marked for Deletion Strengthen MOH’s stewardship capacity to manage health & nutrition services and project activities Number of updated regulations, strategies, legal 0.00 0.00 0.00 4.00 8.00 10.00 framework, and guidelines submitted (Number) Action: This indicator has been Rationale: Revised - Activity scaled down; The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 - The indicator (definition) revised to “Number (Cumulative number) of updated regulations, strategies, legal framework, and guidelines submitted”; - Y2, Y3, Y4, and Y5 targets decreased to 0, 4, 8, and 10 Number of MOH management staff at national and regional 0.00 0.00 0.00 0.00 30.00 55.00 level trained (Number) Rationale: - Training needs assessment delayed; Action: This indicator has been - Definition refined to "Cumulative number of MOH management staff (Senior Management Team and Regional Health Management Team) trained on Revised technical and/or leadership"; - Y2, Y3, Y4, and Y5 targets decreased to 0, 0, 30, and 55 Percentage of target health facilities with at least one HCW 0.00 0.00 50.00 90.00 90.00 90.00 sensitized on GBV guidelines (Percentage) IO Table SPACE The World Bank Health System Strengthening for Human Capital Development in Eswatini (P168564)