The World Bank Implementation Status & Results Report Health System Support Project (KIRA) (P156012) Health System Support Project (KIRA) (P156012) EASTERN AND SOUTHERN AFRICA | Burundi | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2017 | Seq No: 13 | ARCHIVED on 29-Jun-2023 | ISR56943 | Implementing Agencies: MINISTRY OF FINANCE, Ministry of Health Key Dates Key Project Dates Bank Approval Date: 24-Feb-2017 Effectiveness Date: 20-Jun-2017 Planned Mid Term Review Date: 24-Feb-2020 Actual Mid-Term Review Date: 24-Feb-2020 Original Closing Date: 30-Jun-2021 Revised Closing Date: 30-Jun-2023 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) To increase the use of quality Reproductive, Maternal, Neonatal, Child and Adolescent Health services, and, in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency. Has the Project Development Objective been changed since Board Approval of the Project Objective? No Components Table Name Performance-based Payments to Support the Recipient's Free Health Care (FHC) Program:(Cost $91.00 M) Implementation Support for the FHC program-related activities:(Cost $19.24 M) Strengthening the Newly Integrated FHC Program Service Providers:(Cost $2.20 M) Contingent Emergency Response Support:(Cost $0.46 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Overall Risk Rating Substantial Substantial Implementation Status and Key Decisions The project is closing on June 30, 2023 and has had its last implementation support mission on May 22-26, 2023. Currently, the performance of the Project is rated as Moderately satisfactory with a number of key outcome indicators meeting or surpassing their targets. The extent to which the Kira project objectives were achieved is assessed under the two outcomes contained in the PDO statement: (i) increase utilization of services, and (ii) improve the quality of services. The results are based on data reported in the project results framework as of April 2023. The final results framework project data will be available by July 15, 2023 and will include project achievements up to June 30, 2023. In addition, the project has financed two surveys to jointly assess the quality of care and utilization of services with more robust household data. The surveys' results will be validated by July 2023 and will be used for the Implementation and Completion Results Reports (ICR). The PDO also includes a third outcome on emergency response in the event of an eligible crisis. The outcome was to be achieved through the Contingent 6/29/2023 Page 1 of 8 The World Bank Implementation Status & Results Report Health System Support Project (KIRA) (P156012) Emergency Response Component. The achievement on this outcome has not been assessed for the ISR since the CERC was never triggered and the funds originally allocated to that component were absorbed in other components. Utilization of services: The project has provided performance-based subsidies to facilities and groups of community health workers against the volume of services they have provided to the beneficiaries. Health services targeted pertained to maternal, newborn, and reproductive health. As of April 2023, the number of people who have received essential services is over 28 million, representing 83% achievement rate. These services include child vaccination (84% achieved), basic nutrition services received by women and children (78% achieved), and deliveries attended by skilled health personnel (139% achieved). Overall modern contraceptive prevalence rate is 36.1%, representing 47% achievement rate. Contraceptive prevalence among adolescents is currently at 4.9%, representing 92% achievement rate. Most intermediate results indicators (IRIs) have reached their targets: 5 out of the 7 IRIs related to utilization of services have surpassed/fully achieved their target (>100% achievement rate); 1 IRI is substantially achieved and 1 IRI is not achieved. Early results of one of the aforementioned surveys are available (The assessment of the impact of the free healthcare policy in Burundi). The results suggest that from 2012 to 2023, coverage of children fully immunized has increased from 70.3% to 78.9%, and coverage of deliveries with skilled personnel assisted, from 78.4% to 97.2%. Quality of services: Services against which subsidies were provided had to be of a certain quality standard as assessed by a quarterly score used as an increment to the overall amount a facility could receive. The overall quality score of hospital services at the district level is 82.9% as per March 2023 assessment, representing 32% achievement rate. Moreover, the percentage of women that have received a minimum of 4 antenatal care sessions is 35.1%, representing 23% achievement rate. Most IRIs have reached their targets: 5 out of 8 IRIs related to quality of healthcare services have surpassed/fully achieved their target (>100% achievement rate), 2 IRIs are substantially achieved, and 1 IRI is not achieved. Efficiency The efficiency of interventions is high. The project contributed to a pool of funds to finance the free primary health care policy of the government, and the payment of subsidies to health facilities against measured performances. These subsidies represented about 70% of the financial resources received by health facilities countrywide. Survey results suggest they translated into substantial improvement in maternal and child service coverage, that in their turn have translated into impact in terms of lives saved. as compared to the Demographic Health Survey of 2017 in Burundi, the results of these surveys preliminary suggests that the project has reduced Under 5-year old mortality from 78 deaths per 1,000 live births to 71 deaths per 1,000 live births; and has favorably impacted the maternal mortality ratio from 334 deaths per 100,000 live births to 299 deaths per 100,000 live births. The implementation efficiency of the project is high. The project was fully disbursed and kept up with the timeliness of subsidies to beneficiaries. Operational costs as compared to investments costs of the project were about 17%. Moreover, these operational costs were used to verify other investments in PBF from the Government, the German development agency (KfW) and the European Union. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance High High Substantial Macroeconomic Substantial Substantial Substantial Sector Strategies and Policies Moderate Substantial Substantial Technical Design of Project or Program Substantial Substantial Substantial Institutional Capacity for Implementation and Substantial Substantial Substantial Sustainability Fiduciary Substantial Substantial Substantial Environment and Social Moderate Moderate Moderate Stakeholders Moderate Substantial Substantial Other High High High Overall Substantial Substantial Substantial 6/29/2023 Page 2 of 8 The World Bank Implementation Status & Results Report Health System Support Project (KIRA) (P156012) Results PDO Indicators by Objectives / Outcomes Increase the use of quality Reproductive, Maternal, Neonatal, Child and Adolescent Health services IN01313651 ►People who have received essential health, nutrition, and population (HNP) services (Number, Corporate) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 27,965,135.00 28,010,969.00 33,473,918.00 Date 30-Jun-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 This indicator is a CRI indicator and replaces the original indicator (from PAD) which had the same label Comments: but for which definitions were not aligned with CRI guidelines. IN01313652 Number of children immunized (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 7,405,902.00 7,421,180.00 8,884,732.00 Date 01-Feb-2017 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313653 Number of women and children who have received basic nutrition services (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 17,210,234.00 17,225,512.00 22,169,131.00 Date 01-Feb-2017 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313654 Number of deliveries attended by skilled health personnel (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 3,348,999.00 3,364,277.00 2,420,055.00 Date 01-Feb-2017 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313655 ►Percentage of pregnant women who received four antenatal care visits (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 32.35 35.10 35.10 44.50 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313656 ►National quality average score of district hospital (Percentage, Custom) 6/29/2023 Page 3 of 8 The World Bank Implementation Status & Results Report Health System Support Project (KIRA) (P156012) Baseline Actual (Previous) Actual (Current) End Target Value 80.00 85.41 82.90 89.00 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313657 ►Contraceptive prevalence rate for modern methods (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 35.30 36.40 36.10 37.00 Date 29-Dec-2017 31-Dec-2022 30-Apr-2023 30-Jun-2023 This indicator is assessed annually. The current figure is still 2020's one as released by Demographic and Comments: Health Survey. IN01313658 ►Contraceptive prevalence rate among adolescents (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.50 4.90 4.90 5.20 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 This indicator is assessed annually. The current figure is still 2020's one as released by Demographic and Comments: Health Survey. Intermediate Results Indicators by Components Use of Performance-based Payments to Support the Recipient's Free Health Care (FHC) Program IN01313659 ►Number visits to a health facility for Children under five years of age (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 2.20 3.90 3.90 2.60 Date 01-Dec-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 While the baseline and targets are based on DHS, this estimates are reported from PBF subsidies' claims Comments: data. IN01313660 ►Pregnant women receiving antenatal care during a visit to a health provider (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 2,123,403.00 2,420,494.00 1,702,288.00 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 6/29/2023 Page 4 of 8 The World Bank Implementation Status & Results Report Health System Support Project (KIRA) (P156012) IN01313661 ►Number of years-protection couples for modern methods (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 7,716,921.00 8,525,776.00 8,533,041.00 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313662 ►Coverage of births attended by qualified personnel (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 77.30 84.10 76.30 95.00 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313663 ►Pregnant women on ARV protocol for the prevention of mother-child transmission (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 3,885.00 21,578.00 21,578.00 20,825.00 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313664 ►Satisfaction rate of beneficiaries on health care delivered by health centers (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 57.43 99.00 92.30 99.00 Date 30-Dec-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313665 ►Public health facilities that offer FHC and use RBF (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 97.00 100.00 100.00 100.00 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313666 ►Number of new Family Planning acceptors referred by Community Health Workers and who arrived at the health center (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 394,326.00 408,402.00 337,702.00 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313667 ►Pregnant women referred for early antenatal care ANC1 (TRIM1) (Number, Custom) 6/29/2023 Page 5 of 8 The World Bank Implementation Status & Results Report Health System Support Project (KIRA) (P156012) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 474,717.00 479,253.00 446,374.00 Date 01-Jan-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313668 ►Total number of children aged 6-59 months tested and referred by community health workers for malnutrition (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 412,639.00 412,871.00 516,017.00 Date 30-Dec-2016 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313669 ►Children under 2 fully immunized (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 83.30 83.80 79.00 Date 30-Jun-2017 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313670 ►Grievances registered related to delivery of project benefits that are actually addressed (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 82.00 94.00 25.00 Date 25-Feb-2019 31-Dec-2022 30-Apr-2023 30-Jun-2023 The mechanism is operational with data to be reported by July 2022. Comments: IN01313671 ►Sexual violence cases that arrive at a health facility and receive Post Exposition Prophylaxis within 72 hours (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 31.00 53.00 54.00 44.00 Date 12-Feb-2021 31-Dec-2022 30-Apr-2023 30-Jun-2023 This indicator was previously misreported. Comments: IN01313672 ►Laboratories having referred samples to excellence laboratories (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 63.00 50.00 Date 12-Feb-2021 31-Dec-2022 30-Apr-2023 30-Jun-2023 IN01313673 6/29/2023 Page 6 of 8 The World Bank Implementation Status & Results Report Health System Support Project (KIRA) (P156012) ►Satellite laboratories awarded four-star status under regional accreditation program based on WHO/AFRO five-step accreditation approach (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 7.00 7.00 7.00 8.00 Date 12-Feb-2021 31-Dec-2022 30-Apr-2023 30-Jun-2023 Performance-Based Conditions Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P156012 IDA-D1660 Effective USD 50.00 50.00 0.00 51.97 0.00 100% P156012 IDA-D7900 Effective USD 50.00 50.00 0.00 46.38 0.43 99% P156012 TF-B0539 Closed USD 8.30 8.30 0.00 8.30 0.00 100% P156012 TF-B5105 Closed USD 4.60 4.60 0.00 4.57 0.03 99% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P156012 IDA-D1660 Effective 24-Feb-2017 23-Mar-2017 20-Jun-2017 30-Jun-2021 30-Jun-2023 P156012 IDA-D7900 Effective 22-Apr-2021 03-May-2021 19-Jul-2021 30-Jun-2023 30-Jun-2023 P156012 TF-B0539 Closed 15-May-2019 17-Jun-2019 17-Jun-2019 30-Jun-2021 30-Jun-2022 P156012 TF-B5105 Closed 31-Mar-2021 03-May-2021 19-Jul-2021 30-Jun-2021 31-Oct-2022 Cumulative Disbursements 6/29/2023 Page 7 of 8 The World Bank Implementation Status & Results Report Health System Support Project (KIRA) (P156012) Restructuring History Level 2 Approved on 06-Feb-2020 ,Level 2 Approved on 23-Jun-2020 ,Level Approved on 07-Jul-2020 ,Level 2 Approved on 18-Jun-2021 ,Level 2 Approved on 25-May-2022 Related Project(s) P166576-Burundi Health System Support-Additional Financing ,P173252-Health System Support Project (KIRA) Additional Financing 2 6/29/2023 Page 8 of 8