The World Bank Transforming Egypt's Healthcare System Project (P167000) REPORT NO.: RES58450 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF TRANSFORMING EGYPT'S HEALTHCARE SYSTEM PROJECT APPROVED ON JUNE 27, 2018 TO THE ARAB REPUBLIC OF EGYPT HEALTH, NUTRITION & POPULATION MIDDLE EAST AND NORTH AFRICA Regional Vice President: Ferid Belhaj Country Director: Stephane Guimbert Regional Director: Fadia M. Saadah Practice Manager/Manager: Michele Gragnolati Task Team Leader(s): Avril Dawn Kaplan The World Bank Transforming Egypt's Healthcare System Project (P167000) ABBREVIATIONS AND ACRONYMS CHW Community health worker CERC Contingent Emergency Response Category CPR Contraceptive prevalence rate ESMF Environmental and Social Management Framework AFD French Development Agency (Agence Française de Développement) GBV Gender-based violence GAHAR General Authority on Healthcare Accreditation and Regulation GMP Good Manufacturing Practices GRM Grievance Redress Mechanism IVA Independent Verification Agency IPC Infection prevention control IPF Investment Project Financing MOHP Ministry of Health and Population NSR National Safety Requirements NCD Non-communicable diseases PBC Performance Based Conditions PBR Performance Based Results PQI Plasma Quality Index PIESWL Presidential Initiative to Eliminate the Surgical Waiting List PHC Primary Health Centers PTES Program for Treatment at the Expense of the State PDO Project Development Objective PMU Project Management Unit QSI Quality Service Index SEA/H Sexual exploitation, abuse and harassment TEHSP Transforming Egypt's Healthcare System Project UPA Unified Procurement Agency UHIS Universal Health Insurance System The World Bank Transforming Egypt's Healthcare System Project (P167000) BASIC DATA Product Information Project ID Financing Instrument P167000 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 27-Jun-2018 31-Dec-2025 Organizations Borrower Responsible Agency Ministry of Investment and International Cooperation Project Development Objective (PDO) Original PDO The proposed Project Development Objective is to (i) improve the quality of primary and secondary health care services, (ii) enhance demand for health and family planning services, and (iii) support the prevention and control of Hepatitis C. Current PDO The proposed Project Development Objective is to (i) improve the quality of primary and secondary health care services, (ii) enhance demand for health and family planning services, (iii) support the prevention and control of Hepatitis C, and (iv) to provide immediate and effective response to an eligible crisis or emergency. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IBRD-88950 27-Jun-2018 10-Jul-2018 07-Sep-2018 31-Dec-2025 530.00 323.76 206.24 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Transforming Egypt's Healthcare System Project (P167000) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Project Background and Status 1. The proposed restructuring of the Transforming Egypt's Healthcare System Project (TEHSP, P167000) includes the following: i) revision of the Project Development Objective (PDO) to incorporate activities that strengthen quality across the continuum of care; ii) changes to Project components and costs; iii) changes to Performance Based Conditions (PBCs) and their allocations; iv) reallocation between disbursement categories; v) changes to disbursement arrangements; vi) changes to the results framework; vii) update of the technical and economic analysis; and viii) and update of the social and environmental analysis. The Project will also integrate parallel co-financing from the French Development Agency (Agence Française de Développement - AFD) to expand Project impact. 2. The US$530 million loan for TEHSP was approved by the World Bank Board of Executive Directors on June 27, 2018, and became effective on September 7, 2018, with a closing date of December 31, 2023. The PDO at approval was to (i) improve the quality of primary and secondary health care services, (ii) enhance demand for health and family planning services, and (iii) support the prevention and control of Hepatitis C. It is an Investment Project Financing (IPF) with PBCs, with US$ 211.3 million of the loan initially allocated to nine PBCs. The four components of the Project at approval are summarized below:  Component 1: Strengthen Primary Healthcare, Family Planning and Community Activities (US$247.4 million). This component includes four sub-components: i) providing for quality services at primary health centers (PHCs) (US$69.5 million, four PBCs); ii) strengthening the community health worker (CHW) program (US$8.5 million, one PBC); iii) supporting health and family planning activities (US$35.1 million, one PBC); iv) screening for Hepatitis C and risk factors for high burden diseases (US$134.3 million, two PBCs).  Component 2: Strengthen Secondary Level Healthcare (US$274.6 million). This component included three sub- components: i) providing for quality services at hospitals (US$94.0 million); ii) improving the blood bank network (US$50.0 million); and iii) treating Hepatitis C (US$130.6 million, one PBC).  Component 3: Institutional Capacity Building and Project Management (US$8.0 million inclusive of frontend fee). This component supported Project management and monitoring and evaluation, institutional strengthening, and a Technical Advisory Group on Hepatitis C and non-communicable diseases (NCDs) to disseminate lessons from this Project globally.  Component 4: Contingent Emergency Response Category (CERC). This component allowed for a rapid reallocation of Project resources in the event of a natural or man-made disaster or crisis. 3. The Project was restructured in July 2021 and September 2023. The first restructuring was processed to record the CERC activation during the COVID-19 pandemic. A new Component 4: Early COVID-19 Response and an associated PBC were added for US$7.9 million, and the PDO statement was expanded to include “to provide immediate and effective response to an eligible crisis or emergency.” The restructuring dropped a target for PBC 5, “Increased household visits by CHWs,” which could not be met due to the enforcement of social distancing measures during the pandemic. The amount allocated to PBC 5 was reduced accordingly, from US$ 3.0 to US$2.4 million. The restructuring introduced five The World Bank Transforming Egypt's Healthcare System Project (P167000) new PBCs under Component 2, amounting to US$32.2 million. One of the new PBCs aimed to strengthen online certified medical licensing and examination of specialties, while the remaining four new PBCs aimed to strengthen the national blood network. The restructuring also revised the procurement implementation arrangements to include the Unified Procurement Agency (UPA) as the main agency responsible for procuring medical equipment and supplies. The new PBCs and the allocation of funds across components before and after the first restructuring are summarized in Annex 1. The second restructuring was processed to extend the loan closing date by 24 months until December 31, 2025, to enable the loan to fully disburse and have maximum impact for beneficiaries. 4. Achievement towards the PDO and Implementation Progress are rated Moderately Satisfactory. Of the eight PDO indicators, only the indicator pertaining to blood bank activities under Sub-component 2.2 is off track. The project has disbursed US$323.8 million from the loan (61 percent of the loan). Component 1 is currently rated Highly Satisfactory. Screening for Hepatitis C and NCDs exceeded its targets and was completed two years earlier than planned. The target to increase the use of contraceptives was also reached earlier than planned. Furthermore, significant progress was made on the quality improvement of PHCs and in supporting community health workers (CHWs). However, PBC 4, “Improving quality care at PHCs,” has not achieved its results. Component 2 is currently rated Moderately Satisfactory. It has overachieved the targets for Hepatitis C treatment. However, there have been significant delays in both supplying medical commodities and equipment to target hospitals and achieving PBCs related to strengthening the blood bank network. Component 3 is rated Moderately Satisfactory, with strong project management, monitoring and evaluation, and institutional strengthening. However, there is a need to increase the rate of project implementation to meet the disbursement schedule. Component 4 is rated Highly Satisfactory due to the completion of rapid screening for suspected COVID-19 cases early in the pandemic. 5. Procurement and Financial Management are rated Moderately Satisfactory. There have been some delays in uploading procurement documents to the Systematic Tracking of Exchanges in Procurement platform and in completing all documents for the signed contracts. Financial Management has experienced delays in internal audit and in the settlement of accounts between the Ministry of Health and Population (MOHP) and the UPA. To date, all annual audit reports and Interim Financial Reports have been received in a timely manner and were of acceptable quality. There are currently no unresolved audit observations. 6. Environmental and Social Safeguards are also rated Moderately Satisfactory. The project triggered Bank safeguard policy 4.01: Environmental Assessment and is rated environmental Category B. The Environmental and Social Management Framework (ESMF) for the Project was prepared and disclosed on April 26, 2018. As part of the July 2021 restructuring of the Project, an ESMF addendum was prepared and disclosed on June 14, 2021. The project ESMF is being implemented satisfactorily, except for delays in submitting progress reports. B. Rationale for Restructuring 7. The rationale for restructuring is the following: i) reprograming US$63 million of undisbursed IPF funds to ongoing or new activities and PBCs; ii) adapting PBC 4, which has not achieved its results; iii) adapting overly ambitious targets for blood bank PBCs; iv) introducing AFD parallel co-financing; and v) recording a second CERC activation. 8. Reprogramming US$63 million of undisbursed IPF funds. TEHSP was able to disburse rapidly during the first two years of Project implementation, but disbursement has now slowed.1 This is largely due to delayed procurement linked to 1 The Project has only disbursed US$17 million over the past two years. The World Bank Transforming Egypt's Healthcare System Project (P167000) Egypt’s 2019 law, which created the UPA as the sole entity responsible for procurement of all medical and pharmaceutical goods for the public sector. The Project was restructured to accommodate this new institutional arrangement, after which point the UPA needed to be brought up to speed on ongoing procurement and World Bank procedures. Egypt is also facing a shortage of foreign currency, which has created a nationwide backlog in both procurement and clearance of goods at ports. While the Project initially planned to procure three years’ worth of medicines and equipment to strengthen the national blood bank network, this is no longer a viable option given procurement and supply chain constraints. The Project has therefore identified US$28.0 million for blood bank reagents, US$2.8 million for blood bank equipment, and US$1.0 million for supply chain support that can be reprogrammed under Sub-component 2.2. The project also identified US$28.3 million in savings due to the lower-than-expected price of Hepatitis C medication under Sub-component 2.3. These cost savings are indicative of the Government’s success in markedly reducing the cost of Hepatitis C medications through negotiations with pharmaceutical companies and local manufacturing.2 In addition, the Project Management Unit (PMU) has identified that US$1.1 million programmed for the Al-Wissam initiative (which provides certification to family planning providers under Sub-component 1.1), and US$1.8 million in project management costs (Component 3) that can be reprogrammed. All these funds are under the regular IPF portion of the loan and can be reallocated to high performing activities and new priorities aligned with the PDO. 9. Adapting PBC 4, which has not achieved its results. As designed, the project targeted 600 PHCs to pass the Quality Service Index (QSI) under Performance Based Result (PBR) 4.1 (US$48.0 million), and then move on to receive General Authority on Healthcare Accreditation and Regulation (GAHAR) accreditation under PBR 4.2 (US$12.0 million). PHCs that have passed the QSI need varying levels of rehabilitation to attain GAHAR accreditation. However, over the past four years, most capital expenditure for construction and rehabilitation of healthcare facilities was prioritized to Governorates that will be joining phases one and two of the Universal Health Insurance System (UHIS). To date, none of the 496 targeted facilities that have already passed the QSI have obtained accreditation, so PBR 4.2 has not disbursed. The restructuring proposes to revise PBR 4.2 to support fundamental quality improvement measures that will better support PHCs in their journey towards accreditation. 10. Adapting overly ambitious targets for blood bank PBCs. The PBCs 12, 13 and 14 that are linked to improvement of the national blood bank are too ambitious to achieve during the Project’s lifetime. These PBCs incentivize 10 regional plasma centers to pass a Plasma Quality Index (PQI) composite indicator, 12 plasma centers to receive Good Manufacturing Practices (GMP) Certificates, and 250,000 plasma units to be properly collected, transferred, tested, and stored. When these PBCs were designed, the MOHP anticipated having 12 newly established plasma centers. However, only six plasma centers are currently operating. The restructuring proposes to reduce targets accordingly and reallocate US$9.7 million from these PBCs to new activities. 11. Integrating AFD parallel co-financing. AFD has provided Egypt a EUR 25 million loan that supports primary health care and COVID-19 response, which is being implemented by MOHP. The strong working relationship between the MOHP, the World Bank and AFD has encouraged AFD to allocate EUR 23.01 million from its loan to TEHSP through parallel co- financing by restructuring the activities of its Project to match the objectives and structure of TEHSP. 12. Recording a second CERC activation. The World Bank approved the activation of CERC on November 28, 2023, along with the updated CERC Project Operations Manual and Emergency Action Plan. Under the IPF portion of Sub-component 2.1, the project planned to procure US$90.0 million of drugs and medical supplies, equipment, and devices. Activating 2Hassanin A, Kamel S, Waked I, Fort M. Egypt's Ambitious Strategy to Eliminate Hepatitis C Virus: A Case Study. Glob Health Sci Pract. 2021 Mar 31;9(1):187-200. doi: 10.9745/GHSP-D-20-00234. PMID: 33795369; PMCID: PMC8087425. The World Bank Transforming Egypt's Healthcare System Project (P167000) the CERC enables more rapid procurement of these goods using emergency protocols to restock MOHP’s strategic reserves of medical resources that were redirected to Egypt's relief and medical evacuation efforts at the border with Gaza,3 and to ensure the sustainable delivery of healthcare services throughout Egypt during the acute humanitarian emergency in the border region. II. DESCRIPTION OF PROPOSED CHANGES 13. Changes to the PDO: The PDO statement currently has four parts, one of which will be revised. “Primary and secondary care” will be removed from the PDO and replaced by “to improve the quality of health care services" to highlight that the Project’s objective is to strengthen quality across the continuum of care, including at the tertiary level. The Project’s theory of change has been updated to incorporate activities added during the restructuring and is presented in Annex 2. 14. Changes to components and costs: Proposed revisions to component and Sub-component names, along with their justifications are summarized in Table 1. Table 1: Summary of changes to component and sub-component names Component/Sub- Current Proposed revision Justification component Sub-component 1.3 Supporting health and Supporting health and Existing activities support the population agenda, family planning population activities, which is broader than family planning. activities including family planning Component 2 Strengthening Strengthen secondary Existing and new activities improve quality at both secondary level care and tertiary level care levels of care. Component 4 Early COVID-19 COVID-19 response and Activities financed by the Project support more than response recovery the early phase. Sub-component 4.1 - Sub-component 4.1: Early Captures PBC 15 that has already disbursed. COVID-19 response Sub-component 4.2 - Sub-component 4.3: Captures parallel co-financing from AFD for the Ongoing COVID-19 procurement of personal protective equipment and recovery other infection prevention control (IPC) related goods and materials. Component 5 - Restocking MOHP Captures CERC that was activated in November strategic reserves of 2023 for emergency procurement of drugs and medical resources medical supplies, equipment and devices. 15. Changes to PBCs and their allocations. The restructuring will revise allocations for select PBCs and add new PBCs. Annex 3 presents the PBRs and disbursement formulas. Revised PBCs and allocations  Increasing allocation to PBC 2: Percentage of grievances addressed in Project target facilities in accordance with the revised Grievance Redress Mechanism (GRM) Manual issued in 2017 (increased by US$1.25 million, from US$3.0 million to US$4.25 million). The Project has put in place a strong GRM under PBC 2 and is on track to meet 3World Health Organization. November 15, 2023. WHO Egypt Emergency Response During Gaza Crisis. External Situation Report. External Situation Report; World Health Organization. December 18, 2020. WHO-Egypt Flash Appeal. The escalation of conflict in the occupied Palestinian territory. The World Bank Transforming Egypt's Healthcare System Project (P167000) the target of addressing 80 percent of grievances received by December 2023. This PBC will be extended and refined to handle sexual exploitation, abuse, and harassment (SEA/H) cases using a confidential and survivor centered approach. It will finance i) development of training materials that accommodate SEA/H complaints with the support of a specialized firm; ii) training on the SEA/H sensitive GRM delivered to PHC and district level staff in participating Governorates using a training of trainers approach; and iii) ensuring that 80 percent of grievances are addressed using the GRM, in accordance with the new SEA/H procedures.  AFD co-financing of PBR 4.1 and revised PBR 4.2: Improvement of PHC Quality of Services (no change in IBRD funding amount of US$60.0 million). AFD parallel co-financing will be added to support an additional 100 PHCs under PBR 4.1. PBC 4.2 will be revised to support PHCs in completing their GAHAR self-assessment, which is the next step in their journey towards registration and accreditation. The number of PHCs targeted to complete the self-assessment process is 250.  Increasing allocation to PBC5: Increased household visits by CHWs (increased by US$0.6 million, from US$2.4 million to US$3.0 million). The Project is on track to meet the target of having 32 percent of households visited by a CHW by December 2023. A new PBR will be added to extend this PBC for an additional year to maintain results achieved to date.  Increasing allocation to PBC 6: Increased contraceptive prevalence rate (CPR) (increased by US$3.75 million, from US$3.2 million to US$6.95 million). This PBC incentivized improvements in the CPR on a national scale and the project has already achieved both its PBRs. Family planning remains a key priority for MOHP, so an additional PBR will be added to further increase the CPR nationwide.  Reducing allocation to PBC 12: Number of plasma centers passing the PQI composite indicator (decreased by US$3.7 million, from US$9.2 million to US$5.5 million). The target number of plasma centers will be reduced from 10 to 6.  Reducing allocation to PBC 13: Number of plasma centers receiving GMP certificates (decreased by US$3.8 million, from US$7.6 million to US$3.8 million). The target number of plasma centers will be reduced from 12 to 6.  Reducing allocation to PBC 14: Number of plasma units that were properly collected, transferred, tested and stored (decreased by US$2.2 million, from US$3.4 million to US$1.2 million). The cost of plasma units was estimated at US$13.76 during the first project restructuring, which is an underestimate of $93.24 per unit. The unit cost has been updated, and the target number of plasma units will be reduced from 250,000 to 11,000 to meet current demand for the remaining two years of the project.  A new PBC will be added under Sub-component 1.3 to build on and deepen the Project’s successful work to strengthen the national CHW program. CHWs present an entry point to work with communities to raise awareness and prevent gender-based violence (GBV). PBC 16 for US$ 0.9 million will be added to i) develop and integrate a new module on GBV awareness, prevention, and response into the CHW training curriculum using a specialized firm; ii) train CHWs using the new GBV module; and iii) provide supportive supervision to the newly trained CHWs as they start working in communities.  A series of new PBCs will be added under Sub-component 2.1 to improve the quality of surgical care through the Presidential Initiative to Eliminate the Surgical Waiting List (PIESWL). This is a major national initiative, which has achieved success since its launch in 2018. In the past, Egyptians requiring surgery often faced long wait times, The World Bank Transforming Egypt's Healthcare System Project (P167000) which contributed to increased morbidity and mortality. Despite public hospitals being free of charge, people also encountered significant out-of-pocket expenses for surgeries. Increasing access to safe and affordable surgical care is important in Egypt because the population faces increased incidence of NCDs that require advanced care.4 The PIESWL created an effective system to evaluate surgical candidates and link them to participating public and private hospitals, based on medical need. Surgery is provided free of charge, and hospitals are reimbursed a standard rate once the patient verifies that they have not incurred any cost. Since this program was introduced, the government has spent approximately EGP 11.9 billion for more than 1.4 million surgeries. This includes EGP 8.9 billion to cover 701,000 surgeries through the Program for Treatment at the Expense of the State (PTES), which covers the uninsured. The PIESWL program has resulted in a significant increase in the proportion of surgeries on the waiting list delivered in a month; from 77 percent in 2018 to 90 percent by end-2022. A new set of PBCs will be introduced to support the MOHP to continue providing timely and safe surgeries through this initiative and to protect households from catastrophic expenditures linked to surgical care. US$60 million will be allocated to the following four new PBCs. o PBC 17: Timely access to surgical care (US$9.0 million). The PBRs will incentivize the government to provide surgical interventions within 30 days or less from issue date of the operation decree. o PBC 18: Financial projection for surgical care (US$0.6 million). The uninsured do not have protection from high health expenditures are at greatest risk for financial catastrophe. The PBRs will ensure that patients receiving surgery financed by the government under PTES are uninsured and selected in an objective manner, thereby offering financial protection for surgical care. o PBC 19: Safe surgical care (US$16.4 million). The PBRs will incentivize achievement of the National Safety Requirements (NSR, see Annex 4) for Surgery, Anesthesia and Sedation in target hospitals participating in the PIESWL. o PBC 20: Sustainable financing for surgical care (US$34 million). The PBRs will incentivize government commitment to clear PIESWL arrears and ensure that participating hospitals receive payment within 60 days. 16. Reallocation between disbursement categories. The Loan Agreement will be revised to reflect a reallocation between disbursement categories. Category 1 will now cover US$131,089,000; Category 2 will cover US$299,677,000; and Category 5 will cover US$ 97,909,000. The amounts in Categories 3 and 4 will remain unchanged. 17. Changes in disbursement arrangements. The parallel co-financing from AFD will be carried out under the umbrella of the “AFD and World Bank co-financing framework agreement” signed in 2018. A separate co-financing agreement will be prepared and signed between AFD and the World Bank. Under the proposed agreement, the World Bank will provide disbursement services to AFD. The agreed arrangements are presented in Annex 5. 18. Changes in Results Framework. Table 2 summarizes the changes in the Project results framework, along with the justification for each revision. 4Ramon Martinez, Peter Lloyd-Sherlock, Patricia Soliz, Shah Ebrahim, Enrique Vega, Pedro Ordunez, Martin McKee, Trends in premature avertable mortality from non-communicable diseases for 195 countries and territories, 1990–2017: a population-based study, The Lancet Global Health, Volume 8, Issue 4, 2020, Pages e511-e523, The World Bank Transforming Egypt's Healthcare System Project (P167000) Table 2: Revisions to Project results framework Indicator Revision Type Justification PDO indicators Percentage of surgical New PDO Aligned with new PBCs in support of improving the quality interventions provided in 30 days of surgical care. The target is 92 percent. or less from issue date of operation decree Percentage of MOHP medical New PDO Reflects CERC activities. The target is 90 percent. reserves restocked. Number of PHCs passing QSI Increase PDO Reflects AFD parallel co-financing for 100 additional PHCs. composite indicators list target from 600 to 700 CPR Increase PDO Reflects the addition of a new PBR and an end target under target from PBC 6. 65 to 69.4 Intermediate Results Indicators (IRI) Number of CHWs receiving GBV New IRI Aligned with the new PBC for integrating the GBV awareness, prevention, and awareness, prevention and response curriculum into the response training national training for CHWs. The target is 1250 CHWs. Number of hospitals passing New IRI Aligned with the new PBCs in support of improving the NSRs for surgery, anesthesia and quality of surgical care. The target is 250 hospitals. sedation. Percentage of PTES patients New IRI Aligned with the new PBCs in support of improving the receiving surgery through PIESWL quality of surgical care. The target is 100 percent. who are uninsured. Percentage of payments by New IRI Aligned with the new PBCs in support of improving the MOHP that took place within 60 quality of surgical care. The target is 78 percent. days of claim submission for PTES who received a surgical intervention through PIESWL. Number of plasma centers New IRI Aligned with PBC 14. The target is 6 plasma centers. receiving GMP certificates Number of health facilities New IRI Aligned with CERC activities. This indicator will track the stocked with drugs and medical distribution of MOHP medical reserves procured with supplies, equipment and devices. project finances, from the central level to health facilities. Restocking from the central to facility level will be based on a needs assessment. The designated health facilities and the target number will be indicated in the Project Operations Manual. Number of PHCs receiving Revise IRI Under PBR 4.2, PHCs will no longer be working towards National Accreditation indicator accreditation. This indicator will be revised as follows: Certification for healthcare Number of PHCs completing GAHAR self-assessment, quality which have previously passed QSI. The target will be 250 PHCs. The World Bank Transforming Egypt's Healthcare System Project (P167000) Targeted PHCs applying Increase IRI Reflects AFD parallel co-financing for 100 additional PHCs. environmentally positive energy target from and water efficiency measures 600 to 700 Hepatitis C treated patients Decrease IRI The target has been revised after screening 62 million target from people. 1.5 to 1.2 million Number of plasma centers Decrease IRI Sets a realistic target. passing the PQI composite target from indicator. 10 to 6 centers Targeted regional blood banks Decrease IRI Sets a realistic target. that have been connected to the target from national automated blood 11 to 6 blood network. banks. Number of plasma units that Decrease IRI Sets a realistic target. were properly collected, target from transferred, tested and stored. 250,000 to 11,000 Number of hospitals receiving Drop IRI When the Project was designed, GAHAR had not yet National Accreditation indicator developed accreditation standards. The new standards will not be achieved during the timeframe of the Project. Support provided to hospitals has been delayed due to the national backlog in procurement and is being re- programmed. 19. Technical Analysis. The technical analysis conducted for the parent project and revisited during the 2021 restructuring remain relevant. This restructuring expands activities that improve the quality of surgical care. Investing in surgical care is part of building a responsive health system and reducing catastrophic health expenditures. The Lancet Commission on Global Surgery5 found that in 2010, 33 percent of all deaths worldwide, amounting to 16.9 million lives, were lost from conditions needing surgical care. Given the disease profile in lower-middle-income countries like Egypt, the Lancet Commission estimated that between 2015 and 2030, the lost economic output due to surgical conditions would reduce GDP growth by nearly 2 percent. The new surgical PBCs introduced under the restructuring incentivize technically sound approaches to improve surgical care in Egypt. Timely access to surgical care is a core component of quality. People need to obtain services within a timeframe that ensures that their medical condition does not deteriorate or result in mortality. Financial protection is important because the cost of surgical care is a major barrier to access. Half of the world’s population is at risk of facing catastrophic health expenditures if they need surgical care. An estimated 32.8 million people did face catastrophic health expenditures in 2010 from the medical cost of accessing surgical care, and this increases to 48 million people when non-medical costs were also considered.6 5 Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SL, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth. 2016 Feb;25:75-8. doi: 10.1016/j.ijoa.2015.09.006. Epub 2015 Sep 30. PMID: 26597405. 6 Meara et al., 2015. The World Bank Transforming Egypt's Healthcare System Project (P167000) Investing in safer surgical care is technically sound, because globally one quarter of all inpatient operations result in complications, half of which are preventable.7 Finally, ensuring the financial sustainability of the PIESWL is critical until the program can be integrated into UHIS. 20. Economic Analysis. The project remains economically justified. A recent assessment of the impact on health and financial protection of the PIESWL in Egypt was conducted by the World Health Organization.8 Using detailed data on costs (direct and indirect) and health outcomes for five clinical conditions (open heart surgery, cardiac catheterization, cochlear implant, retina replacement and joint replacement), the analysis found that using a social perspective, the combined effect of all interventions studied yielded a cost-effectiveness ratio of EGP 46,795 per Quality Adjusted Life Year gained. Using a standard willingness to pay threshold of 1 GDP per capita (EGP 56,000 in 2020 for Egypt), the cost-benefit ratio stands at 1.14, which therefore translates into an important return on investment. The assessment also highlighted that most interventions are considered unaffordable by the population, since they would expose households to catastrophic health expenditures if paid out-of-pocket. For example, the study found that 35 percent of patients undergoing Ophthalmic and Cardiac catheterization and 68 percent of the patients undergoing cochlear implantation would be pushed below the poverty line. Only an estimated 4.5 percent of the eligible population could afford surgeries without suffering from financial hardship. Investing in this initiative will therefore significantly protect poor households. 21. Environmental and Social Analysis. The Environmental and Social risks associated with the newly introduced PBCs under the same components are already covered by the current ESMF and its addenda. To ensure compliance with the ESMF and World Health Organization standards, the Project will ensure that publicly owned or privately owned hospitals to be contracted for individual surgeries are equipped and are implementing medical waste management plans and IPC measures as required. Under the proposed restructuring, the IVA will ensure that the eligible expenditures are carried out in accordance with the ESMF and its addenda. It will introduce new PBCs that will capitalize on the achievements of the Project, particularly on the level of operationalizing the GRM and introduce a sensitive and survivor centered approach for handling GBV. This will entail structured and expanded learning and capacity building for health care workers to raise their awareness of GBV. 22. Risks. The current overall risk rating of the project is Substantial will not change because of the proposed restructuring. 7World Alliance for Patient Safety. 2009. Safe Surgery Saves Lives. Geneva: World Health Organization 8Khalifa, 2023. Egypt’s Initiative to Eliminate Waiting lists: An Assessment of its Impact on Health, Economy and Financial Protection of Egyptian Households. International Health Economics Association 15th World Congress, Cape Town, 2023. The World Bank Transforming Egypt's Healthcare System Project (P167000) Annex 1: Revised Project allocations by component and sub-component, not including AFD co-financing Current Amount (US$ Rationale for increase/ Original Amount millions) after 2021 Reallocation Revised Amount decrease (US$ millions) restructuring amount (US$ millions) Component 1: Strengthen Primary Healthcare, Family Planning and Community Activities Sub-Component 1.1 Providing for quality services at PHCs PBC 1: Development of quality tools 4,000,000 4,000,000 - 4,000,000 and mechanisms PBC 2: % of grievances addressed in 3,000,000 3,000,000 1,250,000 4,250,000 New PBRs 2.7, 2.8 & 2.9 project target facilities in accordance with the revised GRM Manual PBC 3: Strengthening governance 2,500,000 2,500,000 - 2,500,000 and decentralized management PBC4: Improvement of PHC Quality 60,000,000 60,000,000 - 60,000,000 Total SC1.1 69,500,000 69,500,000 1,250,000 70,750,000 Sub-Component 1.2: Strengthen CHW program PBC 5: Increased household visits by 3,000,000 2,400,000 600,000 3,000,000 New PBR 5.6 CHWs in target Governorates PBC 16: CHWs trained on GBV - - 900,000 900,000 New PBRs 16.1, 16.2 and awareness, prevention and response 16.3 5,500,000 6,100,000 6,138,971 12,238,971 Increase in CHW per diem, number of CHWs IPF portion contracted, ongoing CHW training Total SC 1.2 8,500,000 8,500,000 7,638,971 16,138,971 Sub-Component 1.3: Supporting health and population activities, including family planning PBC 6: Increased CPR 3,200,000 3,200,000 3,750,000 6,950,000 New PBR 6.3 31,900,000 21,991,000 (1,101,768) 20,889,232 Revised budget based on IPF portion needs. Total SC 1.3 35,100,000 25,191,000 2,648,232 27,839,232 Sub-Component 1.4: Screening for Hepatitis C and risk factors for high burden diseases PBC 7: NCD screening 4,000,000 4,000,000 - 4,000,000 PBC8: Hepatitis C screening 129,600,000 129,600,000 - 129,600,000 700,000 700,000 (327,029) 372,971 Reduced demand for tablets IPF for Hepatitis C screening. The World Bank Transforming Egypt's Healthcare System Project (P167000) Current Amount (US$ Rationale for increase/ Original Amount millions) after 2021 Reallocation Revised Amount decrease (US$ millions) restructuring amount (US$ millions) Total SC 1.4 134,300,000 134,300,000 (327,029) 133,972,971 Total Component 1 247,400,000 237,491,000 11,210,174 248,701,174 Component 2: Strengthen secondary and tertiary level care Sub-Component 2.1: Providing for quality services at hospitals PBC 10: Number of conducted 2,000,000 - 2,000,000 rounds of the online certified medical licensing and specialties examination PBC 17: Timely access to surgical 9,000,000 9,000,000 New PBC care PBC 18: Financial protection for 600,000 600,000 New PBC surgical care PBC 19: Safe surgical care 16,400,000 16,400,000 New PBC PBC 20: Financial sustainability of 34,000,000 34,000,000 New PBC PIESWL IPF portion 94,000,000 94,000,000 (89,600,000) 4,400,000 Reallocated to CERC 2 Total SC 2.1 94,000,000 96,000,000 (29,600,000) 66,400,000 Sub-component 2.2: Improve the blood bank network PBC 11: Development of plasma 10,000,000 - 10,000,000 quality tools PBC 12: Number of plasma centers 9,200,000 (3,680,000) 5,520,000 Decreased PBC target passing the PQI composite indicator PBC 13: Number of plasma centers 7,560,000 (3,780,000) 3,780,000 Decreased PBC target receiving GMP Certificates PBC 14: Number of plasma units that 3,440,000 (2,263,000) 1,177,000 Decreased PBC target were properly collected, transferred, tested and stored 50,000,000 50,000,000 (31,760,000) 18,240,000 Lower demand for Nucleic IPF portion Acid Tests, blood bank equipment Total SC 2.2 50,000,000 80,200,000 (41,483,000) 38,717,000 Sub-component 2.3: Treatment of Hep C The World Bank Transforming Egypt's Healthcare System Project (P167000) Current Amount (US$ Rationale for increase/ Original Amount millions) after 2021 Reallocation Revised Amount decrease (US$ millions) restructuring amount (US$ millions) PBC 9: Increased confirmation 2,000,000 2,000,000 - 2,000,000 testing post Hepatitis C treatment 128,600,000 98,400,000 (28,315,808) 70,084,192 Lower cost of hepatitis C IPF portion treatment Total SC 2.3 130,600,000 100,400,000 (28,315,808) 72,084,192 Total Component 2 274,600,000 276,600,000 (99,398,808) 177,201,192 Component 3: Institutional Capacity Building and Project Management 8,000,000 8,000,000 (1,811,366) 6,188,634 Lower equipment, training IPF portion costs Total Component 3 8,000,000 8,000,000 (1,811,366) 6,188,634 Component 4: COVID-19 Response Sub-Component 4.1: Early COVID-19 response PBC 15: Number of clinical 7,909,000 - 7,909,000 screenings and polymerase chain reaction testing of suspected COVID- 19 Total SC4.1 7,909,000 - 7,909,000 Sub-Component 4.2: Ongoing COVID-19 response and continuous improvement in IPC IPF portion 0 - Total SC4.2 0 - Total Component 4 7,909,000 - 7,909,000 Component 5: Restocking MOHP medical reserves 7.99 IPF portion - - 90,000,000 90,000,000 Total Component 5 - 90,000,000 90,000,000 Project total 530,000,000 530,000,000 (0) 530,000,000 The World Bank Transforming Egypt's Healthcare System Project (P167000) Annex 2: Theory of Change Activities Outputs Outcomes PDOs Impact Strengthen primary health care and community activities (C1) Providing for quality services at PHCs (SC 1.1) Develop PHC quality tools  PHC needs assessments (PBC1) application of QSI and  Service mapping & utilization surveys Improved average quality of clinical Reduced self-assessment (PBC4)  Updated National Accreditation standards care score at targeted PHCs Improved mortality and  PHCs pass QSI and complete self-assessment quality of morbidity Strengthen systems to  Grievance manual Improved patient satisfaction level health care address grievances (PBC2)  Staff trained on grievance system services  Patient grievances addressed Women and children received basic Reduced total nutrition services fertility rates Improved district governance  Staff trained on fiduciary practices Enhanced (PBC 3)  Improved Financial Governance Certificates demand for Strengthen CHW program (SC 1.2) health & More Strengthened CHW program  CHWs contracted Increased household visits by CHWs family equitable  CHWs trained on GBV (PBC 16) (PBC 5) planning distribution of Supporting health, population and family planning activities (SC 1.3) services health Visiting doctor program  Family Planning doctors contracted Increased contraceptive prevalence outcomes Al-Wissam initiative  Incentives for Family Planning centers rate (PBC 6) Procure commodities  Increased availability of contraception Strengthen secondary and tertiary level care (C2) Providing for access to quality services at hospitals (SC 2.1) Online certified medical  Examination module developed Improvement in average quality of licensing and specialties  IT examination system functional clinical care score at targeted hospitals examination (PBC 10) Reduced PIESWL  Hospitals pass NSRs (PBC19) Reduced surgical wait times, financial mortality and  Hospitals paid within 60 days (PBC 20) protection for surgery (PBC 17, 18) Improve morbidity quality of Improve the blood bank network (SC 2.2) health care Reduced Development of plasma  Plasma needs assessment Plasma units properly collected, services poverty by quality tools (PBC 11),  Multi-year human resource & business plans transferred, tested and stored (PBC 14) decreasing application of PQI (PBC 12)  Training curriculum OOP  Plasma centers pass PQI Blood units dispensed at MOHP GMP Certificates (PBC 13)  Plasma centers receive GMP affiliated hospitals screened using NAT IT system for blood network  Blood banks connected to national network The World Bank Transforming Egypt's Healthcare System Project (P167000) Activities Outputs Outcomes PDOs Impact Procure NAT  Increased availability of NAT Screening for hepatitis C and other NCDs and treatment of Hepatitis C (C1 and C2) Screening for Hep C and risk factors for high burden diseases (SC 1.4) Nationwide screening &  Screening teams deployed & equipped Increased NCD screening (PBC 7) communications campaigns Increased awareness of NCD risks Support Referral of NCDs high risk to  Increased referral for treatment prevention Hep C Increased Hep C screening (PBC 8) specialized care & control of eliminated Treatment of Hep C (SC 2.3) Hep C Procurement of treatment &  Increased availability of Hep C treatment Increase in Hep C treatment & confirmation tests confirmation testing (PBC 9) COVID-19 Response (C4) Early COVID-19 response (C4.1) Training medical staff &  Increased availability of trained staff early in Provide incentive pay the Pandemic Clinical screenings of suspected COVID- immediate Pandemic Training on PCR sample  Increased availability of PCR tests 19 cases by a trained provider response to controlled acquisition emergency Continued control of COVID-19 and IPC (C4.2) Procurement of PPE  Increased availability of PPE Improved IPC at health facilities Restocking MOHPs medical reserves (C5) Emergency procurement of  Increased availability of inputs to care Provide Medical medical & supplies, Maintain availability of health services immediate reserves equipment, consumables, throughout Egypt response to restocked medicines crisis *Red indicates activities, outputs, outcomes, impacts added during restructuring The World Bank Transforming Egypt's Healthcare System Project (P167000) Annex 3: Summary of revisions to the PBC matrix PBC Status Number/Name PBR Procedure Disbursement formula Sub-Component 1.1 Providing for quality services at PHCs REVISED PBC 2: Percentage of 2.7 GRM training materials MOHP finalizes SEA/H related GRM US$250,000 to be awarded upon grievances addressed that accommodate training materials. verification of the training New PBRs added to in Project target SEA/H complaints are materials that accommodate expand GRM to facilities in developed with support IVA verifies through document review SEA/SH complaints. accommodate accordance with the of technically sound that training materials meet quality SEA/H cases revised GRM Manual experts. standards according to international issued in 2017 2.7 best practice and use of a survivor centered approach, as described in the US$ 4,250,000 POM. 2.8 Training on the SEA/H MOHP trains staff on SEA/H sensitive For every % point over 50 percent (Increased by sensitive GRM delivered GRM. achievement, US$10,000 will be US$1,250,000) to all PHC and district awarded up to a maximum of level staff in Percentage of staff trained is US$500,000. participating calculated as follows: numerator is the Governorates using a number of staff at PHC and district training of trainers’ management office levels in target approach. governorates who received training and have basic knowledge on correct handling SEA/H complaints; denominator is the total number of staff at the same levels and in the same target governorates. IVA verifies percentage through document review and interviews with a random sample of PHC and district level staff. IVA may also attend training when possible. Verification ensures that Training of Trainers was completed at central level; Trainers provided decentralized training of PHC and district staff in target governorates; and knowledge of The World Bank Transforming Egypt's Healthcare System Project (P167000) PBC Status Number/Name PBR Procedure Disbursement formula Trainers, district and PHC staff meet a minimum threshold, as described in the POM. 2.9 By June 30, 2025, 80 MOHP facilities use SEA/H sensitive US$500,000 will be awarded for percent of grievances GRM. achieving 80 percent or more. addressed using the GRM, in accordance Percentage of grievances addressed is with the GRM Manual. calculated as follows: numerator is the number of grievances received and addressed in the target governorates using the GRM; denominator is the total number of grievances received in the target governorates. IVA verifies percentage of grievances addressed through desk review of relevant documents; field visits to ensure GRM sensitive to SEA/H cases is in place; and to conduct surveys and feedback requests, as described in the POM. REVISED PBC 4: Improvement 4.1 Number of facilities No changes US$ 60,000,000 of PHC Quality of passing the QSI. PBR 4.2 adapted. Services 4.2 Number of facilities MOHP proposes a batch of PHCs that US$48,000 will be awarded for PHCs are rewarded completing GAHAR self- have completed the GAHAR self- each facility that completes the for achieving US$72,000,000 assessment, which assessment. All PHCs in the batch must GAHAR self-assessment. The GAHAR self- previously passed QSI. be in the project target governorates; minimum payment threshold is assessment, not full have been pre-identified for project US$2,400,000 up to a maximum of accreditation. support in the POM; and have received US$12,000,000. the QSI certification. Each batch should be composed of no less than 50 PHCs for a grand total of 250 PHCs under all batches. IVA verifies the batches through document review of GAHAR training The World Bank Transforming Egypt's Healthcare System Project (P167000) PBC Status Number/Name PBR Procedure Disbursement formula and self-assessment records; and follow up phone interviews with a random subset of facilities. IVA confirms that GAHAR provided training on the self-assessment process, the facility submitted self-assessment to GAHAR, which included a facility improvement plan; and GAHAR approved the self-assessment. Sub-Component 1.2: Strengthen CHW program REVISED PBC 5: Increased 5.6 By June 30, 2025, 32 IVA to verifies that the % of US$600,000 will be awarded for household visits by percent of households households visited by CHW in the past maintaining target of 32 percent. New PBR added CHWs (in are visited by CHW. year has reached the set targets. participating governorates) US$ 3,000,000 (Increased by US$600,000) New PBC 16: CHWs 16.1Development and MOHP develops and adopts a new US$250,000 will be awarded upon trained on GBV integrated of new module on GBV awareness, prevention verification that the curriculum has New PBC added to awareness, module on GBV and response. The module is been developed and integrated integrate activities prevention and awareness, prevention, developed based on formative into the nationwide CHW training to raise awareness response. and response into research and adopts a survivor curriculum. about GBV, screen national CHW training centered approach inclusive of people for survivors and US$ 900,000 curriculum. with disabilities. Approach is in refer them for accordance with GBV national and holistic care international guidelines. The module is developed with support of technically sound experts. Module is integrated into the national CHW training curriculum. IVA verifies through desk review that MOHP has developed GBV awareness, The World Bank Transforming Egypt's Healthcare System Project (P167000) PBC Status Number/Name PBR Procedure Disbursement formula prevention and response training module using technically sound experts and in accordance with international best practice and MOHP has integrated the new module into CHW training nationally. 16.2 Number of CHWs MOHP provide high quality training to US$400 will be awarded for every receiving GBV CHWs using updated module on GBV CHW trained. awareness, prevention, awareness, prevention and response. and response training. Each batch for verification should be The minimum payment threshold composed of no less than 250 trained is US$100,000 up to a maximum CHWs for a grand total of 1,250 CHWs payment amount of US$500,000. under all batches. IVA verifies, by attending select training and conducting follow up interviews with a random sample of CHWs, that CHWs were trained on the new GBV materials. 16.3 Supportive supervision MOHP conducts supportive supervision US$150,000 will be awarded upon of trained CHWs to of newly trained CHWs as they start verification of supportive ensure high quality and working with households to ensure supervision and recommendations appropriate GBV high quality and appropriate GBV report. messages are delivered messages are delivered. MOHP in households. produces supportive supervision report, acceptable to the World Bank, including recommendations to improve GBV training for CHWs. IVA verifies that high quality supportive supervision documented in report has taken place. Sub-Component 1.3: Supporting health, population and family planning activities The World Bank Transforming Egypt's Healthcare System Project (P167000) PBC Status Number/Name PBR Procedure Disbursement formula REVISED PBC6: Increased 6.3 Percent of women using Definition of CPR is aligned with that For each half % point increase in CPR modern contraceptive. used in the Egyptian Family Health contraceptive prevalence rate New PBR added for Survey for 2021. above 66.4%, US$625,000 will be year 7. US$6,950,000 awarded up to a maximum amount IVA conducts a national nationally of US$3,750,000. (Increased by US$ representative population survey or 3,750,000) relies on other nationally representative population survey acceptable to the World Bank with a methodology described in the POM. Sub-Component 2.1: Providing for quality services at hospitals NEW PBC 17: Timely 17.1Percentage of surgical MOHP submits the percentage of For each % point increase above access to surgical interventions that were surgical interventions provided the baseline of 77%, US$200,000 care provided through the through the PIESWL completed within will be awarded up to a maximum PIESWL within 30 days 30 days. A minimum of 10,000 PIESWL amount of US$3,000,000. US$ 9,000,000 from issue date of surgeries must be performed during operation decree. the 6-month reporting period to be Period covering January eligible for this PBC. 1, 2024 – June 30, 2024. 17.2Percentage of surgical Percentage is calculated as follows: For each % point increase above interventions that were numerator is the number of surgical the baseline of 77%, US$200,000 provided through the interventions provided through the will be awarded up to a maximum PIESWL within 30 days PIESWL within 30 days of the operation amount of US$3,000,000. from issue date of decree; denominator is the total operation decree. number of surgeries provided through Period covering July 1, the PIESWL in the same period. 2024 – December 31, This calculation excludes patients who 2024. received liver transplants and patients 17.3Percentage of surgical who had to delay their surgery due to For each % point increase above interventions that were medical necessity. the baseline of 77%, US$200,000 provided through the will be awarded up to a maximum PIESWL within 30 days IVA verifies wait time through desk amount of US$3,000,000. from issue date of review of medical records and phone operation decree. interviews with a random subset of Period covering January patients. 1, 2025 – June 30, 2025. The World Bank Transforming Egypt's Healthcare System Project (P167000) PBC Status Number/Name PBR Procedure Disbursement formula NEW PBC 18: Financial 18.1Percentage of PTES MOHP submits percentage of patients For each % point increase above protection patients receiving a that received surgery through the the threshold of 95%, US$40,000 surgical intervention PIESWL who were not covered by will be awarded up to a maximum US$ 600,000 through the PIESWL health insurance and who received a amount of US$200,000. who are uninsured. surgical decree through an objective Period covering January process, as described in the POM. A 1, 2024 – June 30, 2024. minimum of 10,000 PIESWL surgeries 17.1Percentage of PTES must be performed during the 6- For each % point increase above patients receiving a month reporting period to be eligible the threshold of 95%, US$40,000 surgical intervention for this PBC. will be awarded up to a maximum through the PIESWL amount of US$200,000. who are uninsured. Percentage is calculated as follows: Period covering July 1, numerator is the number of people 2024 – December 31, who received PTES decrees for surgical 2024. intervention who are uninsured. 17.2Percentage of PTES Denominator is number of people who For each % point increase above patients receiving received PTES decrees for surgery. the threshold of 95%, US$40,000 surgical intervention will be awarded up to a maximum through the PIESWL IVA verifies through document review amount of US$200,000. who are uninsured. and phone interviews with a random Period covering January subset of patients that those who 1, 2025 – June 30, 2025. received a PTES decree for surgery are not covered by any public or private health insurance and were selected through an objective process. New PBC 19: Safe surgical 19.1Number of hospitals MOHP proposes a batch of hospitals Each hospital verified would be care meeting the National that have met the NSRs for Surgery, awarded a maximum amount of Safety Requirements Anesthesia and Sedation. The hospitals US$65,600 if it receives a total US$ 16,400,000 (NSR) for Surgery, need to be in the project target score of at least 80 percent for all Anesthesia and governorates and have been pre- Surgery, Anesthesia and Sedation Sedation. identified for project support. Each NSRs and no single NSR receives a respective batch should be composed score of less than 50 percent. The of not less than 50 hospitals covering minimum payment threshold is the curative and private sectors for a US$3,280,000 up to a maximum of grand total of 250 hospitals under all US$16,400,000. batches. The World Bank Transforming Egypt's Healthcare System Project (P167000) PBC Status Number/Name PBR Procedure Disbursement formula IVA verifies through suitable scientific random sampling technique acceptable to the World Bank that a set number of hospitals presented by MOHP for verification have met the NSRs for Surgery, Anesthesia and Sedation as described in the POM. The batches will be verified towards the certification or noncertification of the entire batch. For a given batch to be verified for certification, 80 percent of the sampled hospitals will have to total score of at least 80 percent for all Surgery, Anesthesia and Sedation NSRs; and no individual NSRs can have a score of less than 50 percent. NEW PBC 20: Financial 20.1Between January 1, MOHP clears arrears in increments US$5,000,000 will be awarded for sustainability of 2024, and December equal or greater than US$5 million, or every US$5,000,000, or its Presidential Initiative 30, 2024, Government its equivalent in local currency. equivalent in local currency, to Eliminate the releases US$25 million, transferred by the government to Surgical Waiting List or its equivalent in local The USD: EGP exchange rate on clear PIESWL arrears, up to a currency, to clear part December 15, 2023 will be used. maximum of US$25,000,000. US$34,000,000 of the financial arrears This will be specifically earmarked of the PIESWL account. External auditor verifies that MOHP for the PIESWL account and money was received at bank account subsequently verified by the for PIESWL to clear arrears. annual financial audit. The World Bank Transforming Egypt's Healthcare System Project (P167000) PBC Status Number/Name PBR Procedure Disbursement formula 20.2Percentage of payments MOHP submits percentage. A For each % point increase above by MOHP within 60 minimum of 10,000 PIESWL surgeries the threshold of 46%, US$ 281,250 days of claim must be performed during the 6- will be awarded up to a maximum submission for PTES month reporting period to be eligible amount of US$9,000,000. patient who received a for this PBC. surgical intervention through PIESWL. Period Percentage is calculated as follows: covering January 1, numerator is the number of claims 2025 – June 30, 2025. paid by MOHP for PETS patient who received a surgical intervention through PIESWL within 60 days claim submission; denominator is number of claims received for PETS who received a surgical intervention through PIESWL. IVA verifies through desk review of hospital invoices and MOHP bank transfer statements that MOHP payments were made within 60 days or less from the date of claim submission by the providers. Sub-component 2.2: Improve the blood bank network REVISED PBC 12: Number of MOHP submits each plasma center’s Each plasma center achieving at plasma center score on the PQI composite indicator least 60 percent in the Plasma Target reduced, passing the PQI list. Quality Index (PQI) composite funding reduced composite indicator indicator list will be awarded accordingly IVA verifies scores though facility visits, US$920,000. The minimum US$5,520,000 according to the POM. disbursement threshold will be US$920,000 up to a maximum (Decreased by equal to the allocated PBC amount US$3,680,000) of US$5,520,000. REVISED PBC 13: Number of MOHP submits each plasma center Each plasma center achieving the plasma centers that has received a GMP certificate. national GMP certificate will be receiving GMP awarded US$630,000. The Certificates minimum disbursement threshold The World Bank Transforming Egypt's Healthcare System Project (P167000) PBC Status Number/Name PBR Procedure Disbursement formula Target reduced, IVA verifies that each plasma center will be US$630,000 up to a funding reduced US$3,780,000 has received a GMP certificate through maximum equal to the allocated accordingly desk review and proof of GMP PBC amount of US$3,780,000 (Decreased by US$ attainment. 3,780,000) REVISED PBC 14: Number of MOHP submits plasma units. Each plasma unit that was properly Plasma units that collected, transferred, tested and Target reduced, were properly IVA verifies the total number of plasma stored will be awarded US$107 to funding reduced collected, units that were properly collected, a maximum equal to accordingly transferred, tested transferred, tested and stored US$1,177,000. and stored according to procedures set forth in the POM. US$1,177,000 (Decreased by US$2,263,000) The World Bank Transforming Egypt's Healthcare System Project (P167000) Annex 4: National Safety Requirements (NSR) for Surgery, Anesthesia and Sedation Measure Points Evidence of Compliance Methodology 1. Precise site where a surgery or /2 a. Hospital has an approved policy for site Surveyor may review the hospital policy to invasive procedure shall be marking in the hospital ensure the presence of all required performed is clearly marked by /2 b. Staff are trained on implementing site components in the policy followed by the physician with patient’s marking observing a patient going for surgery and involvement (National Safety /2 c. Site marking is a unified mark all over the invasive procedure for the presence of a Requirement 17) hospital and performed by the responsible clear, approved, non-washable mark on the physician for the surgery and invasive surgery or invasive procedure site (when procedure applicable) and interviewing staff about policy /2 d. Site marking is performed before the patient orientation and implementation. enters the operation room /2 e. The hospital tracks, collects, analyzes and reports data on site marking process /2 f. The hospital acts on improvement opportunities identified in its site marking process NSR 17 score /12 Minimum score is 6/12 (50%) 2. Documents and equipment /2 a. The hospital has an approved policy for Surveyor may review the hospital policy needed for procedures and preoperative verification of all needed followed by tracing a patient underwent or anesthesia or sedation are documents and equipment. going for surgery and invasive procedure to verified to be on hand, correct, ensure the correct verification process for and properly functioning before needed documents and other requested calling for the patient (NSR 18) /2 b. There is recorded evidence of preoperative orders as blood booking or investigations. The verification of all needed documents and surveyor will observe patient endorsement to equipment before each surgery and invasive the operating room or other invasive procedure. procedure unit and review the document of /2 c. The hospital tracks, collects, analyzes and endorsement. Also, the checklist showing the reports data on preoperative verification availability and functioning of equipment shall process. be reviewed. /2 d. The hospital acts on improvement opportunities identified in its preoperative verification process. NSR 18 score /8 Minimum score is 4/8 (50%) The World Bank Transforming Egypt's Healthcare System Project (P167000) 3. Correct patient, procedure and /2 a. Hospital has approved policy to ensure the Surveyor may review the policy and body part is confirmed correct patient, procedure, and body part. procedure for preventing the wrong patient, preoperatively and just before /2 b. Time out is implemented before all surgery wrong site/side, and wrong surgery/invasive starting a surgical or invasive and invasive procedures immediately before procedure and ensure that it supports procedure (time out) (NSR 19) the start of surgery or invasive procedure. patient, procedure, as well as part of body The surgery or invasive procedure team is verification just before start of the procedure, involved in the time out process, including the regardless whether the patient is performing physician, the nurse, the anesthetized, sedated or awake (time out). anesthesiologist when applicable. This is followed by observing a case during the /2 c. The hospital tracks, collects, analyzes and time-out process and review the document reports data on time out process. used to record this process. Document review /2 d. The hospital acts on improvement is the open and closed medical record will opportunities identified in time out process. also be performed in addition to staff NSR 19 score /8 Minimum score is 4/8 (50%) interviews on how to perform the process and its special circumstances. 4. Accurate counting of sponges, /2 a. Counting of sponges, needles, towels, or Surveyor may review the policy and needles, and instruments pre instruments is done pre, during and after the procedure to ensure that it covers the role of and post procedure is verified surgery of invasive procedure by two staff as nurses and surgeons, pre and post operative the second one is acting as witness for the count double verification, as well as steps to first one be taken in case of discrepancy between pre /2 b. There is a record for the preoperative, and postoperative counts. The surveyor could intraoperative and postoperative count of observe a case during or after surgery or sponges, needles, towels or instruments invasive procedure or review the count sheet /2 c. The performing physician confirmed the in the closed or open medical record. A process and signed the count sheet surgical or procedure team interview will also /2 d. The hospital tracks, collects, analyzes and be done. reports data on the counting process. /2 e. The hospital acts on improvement opportunities identified in the counting process NSR 20 score /10 Minimum score is 5/10 (50%) Total Score /38 Minimum score is 30.4/38 (80%) Scoring methodology: Look back period is one month before the surveyor’s visit. The World Bank Transforming Egypt's Healthcare System Project (P167000) During the survey visit, each NRS is scored for the evidence of compliance (EOC). These are mathematical rules that depend on summation and percentage calculation of scores of each EOC as follows:  Met: when the hospital shows 80% or more compliance with requirements during the required lookback period with a total score of 2.  Partially met: when the hospital shows less than 80% but more than or equal to 50% compliance with requirements during the required lookback period with a total score of 1.  Not met: when the hospital shows less than 50% compliance with requirements during the required lookback period with a total score of 0.  Not applicable: when the surveyor determines that, the standard requirements are out of the organization scope (the score is deleted from the numerator and denominator). Reference document: Further details on the key words and intent of each NSR can be found in Section 2 of the GAHAR Handbook for Hospital Registration Requirements, Version 2, effective May 1, 2021. The NSRs and scoring methodology are available at: https://www.gahar.gov.eg/upload/hospital-registration-v.2-final.pdf The World Bank Transforming Egypt's Healthcare System Project (P167000) Annex 5: Disbursement Arrangements for AFD parallel co-financing 1. The disbursement arrangements for PBC 4.1 with parallel co-financing from AFD. EUR 8.0 million will remain in an AFD Project account in the name of and detained by the MOHP, which has already been opened at the Central Bank of Egypt. The World Bank will finance costs of the Independent Verification Agency (IVA) for the 600 PHCs financed by the World Bank, and 100 PHCs financed by AFD. PHCs financed by AFD will be from the Governorates of Dakahliya and Sharkeya. A meeting will be held between all relevant parties to review the existing verification approach, which has already been applied by the IVA for 496 PHCs verified under TEHSP. MOHP will submit a batch of at least 100 PHCs that will be financed by AFD to the IVA for verification. The IVA will conduct verification, and send a report for comments to MOHP, the World Bank and AFD. All parties will have 10 working days to provide comments. Thereafter, the IVA will submit the revised report to MOHP. MOHP will submit the final report to the World Bank for no-objection. If the final report receives the World Bank’s no-objection, the World Bank will send notification to AFD that approval has been made. AFD will then send an official notification to MOHP to confirm the transfer of funds from the dedicated AFD project account to the MOHP account. MOHP will then proceed with this transfer. If the final report does not receive the World Bank’s no-objection, the World Bank will send notification to AFD of non-approval, and the MOHP will not be authorized to transfer funds. 2. The disbursement arrangements for the parallel co-financing of sub-component 4.2. EUR 2,914,961 has been committed to contracts that are already signed and for which the UPA followed the AFD procurement guidelines. AFD is satisfied with UPA’s performance. The World Bank will follow up on the execution of these contracts, as well as verification of delivery of the supplies, verification of the payment and transfer completion to the suppliers. Moving forward with the remaining EUR 12.08 million, MOHP will submit a list of equipment to the World Bank. The World Bank will review and provide a technical no objection. The MOHP will send the approved list of equipment to UPA. UPA will upload the associated procurement plan in STEP, which will follow the World Bank’s procurement procedures. The World Bank will provide a no objection at each step of the procurement process, keeping AFD in copy. Since this is a prior review contract, UPA is required to provide AFD with a copy of the evaluation report (including prequalification report and shortlisting report, as applicable) at the time it is submitted to the World Bank. If the bidder does not meet AFD's financing eligibility requirements, AFD will promptly inform the World Bank and UPA. AFD and the World Bank will then consult with the Recipient to determine the appropriate course of action. The UPA will report expenses to the PMU, which will in turn report those expenses to the World Bank. The World Bank will then report the expenses to the AFD in EUR. The EUR:EGP exchange rate used to report expenses incurred by UPA will be the exchange rate used for the initial transfer of the EUR15 million between MOHP and UPA, which was on March 21, 2021. The World Bank Transforming Egypt's Healthcare System Project (P167000) III. SUMMARY OF CHANGES Changed Not Changed Project's Development Objectives ✔ Results Framework ✔ PBCs ✔ Components and Cost ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Economic and Financial Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ Implementing Agency ✔ DDO Status ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Technical Analysis ✔ The World Bank Transforming Egypt's Healthcare System Project (P167000) IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_PDO_TABLE PROJECT DEVELOPMENT OBJECTIVE Current PDO The proposed Project Development Objective is to (i) improve the quality of primary and secondary health care services, (ii) enhance demand for health and family planning services, (iii) support the prevention and control of Hepatitis C, and (iv) to provide immediate and effective response to an eligible crisis or emergency. Proposed New PDO The proposed Project Development Objective is to (i) improve the quality of health care services, (ii) enhance demand for health and family planning services, (iii) support the prevention and control of Hepatitis C, and (iv) to provide immediate and effective response to an eligible crisis or emergency. OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) Component 1: Strengthen Component 1: Strengthen Primary Healthcare, Family Primary Healthcare, Family 237.41 Revised 248.70 Planning and Community Planning and Community Activities Activities Component 2: Strengthen Component 2: Strengthen 276.60 Revised secondary and tertiary level 177.20 Secondary Level Healthcare care Component 3: Institutional Component 3: Institutional Capacity Building and Project 8.00 Revised Capacity Building and Project 6.19 Management Management Component 5: Contingency Component 6: Contingency 0.00 Revised 0.00 Emergency Response Emergency Response Component 4: Contingency Component 4:COVID-19 Emergency Response-Early 7.99 Revised 7.91 response and recovery COVID-19 Response Component 5: Restocking 0.00 New Ministry of Health and 90.00 Population medical reserves TOTAL 530.00 530.00 OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES The World Bank Transforming Egypt's Healthcare System Project (P167000) Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IBRD-88950-001 | Currency: USD Current Expenditure Category: G W CS NCS T IOC P1.1(iii); 1.2(i;ii;iv); P1.3(i-v;vii); iLap Category Sequence No: 1 P1.4 (ii); P2.1, 2.2, 2.3 (I;ii);P3 277,866,000.00 69,488,606.17 131,089,000.00 100.00 100.00 iLap Category Sequence No: 2 Current Expenditure Category: EE P1.1(i;ii;iv), P1.2(iii), P1.3(vi), P1.4(i), P2.3(iii) 242,900,000.00 178,780,000.00 299,677,000.00 100.00 100.00 iLap Category Sequence No: 3 Current Expenditure Category: PREMIUM FOR CAPS/COLLARS 0.00 0.00 0.00 iLap Category Sequence No: 5 Current Expenditure Category: Emergency Exp Eligible Expenditures P4.1; P5 7,909,000.00 0.00 97,909,000.00 100.00 100.00 iLap Category Sequence No: FEF Current Expenditure Category: FRONT END FEE 1,325,000.00 1,325,000.00 1,325,000.00 Total 530,000,000.00 249,593,606.17 530,000,000.00 OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 2018 0.00 0.00 2019 163,893,167.00 163,893,167.00 2020 117,040,979.00 117,040,979.00 2021 40,000,000.00 24,535,364.00 The World Bank Transforming Egypt's Healthcare System Project (P167000) 2022 94,019,476.00 10,425,414.00 2023 80,023,546.00 121,538,414.00 2024 35,022,832.00 62,566,662.00 2025 0.00 30,000,000.00 . The World Bank Transforming Egypt's Healthcare System Project (P167000) . Results framework COUNTRY: Egypt, Arab Republic of Transforming Egypt's Healthcare System Project Project Development Objectives(s) The proposed Project Development Objective is to (i) improve the quality of primary and secondary health care services, (ii) enhance demand for health and family planning services, (iii) support the prevention and control of Hepatitis C, and (iv) to provide immediate and effective response to an eligible crisis or emergency. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Improve the quality of primary health care services Number of PHCs passing Quality Services Index PBC 4 0.00 80.00 240.00 370.00 500.00 600.00 700.00 composite indicators list (Number) Action: This indicator has been Revised Percentage improvement in the average quality of clinical care score at all 0.00 40.00 50.00 60.00 70.00 80.00 80.00 targeted PHCs, measured through independent direct observations (Percentage) Improve the quality of secondary and tertiary health care services (Action: This Objective has been Revised) Percentage improvement in the average quality of 0.00 40.00 50.00 60.00 70.00 80.00 80.00 clinical care score at all The World Bank Transforming Egypt's Healthcare System Project (P167000) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 targeted hospitals measured through independent direct observations (Percentage) Percentage of blood units dispensed at MOHP affiliated hospitals that 0.00 0.00 20.00 50.00 70.00 90.00 90.00 have been screened utilizing the Nucleic Acid test (Percentage) Percentage of surgical interventions provided in 30 days or less from issue date PBC 17 77.00 92.00 of operation decree (Percentage) Action: This indicator is New Enhance Demand for Health and Family Planning Services Contraceptive prevalence 58.00 62.00 65.00 69.40 rate (Percentage) Action: This indicator has been Revised Prevention and control of Hepatitis C Number of people screened for Viral Hepatitis C 0.00 7,000,000.00 14,000,000.00 21,000,000.00 28,000,000.00 35,000,000.00 35,000,000.00 (Number) Percent Female 0.00 50.00 (Percentage) The World Bank Transforming Egypt's Healthcare System Project (P167000) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Percentage of people who received treatment for Hepatitis C who have taken the final confirmation test 0.00 70.00 70.00 75.00 75.00 80.00 80.00 for sustained virological response (SVR) using a random sampling methodology (Percentage) Contingency Emergency and Response Number of clinical screenings of suspected COVID-19 cases by a trained physician/nurse at port of PBC 15 0.00 0.00 0.00 200,000.00 200,000.00 200,000.00 200,000.00 entries, quarantine facilities, community and/or healthcare facilities (Number) Percent of Ministry of Health and Population 0.00 90.00 medical reserves restocked (Percentage) Rationale: Action: This indicator is CERC was activated to replenish MOPH strategic reserves. New PDO Table SPACE The World Bank Transforming Egypt's Healthcare System Project (P167000) Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Strenghten Primary Healthcare, Family Planning and Community Activities PHC mapping exercise, needs assessments and new 0.00 3.00 3.00 4.00 4.00 4.00 4.00 accreditation tool completed. (Number) Increased household visits 7.00 12.00 17.00 0.00 27.00 32.00 32.00 by CHWs (Percentage) Percentage of participating districts certified for 0.00 20.00 40.00 60.00 80.00 100.00 100.00 enhanced governance performance (Percentage) Client user satisfaction and utilization surveys 0.00 1.00 2.00 3.00 4.00 5.00 5.00 conducted in project target areas (Number) Grievances addressed in project target facilities using the GRM in PBC 2 0.00 0.00 20.00 40.00 60.00 80.00 80.00 accordance with the revised manual issued in 2017 (Percentage) Average patient satisfaction 0.00 45.00 50.00 55.00 60.00 65.00 65.00 level (Percentage) Targeted people screened 0.00 4,000,000.00 8,000,000.00 12,000,000.00 16,000,000.00 20,000,000.00 20,000,000.00 for NCDs (Number) Percent Female 0.00 50.00 (Percentage) The World Bank Transforming Egypt's Healthcare System Project (P167000) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Targeted PHCs applying environmentally-positive 0.00 80.00 240.00 370.00 500.00 600.00 700.00 energy and water efficiency measures (Number) Action: This indicator has been Revised People who have received essential health, nutrition, 0.00 3,400,000.00 and population (HNP) services (CRI, Number) Number of women and children who have 0.00 3,400,000.00 received basic nutrition services (CRI, Number) Number of CHWs receiving GBV awareness, prevention 0.00 1,200.00 and response training (Number) Action: This indicator is New Strengthen Secondary and Tertiary Level Healthcare (Action: This Component has been Revised) Targeted regional blood banks that have been connected to the national 0.00 0.00 0.00 0.00 0.00 0.00 6.00 automated blood network. (Amount(USD)) Action: This indicator has been Revised The World Bank Transforming Egypt's Healthcare System Project (P167000) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Targeted Hep C patients 0.00 50,000.00 287,500.00 525,500.00 900,000.00 1,200,000.00 1,200,000.00 treated (Number) Percent Female 0.00 40.00 (Percentage) Number of PHCs completing GAHAR self-assessment 0.00 250.00 (Number) Number of Hospitals receiving National Accreditation Certification 0.00 2.00 9.00 14.00 20.00 27.00 27.00 for healthcare quality in target governorates (Number) Action: This indicator has been Marked for Deletion Number of plasma centers PBC 12, passing the PQI composite 0.00 6.00 12 indicator. (Number) Number of plasma units that were properly PBC 14, collected, transferred, 0.00 11,000.00 14 tested and stored. (Number) Number of conducted rounds of the national online PBC 10 0.00 0.00 0.00 1.00 2.00 2.00 2.00 licensing/specialization examinations. (Number) The World Bank Transforming Egypt's Healthcare System Project (P167000) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Number of hospitals passing National Safety Requirements for Surgery, 0.00 250.00 Anesthesia and Sedation. (Number) Action: This indicator is New Number of plasma centers receiving Good 0.00 6.00 Manufacturing Practices certificates (Number) Action: This indicator is New Percentage of uninsured PTES patients receiving surgery through the PIESWL 0.00 100.00 under PTES who are not covered by health insurance. (Percentage) Action: This indicator is New Percentage of payments by MOHP within 60 days of claim submission for PTES patient who received a 0.00 78.00 surgical intervention through PIESWL. (Percentage) The World Bank Transforming Egypt's Healthcare System Project (P167000) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Action: This indicator is New Number of health facilities stocked with drugs, medical TBD based on needs 0.00 supplies, equipment and assessment devices (Text) Rationale: Action: This indicator is This indicator will track distribution of MOHP medical reserves, procured with project finances, from central level to health facilities. Restocking from the central New to facility level will be based on needs assessment. Designated health facilities and target number will be agreed upon in the Project Operations Manual. Institutional Capacity Building ad Project Management Project results published regularly on external MOHP 0.00 Yes website (Text) IO Table SPACE Performance-Based Conditions Matrix DLI IN01361922 ACTION PBC 1 Development of quality tools and mechanisms Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome No Text 4,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline Accreditation guidelines developed. The World Bank Transforming Egypt's Healthcare System Project (P167000) DLR 1.1: Accreditation Guidelines for PHC facilities updated (US$1,000,000) DLR 1.2 : PHC See Annex 1 to PAD DLI Verification Year 0 Services Mapping exercise completed 3,000,000.00 Protocol Table (US$1,000,000) DLR 1.3 : PHC Needs assessment carried out (US$1,000,000) Year 1 0.00 Year 2 0.00 DLR 1.4: PHC Needs assessment carried out on See Annex 1 to PAD DLI Verification Year 3 1,000,000.00 facilities which require re-accreditation Protocol Table Year 4 0.00 Year 5 0.00 Year 6 0.00 Year 7 0.00 DLI IN01361931 ACTION PBC 2 Grievances addressed in project target facilities using the GRM in accordance with the revised manual issued in 2017 Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Percentage 7,500,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 See Annex 1 to PAD DLI Verification Year 0 0.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 1 0.00 5,000,000.00 Protocol Table The World Bank Transforming Egypt's Healthcare System Project (P167000) See Annex 1 to PAD DLI Verification Year 2 20.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 3 40.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 4 60.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 5 80.00 500,000.00 Protocol Table Year 6 0.00 Year 7 0.00 Action: This PBC has been Revised. See below. DLI IN01370703 ACTION PBC 2 Grievances addressed in project target facilities using the GRM in accordance with the revised manual issued in 2017 Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Percentage 4,250,000.00 58.82 Period Value Allocated Amount (USD) Formula Baseline 0.00 See Annex 1 to PAD DLI Verification Year 0 0.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 1 0.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 2 20.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 3 40.00 500,000.00 Protocol Table The World Bank Transforming Egypt's Healthcare System Project (P167000) See Annex 1 to PAD DLI Verification Year 4 60.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 5 80.00 500,000.00 Protocol Table Year 6 80.00 750,000.00 See Annex 3 to 2023 RP Year 7 80.00 500,000.00 See Annex 3 to 2023 RP DLI IN01361934 ACTION PBC 3 Percentage of participating districts certified for enhanced governance performance Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome No Percentage 2,500,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 See Annex 1 to PAD DLI Verification Year 0 0.00 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 1 20.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 2 40.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 3 60.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 4 80.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 5 100.00 500,000.00 Protocol Table Year 6 0.00 The World Bank Transforming Egypt's Healthcare System Project (P167000) Year 7 0.00 DLI IN01361941 ACTION PBC 4 Number of PHCs passing Quality Services Index composite indicators list Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome No Number 60,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 See Annex 1 to PAD DLI Verification Year 0 240.00 0.00 Protocol Table Year 1 370.00 0.00 Year 2 500.00 0.00 Year 3 600.00 0.00 Year 4 0.00 Year 5 60,000,000.00 Year 6 0.00 Year 7 0.00 Action: This PBC has been Revised. See below. The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI IN01370699 ACTION PBC 4 Number of PHCs passing Quality Services Index composite indicators list and GAHAR self-assessment Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Text 60,000,000.00 51.33 Period Value Allocated Amount (USD) Formula 0 PHCs pass QSI; 0 complete GAHAR self Baseline assessment 0 PHCs pass QSI; 0 complete GAHAR self See Annex 1 to PAD DLI Verification Year 0 0.00 assessment Protocol Table 100 PHCs pass QSI; 0 complete GAHAR self Year 1 8,000,000.00 assessment 200 PHCs pass QSI; 0 complete GAHAR self Year 2 8,000,000.00 assessment 300 PHCs pass QSI; 0 complete GAHAR self Year 3 8,000,000.00 assessment 400 PHCs pass QSI; 0 complete GAHAR self Year 4 8,000,000.00 assessment 600 PHCs pass QSI; 0 complete GAHAR self Year 5 16,000,000.00 assessment 600 PHCs pass QSI; 0 complete GAHAR self Year 6 0.00 assessment 600 PHCs pass QSI; 250 complete GAHAR self Year 7 12,000,000.00 See Annex 3 of 2023 RP assessment The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI IN01361944 ACTION PBC 5 Increased household visits by CHWs Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome No Percentage 2,400,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 7.00 Year 0 0.00 0.00 0.00 Year 1 12.00 600,000.00 See procedure Year 2 17.00 600,000.00 See procedure Year 3 0.00 0.00 See procedure Year 4 27.00 600,000.00 See procedure Year 5 32.00 600,000.00 See procedure Year 6 0.00 Year 7 0.00 Action: This PBC has been Revised. See below. The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI IN01389002 ACTION PBC 5 Increased household visits by CHWs Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome No Percentage 3,000,000.00 60.00 Period Value Allocated Amount (USD) Formula Baseline 7.00 Year 0 0.00 0.00 0.00 Year 1 12.00 600,000.00 See procedure Year 2 17.00 600,000.00 See procedure Year 3 0.00 0.00 See procedure Year 4 27.00 600,000.00 See procedure Year 5 32.00 600,000.00 See procedure Year 6 0.00 Year 7 32.00 600,000.00 See Annex 3 DLI IN01361946 ACTION PBC 6 Contraceptive prevalence rate Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Percentage 3,200,000.00 0.00 Period Value Allocated Amount (USD) Formula The World Bank Transforming Egypt's Healthcare System Project (P167000) Baseline 58.00 Year 0 0.00 Year 1 0.00 Year 2 0.00 See Annex 1 to PAD DLI Verification Year 3 62.00 1,600,000.00 Protocol Table Year 4 0.00 See Annex 1 to PAD DLI Verification Year 5 65.00 1,600,000.00 Protocol Table Year 6 0.00 Year 7 0.00 Action: This PBC has been Revised. See below. DLI IN01370726 ACTION PBC 6 Contraceptive prevalence rate Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Percentage 6,950,000.00 46.04 Period Value Allocated Amount (USD) Formula Baseline 58.00 Year 0 0.00 Year 1 0.00 The World Bank Transforming Egypt's Healthcare System Project (P167000) Year 2 0.00 See Annex 1 to PAD DLI Verification Year 3 62.00 1,600,000.00 Protocol Table Year 4 0.00 See Annex 1 to PAD DLI Verification Year 5 65.00 1,600,000.00 Protocol Table Year 6 0.00 Year 7 69.40 3,750,000.00 See Annex 3 to 2023 RP DLI IN01361947 ACTION PBC 7 Targeted people screened for NCDs Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Number 4,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 See Annex 1 to PAD DLI Verification Year 0 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 1 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 2 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 3 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 4 0.00 Protocol Table The World Bank Transforming Egypt's Healthcare System Project (P167000) See Annex 1 to PAD DLI Verification Year 5 4,000,000.00 Protocol Table Year 6 0.00 Year 7 0.00 DLI IN01361948 ACTION PBC 8 Number of people screened for Viral Hepatitis C Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Number 129,600,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 See Annex 1 to PAD DLI Verification Year 0 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 1 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 2 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 3 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 4 0.00 Protocol Table See Annex 1 to PAD DLI Verification Year 5 129,600,000.00 Protocol Table Year 6 0.00 Year 7 0.00 The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI IN01361949 ACTION Percentage of people who received treatment for Hepatitis C who have taken the final confirmation test for sustained PBC 9 virological response (SVR) using a random sampling methodology Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Percentage 2,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 See Annex 1 to PAD DLI Verification Year 0 70.00 200,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 1 70.00 400,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 2 70.00 500,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 3 70.00 400,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 4 70.00 300,000.00 Protocol Table See Annex 1 to PAD DLI Verification Year 5 70.00 200,000.00 Protocol Table Year 6 0.00 Year 7 0.00 The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI IN01361950 ACTION PBC 10 Number of conducted rounds of the national online licensing/specialization examinations. Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 2,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 0.00 Year 1 1.00 0.00 Year 2 2.00 0.00 Year 3 2.00 0.00 Year 4 0.00 Year 5 2,000,000.00 See procedure Year 6 0.00 Year 7 0.00 DLI IN01361951 ACTION PBC 11 Development of Plasma Quality Tools Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 10,000,000.00 0.00 Period Value Allocated Amount (USD) Formula The World Bank Transforming Egypt's Healthcare System Project (P167000) Baseline Plasma Quality Tools developed Year 0 0.00 0.00 Year 1 0.00 0.00 Year 2 0.00 0.00 Year 3 0.00 0.00 Plasma centers needs assessment; human resources needs assessment; Business plan for Year 4 the Plasma Safety and Sufficiency Program 10,000,000.00 See procedure developed; DLR 11.4: a quality training curriculum for staff at plasma centers Year 5 0.00 0.00 Year 6 0.00 Year 7 0.00 DLI IN01361952 ACTION PBC 12 Number of plasma centers passing the PQI composite indicator. Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 9,200,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 0.00 Year 1 3.00 0.00 The World Bank Transforming Egypt's Healthcare System Project (P167000) Year 2 6.00 0.00 Year 3 10.00 0.00 Year 4 0.00 Year 5 9,200,000.00 See procedure Year 6 0.00 Year 7 0.00 Action: This PBC has been Revised. See below. DLI IN01370704 ACTION PBC 12 Number of plasma centers passing the PQI composite indicator. Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 5,520,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 0.00 Year 1 0.00 0.00 Year 2 0.00 0.00 Year 3 0.00 0.00 Year 4 0.00 0.00 Year 5 0.00 0.00 The World Bank Transforming Egypt's Healthcare System Project (P167000) Year 6 0.00 0.00 Year 7 6.00 5,520,000.00 See procedure 2021 RP DLI IN01361953 ACTION PBC 13 Number of plasma centers receiving Good Manufacturing Practices (GMP) certificates Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 7,560,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 0.00 Year 1 0.00 0.00 Year 2 0.00 0.00 Year 3 0.00 0.00 Year 4 0.00 0.00 Year 5 12.00 7,560,000.00 See procedure Year 6 0.00 Year 7 0.00 Action: This PBC has been Revised. See below. The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI IN01370705 ACTION PBC 13 Number of plasma centers receiving Good Manufacturing Practices (GMP) certificates Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 3,780,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 0.00 Year 1 0.00 0.00 Year 2 0.00 0.00 Year 3 0.00 0.00 Year 4 0.00 0.00 Year 5 0.00 0.00 Year 6 0.00 0.00 Year 7 6.00 3,780,000.00 See procedure 2021 RP DLI IN01361954 ACTION PBC 14 Number of plasma units that were properly collected, transferred, tested and stored. Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 3,440,000.00 0.00 Period Value Allocated Amount (USD) Formula The World Bank Transforming Egypt's Healthcare System Project (P167000) Baseline 0.00 Year 0 0.00 0.00 Year 1 50,000.00 0.00 Year 2 150,000.00 0.00 Year 3 250,000.00 0.00 Year 4 0.00 Year 5 3,440,000.00 See Procedure Year 6 0.00 Year 7 0.00 Action: This PBC has been Revised. See below. DLI IN01370727 ACTION PBC 14 Number of plasma units that were properly collected, transferred, tested and stored. Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 1,177,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 0.00 Year 1 0.00 0.00 Year 2 0.00 0.00 The World Bank Transforming Egypt's Healthcare System Project (P167000) Year 3 0.00 0.00 Year 4 0.00 0.00 Year 5 0.00 0.00 Year 6 0.00 0.00 Year 7 11,000.00 1,177,000.00 DLI IN01361955 ACTION Number of clinical screenings of suspected COVID-19 cases by a trained physician/nurse at port of entries, quarantine PBC 15 facilities, community and/or healthcare facilities Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 7,909,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 0.00 Year 1 200,000.00 0.00 Year 2 200,000.00 0.00 Year 3 200,000.00 7,909,000.00 unit cost of US$39.55 Year 4 0.00 Year 5 0.00 Year 6 0.00 The World Bank Transforming Egypt's Healthcare System Project (P167000) Year 7 0.00 DLI IN01380080 ACTION PBC 16 CHWs trained on GBV awareness, prevention and response Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 900,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 Year 1 0.00 Year 2 0.00 Year 3 0.00 Year 4 0.00 Year 5 0.00 Development and integrated of new module on Year 6 GBV prevention and response into national CHW 750,000.00 See Annex 3 of 2023 RP training curriculum. 1250 CHWs trained Supportive supervision report to ensure newly Year 7 trained CHWs deliver high quality and appropriate 150,000.00 See Annex 3 of 2023 RP GBV messages in households. Action: This PBC is New The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI IN01370728 ACTION PBC 17 Percentage of surgical interventions provided in 30 days or less from issue date of operation decree Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Percentage 9,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 77.00 Year 0 0.00 Year 1 0.00 Year 2 0.00 Year 3 0.00 Year 4 0.00 Year 5 0.00 . Year 6 92.00 6,000,000.00 See Annex 3 in 2023 RP Year 7 92.00 3,000,000.00 See Annex 3 in 2023 RP Action: This PBC is New The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI IN01370670 ACTION PBC 18 Percentage of PTES patients receiving surgical intervention through the PIESWL who are uninsured. Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 600,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 Year 1 0.00 Year 2 0.00 Year 3 0.00 Year 4 0.00 Year 5 0.00 100% of PTES patients receiving surgical intervention through the PIESWL are uninsured. Period covering January 1, 2024 – June 30, 2024. Year 6 100% of PTES patients receiving surgical 400,000.00 See Annex 3 of 2023 RP intervention through the PIESWL are uninsured. Period covering July 1, 2024 – December 31, 2024. 100% of PTES patients receiving surgical Year 7 intervention through the PIESWL are uninsured. 200,000.00 See Annex 3 of 2023 RP Period covering January 1, 2025 – June 30, 2025. Action: This PBC is New Rationale: The World Bank Transforming Egypt's Healthcare System Project (P167000) This PBC aims to improve financial protection against out of pocket expenditures for surgical care DLI IN01370731 ACTION PBC 19 Number of hospitals meeting the National Safety Requirements (NSR) for Surgery, Anesthesia and Sedation. Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Number 16,400,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 0 0.00 Year 1 0.00 Year 2 0.00 Year 3 0.00 Year 4 0.00 Year 5 0.00 Year 6 0.00 Year 7 250.00 16,400,000.00 See Annex 3 of 2023 RP Rationale: Action: This PBC is New This PBC measures surgical safety. The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI IN01370736 ACTION PBC 20 Financial sustainability of Presidential Initiative to Eliminate the Surgical Waiting List Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Text 34,000,000.00 0.00 Period Value Allocated Amount (USD) Formula 0% of payments by MOHP that took place within Baseline 60 days of claim submission for PTES who received a surgical intervention through PIESWL Year 0 0.00 Year 1 0.00 Year 2 0.00 Year 3 0.00 Year 4 0.00 Year 5 0.00 Between January 1, 2024 and December 30, 2024, Government releases US$25 million, or its Year 6 25,000,000.00 See Annex 3 of 2023 RP equivalent in local currency, to clear part of the financial arrears of the PIESWL account. 78% of payments by MOHP that took place within 60 days of claim submission for PTES who Year 7 9,000,000.00 See Annex 3 of 2023 RP received a surgical intervention through PIESWL. Period covering January 1, 2025 – June 30, 2025. Rationale: Action: This PBC is New This PBC measures the financial sustainability of the Presidential Initiatie. The World Bank Transforming Egypt's Healthcare System Project (P167000) Verification Protocol Table: Performance-Based Conditions DLI_TBL_VERIFICATION PBC 1 Development of quality tools and mechanisms DLR 1.1: Accreditation Guidelines for PHC facilities updated DLR 1.2 : PHC Services Mapping exercise completed DLR 1.3 : Description PHC Needs assessment carried out DLR 1.4 : PHC Needs assessment carried out for re-accreditation Data source/ Agency MoHP Verification Entity IVA Year 0 - Verify that the MOHP has finalized and officially issued the National Quality Accreditation Guidelines for Primary Health Care facilities. Year 0 - Verify that the MOHP has completed the PHC services mapping exercise and issued the relevant report in the targeted Governorates in a manner satisfactory to the Bank. Year 0 - Verify that the MOHP has carried out a needs assessment in the target Governorates and has produced a detailed Procedure report acceptable to the Bank illustrating the needs of all PHCs. Year 3- Verify that the MOHP has carried out a needs assessment in the target Governorates and has produced a detailed report acceptable to the Bank illustrating the needs of all PHCs that have lost their accreditation status starting 2016. DLI_TBL_VERIFICATION PBC 2 Grievances addressed in project target facilities using the GRM in accordance with the revised manual issued in 2017 This indicator is to track the percentage of all received and addressed grievances as per the new GRM manual (2017) out of Description the total received in project target facilities Data source/ Agency MOHP Verification Entity IVA Year 0 - Verify with the MoHP that the staff have received the GRM manual (prepared in 2016), as defined in the Operations Procedure manual. The World Bank Transforming Egypt's Healthcare System Project (P167000) Year 1 - Verify with the MoHP that the staff are trained on the new GRM tool (issued 2016), as defined in the Operations manual. The percentage is calculated as the number of staff at PHC and district management offices levels in the target governorates who are trained on the GRM mechanism divided by the total number of staff at the same levels and in the same target governorates. Year 2,3,4,5- Verify % of grievances addressed, using records of the central grievance department at the MOHP and Governorate level documentation. This is calculated by dividing the number of grievances received and addressed using the revised GRM manual divided by the total number of grievances received in the target governorates. DLI_TBL_VERIFICATION PBC 2 Grievances addressed in project target facilities using the GRM in accordance with the revised manual issued in 2017 This indicator is to track the percentage of all received and addressed grievances as per the new GRM manual (2017) out of Description the total received in project target facilities. In 2023, the GRM will be updated to accommodate SEA/H survivors. Data source/ Agency MOHP Verification Entity IVA Year 0 - Verify with the MoHP that the staff have received the GRM manual (prepared in 2016), as defined in the Operations manual. Year 1 - Verify with the MoHP that the staff are trained on the new GRM tool (issued 2016), as defined in the Operations manual. The percentage is calculated as the number of staff at PHC and district management offices levels in the target governorates who are trained on the GRM mechanism divided by the total number of staff at the same levels and in the same target governorates. Procedure Year 2,3,4,5- Verify % of grievances addressed, using records of the central grievance department at the MOHP and Governorate level documentation. This is calculated by dividing the number of grievances received and addressed using the revised GRM manual divided by the total number of grievances received in the target governorates. Year 6 - Very that GRM training materials that accommodate SEA/SH complaints are developed with specialized firm; Verify that training on the SEA/H sensitive GRM delivered to all PHC and district level staff in participating Governorates using a training of trainers approach. Year 6&7 (through June 30, 2025) - Verify % of grievances addressed, using records of the central grievance department at the MOHP and Governorate level documentation. This is calculated by dividing the number of grievances received and The World Bank Transforming Egypt's Healthcare System Project (P167000) addressed using the revised GRM manual that has been updated to accommodate SEA/H divided by the total number of grievances received in the target governorates. DLI_TBL_VERIFICATION PBC 3 Percentage of participating districts certified for enhanced governance performance The indicator would measure the percent of districts participating in the Project for being certified for enhanced governance Description performance Data source/ Agency MoHP training Verification Entity MoHP training Year 1,2,3,4,5 – Verify the percentage of districts out of the total number of districts in the target governorates who have been certified in enhanced governance performance. A district is certified for enhanced governance performance when it: a) falls in the project target governorates; b) at least 2 management level positions and 3 fiduciary level position persons from that same district and its affiliated facilities have successfully completed the fiduciary training, as deemed acceptable to the Bank; and c) applying smart technology tools to Procedure monitor/safeguard project assets, and that the 9 project target health directorates and central MOH are at all times (as deemed acceptable to the bank) : a) Providing quarterly reporting to confirm budget execution in compliance with the approved budgets to MOH; and b) Performing satisfactory public advertising & dissemination of information on contracts awards, value, execution time and progress for project . DLI_TBL_VERIFICATION PBC 4 Number of PHCs passing Quality Services Index composite indicators list Measures the number of PHCs that have been confirmed as passing the (QSI) composite indicator list by an Independent Description Verification Agency in project target governorates. Data source/ Agency Field visits to PHCs, MOHP data. Verification Entity IVA DLR 4.1: Year 1,2,3,4,5 – Verify, and through a suitable scientific random sampling technique acceptable to the Bank, that a set number of PHCs presented by MOHP for verification have met the Quality of Service index (QSI) indicators list as Procedure described in the POM. For each respective DLI Target, MOHP will propose a batch of PHCs that are: i) in the project target governorates; and ii) have been pre-identified for project support. Each respective batch should be composed of not less than 50 and no more The World Bank Transforming Egypt's Healthcare System Project (P167000) than 150 PHCs for a grand total of 600 PHCs under all batches. The batches, will then be verified according to a suitable sampling basis towards the certification or non-certification of the whole respective batch. For a given batch to be verified for certification, 80% of the sampled PHCs will have to score at least 80% or more of the total score of the QSI tool. DLR 4.2: Year 1,2,3,4,5 – Verify, and through a suitable scientific random sampling technique acceptable to the Bank, that a batch of PHCs have been accredited in a manner that is compliant with, in process and substance, the National Accreditation tool for Primary Healthcare Facilities developed under the support of the project as described in the POM. For each respective DLI target, MOHP will propose a batch of PHCs that have been accredited through the national Egyptian official accrediting body for healthcare services, and that all PHCs in the batch are: i) in the project target governorates; ii) have been pre-identified for project support in the project’s operations manual; and iii) have received the QSI certification under the same project. Each respective batch should be composed of not less than 50 and no more than 150 PHCs for a grand total of 600 PHCs under all batches. The batches, will then be verified according to a suitable sampling basis towards the compliance or non-compliance of the whole respective batch with the Accreditation process and substance described. DLI_TBL_VERIFICATION PBC 4 Number of PHCs passing Quality Services Index composite indicators list and GAHAR self-assessment Measures the number of PHCs that have been confirmed as passing the (QSI) composite indicator list by an Independent Description Verification Agency in project target governorates, and the number of PHCs that passed the GAHAR self assessment. Data source/ Agency Field visits to PHCs, MOHP data. Verification Entity IVA DLR 4.1: Year 1,2,3,4,5 – Verify, and through a suitable scientific random sampling technique acceptable to the Bank, that a set number of PHCs presented by MOHP for verification have met the Quality of Service index (QSI) indicators list as described in the POM. Procedure For each respective DLI Target, MOHP will propose a batch of PHCs that are: i) in the project target governorates; and ii) have been pre-identified for project support. Each respective batch should be composed of not less than 50 and no more than 150 PHCs for a grand total of 600 PHCs under all batches. The batches, will then be verified according to a suitable sampling basis towards the certification or non-certification of the whole respective batch. The World Bank Transforming Egypt's Healthcare System Project (P167000) For a given batch to be verified for certification, 80% of the sampled PHCs will have to score at least 80% or more of the total score of the QSI tool. Year 6 - A batch of at least 100 PBCs will be added through AFD co-financing. DLR 4.2: Years 6 and 7 – Verify, and through a suitable scientific random sampling technique acceptable to the Bank, that a batch of 250 PHCs completes the GAHAR self assessment. MOHP will propose a batch of 250 PHCs that are: i) in the project target governorates; ii) have been pre-identified for project support in the project’s operations manual; and iii) have received the QSI certification under the same project. DLI_TBL_VERIFICATION PBC 5 Increased household visits by CHWs This indicator will measure the CHW coverage rate defined as the percentage of households in targeted communities visited Description by CHWs in the past year. Data source/ Agency MOHP Verification Entity IVA Years 1,2,3,4,5: Verify that CHW coverage rate has increased and reached the set targets.Years 1,2,3,4,5: Verify that CHW coverage rate has increased and reached the set targets. DLR 5.1 For reaching the target of 12%, US$600,000 will be awarded. DLR 5.2 For reaching the target of 17%, US$600,000 will be awarded. Procedure DLR 5.3 0 DLR 5.4 For reaching the target of 27%, US$600,000 will be awarded. DLR 5.5 For reaching the target of 32%, US$600,000 will be awarded. The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI_TBL_VERIFICATION PBC 5 Increased household visits by CHWs This indicator will measure the CHW coverage rate defined as the percentage of households in targeted communities visited Description by CHWs in the past year. Data source/ Agency MOHP Verification Entity IVA Years 1,2,3,4,5: Verify that CHW coverage rate has increased and reached the set targets.Years 1,2,3,4,5: Verify that CHW coverage rate has increased and reached the set targets. DLR 5.1 For reaching the target of 12%, US$600,000 will be awarded. DLR 5.2 For reaching the target of 17%, US$600,000 will be awarded. DLR 5.3 Procedure 0 DLR 5.4 For reaching the target of 27%, US$600,000 will be awarded. DLR 5.5 For reaching the target of 32%, US$600,000 will be awarded. PBR 5.6 For maintaining the target of 32%, US$600,000 will be awarded. See Annex 3. DLI_TBL_VERIFICATION PBC 6 Contraceptive prevalence rate Contraceptive Prevalence Rate: The percent of women of reproductive age who are using (or whose partner is using) a contraceptive method at a particular point in time. The indicator is calculated as follows: (# of women 15-49 using a Description contraceptive method / total # of women aged 15-49) x 100. The National prevalence will be measured through a nationally representative survey. Data source/ Agency DHS and nationally representative population surveys/MOHP Verification Entity MOHP The World Bank Transforming Egypt's Healthcare System Project (P167000) Years 3 and 5- Verify % contraceptive prevalence rate (CPR) to be collected through DHS and population survey. The survey Procedure would be carried out in year 3 and 5. DLI_TBL_VERIFICATION PBC 6 Contraceptive prevalence rate Contraceptive Prevalence Rate: The percent of women of reproductive age who are using (or whose partner is using) a contraceptive method at a particular point in time. The indicator is calculated as follows: (# of women 15-49 using a contraceptive method / total # of women aged 15-49) x 100. The National prevalence will be measured through a nationally Description representative survey. Year 7: Definition of contraceptive prevalence rate is to match the Egyptian Family Health Survey for 2021. Data source/ Agency DHS and nationally representative population surveys/MOHP Verification Entity MOHP Years 3 and 5- Verify % contraceptive prevalence rate (CPR) to be collected through DHS and population survey. The survey would be carried out in year 3 and 5. Procedure Year 7: IVA conducts a national nationally representative population survey or relies on other nationally representative population survey acceptable to the World Bank with a methodology described in the POM. DLI_TBL_VERIFICATION PBC 7 Targeted people screened for NCDs To measure the number of persons screened for NCD’s as per the set protocol in the POM on the national level. Data to be Description supplied through MOHP and verified by IVA. Data source/ Agency MOHP data, spot checks, spot checks on screened individuals, Third party data Verification Entity IVA Year 0-5: Verify the number of people screened for blood pressure level, blood sugar level and BMI at the community level, through mobile teams, in PHCs and hospitals anywhere in Egypt in a manner and using the testing methods defined in the NCD screening protocol in the POM. Procedure The verification Agency shall verify the data through a mix of: a) checking relevant MOHP documentation; b) spot checks on activities; and c) tracking a sample of screened individuals and communicating with them. The World Bank Transforming Egypt's Healthcare System Project (P167000) DLI_TBL_VERIFICATION PBC 8 Number of people screened for Viral Hepatitis C Measures the number of people screened through project support for Viral Hepatitis C as per the protocol in the Project Description Operation Manual. Numbers to be verified by Independent Verification Agency. Data source/ Agency MOHP data, spot checks, spot checks on screened individuals, Third party data Verification Entity IVA Year 0-5: Verify the number of people screened for Viral Hepatitis C at the community level, through mobile teams, in PHCs and hospitals anywhere in Egypt in a manner and using the testing methods defined in the Hep C screening protocol in the POM. Every person can be screened only once for the primary screening test. Procedure The verification Agency shall verify the data through a mix of: a) checking relevant MOHP documentation; b) spot checks on activities; c) tracking a sample of screened individuals and communicating with them; and/or d) Third party reports. DLI_TBL_VERIFICATION Percentage of people who received treatment for Hepatitis C who have taken the final confirmation test for sustained PBC 9 virological response (SVR) using a random sampling methodology Measures the number of people screened through project support for Viral Hepatitis C as per the protocol in the Project Description Operation Manual. Numbers to be verified by Independent Verification Agency. Data source/ Agency MOHP data, spot checks, spot checks on screened individuals, Third party data Verification Entity IVA Year 0-5: Verify the number of people who have taken the confirmation test and have been confirmed as cured of Hep C of the total number treated that year under the project, using the confirmation testing methods defined in the POM. Procedure The verification agency shall verify the data through a mix of: a) checking relevant MOHP documentation; b) spot checks on activities; c) tracking a sample of treated individuals and communicating with them; and/or d) third party reports. DLI_TBL_VERIFICATION PBC 10 Number of conducted rounds of the national online licensing/specialization examinations. Description This indicator measures the establishment of the system and a subsequent two rounds of national examinations. MOHP Data source/ Agency Verification Entity IVA The World Bank Transforming Egypt's Healthcare System Project (P167000) PBC 10 (Years 3,4,5): US$1,000,000 to be awarded on every satisfactory conducted round of the national medical licensing Procedure and specialties online examinations as verified by IVA. DLI_TBL_VERIFICATION PBC 11 Development of Plasma Quality Tools This PBC will support the needed foundational studies and technical analyses of the systems required for addressing the knowledge gap towards achieving a sustainable BPSP that offers persistent quality results. The EEs will include the non- Description salary operating costs associated with the development, review, consultations for and adoption of the reports. MOHP Data source/ Agency IVA Verification Entity PBR 11.1: Plasma centers needs assessment; PBR 11.2: Human resources needs assessment; PBR 11.3: Developing a business plan for the Plasma Safety and Sufficiency Program; PBR 11.4: Developing a quality training curriculum for staff at plasma centers. (Years 3,4,5): Upon finalization and official adoption by MOHP of the following reports that are acceptable to the World Bank in form and substance and as verified by an IVA, the equivalent amounts will be awarded, respectively, as follows: Procedure PBR 11.1: Plasma centers needs assessment: US$2,000,000. PBR 11.2: Human resources need assessment: US$2,000,000 PBR 11.3: Business plan for the Plasma Safety and Sufficiency Program: US4,000,000 PBR 11.4: Quality training curriculum for staff at plasma centers: US$2,000,000 DLI_TBL_VERIFICATION PBC 12 Number of plasma centers passing the PQI composite indicator. The indicator measures the incremental levels of higher quality services for plasma products in terms of process, patient Description perspective and system perspective. All target Plasma centers will be assessed for results using a composite list of indicators titled Plasma Quality index (PQI). The World Bank Transforming Egypt's Healthcare System Project (P167000) MOHP Data source/ Agency IVA Verification Entity (Years 3,4,5): Upon verification by an IVA, each plasma center achieving at least 60% in the Plasma Quality Index (PQI) composite indicator list will be awarded US$920,000. The minimum disbursement threshold will be US$920,000 up to a Procedure maximum equal to the allocated PBC amount. DLI_TBL_VERIFICATION PBC 12 Number of plasma centers passing the PQI composite indicator. The indicator measures the incremental levels of higher quality services for plasma products in terms of process, patient Description perspective and system perspective. All target Plasma centers will be assessed for results using a composite list of indicators titled Plasma Quality index (PQI). MOHP Data source/ Agency IVA Verification Entity (Years 3,4,5,6,7): Upon verification by an IVA, each plasma center achieving at least 60% in the Plasma Quality Index (PQI) composite indicator list will be awarded US$920,000. The minimum disbursement threshold will be US$920,000 up to a Procedure maximum equal to the allocated PBC amount. DLI_TBL_VERIFICATION PBC 13 Number of plasma centers receiving Good Manufacturing Practices (GMP) certificates The PBC will support 12 newly established plasma centers achieve the official national GMP certification for the their BPSP Description processes from the Egyptian Drug Authority (EDA) which is a legal requirement (MOHP Decree 536/2007). MOHP Data source/ Agency IVA Verification Entity The World Bank Transforming Egypt's Healthcare System Project (P167000) (Years 3,4,5): Upon verification by an IVA, each plasma center achieving the national Good Manufacturing Practice (GMP) certificate will be awarded US$630,000. The minimum disbursement threshold will be US$630,000 up to a maximum equal Procedure to the allocated PBC amount. DLI_TBL_VERIFICATION PBC 13 Number of plasma centers receiving Good Manufacturing Practices (GMP) certificates The PBC will support 6 newly established plasma centers achieve the official national GMP certification for the their BPSP Description processes from the Egyptian Drug Authority (EDA) which is a legal requirement (MOHP Decree 536/2007). MOHP Data source/ Agency IVA Verification Entity (Years 3,4,5,6,7): Upon verification by an IVA, each plasma center achieving the national Good Manufacturing Practice (GMP) certificate will be awarded US$630,000. The minimum disbursement threshold will be US$630,000 up to a maximum Procedure equal to the allocated PBC amount. DLI_TBL_VERIFICATION PBC 14 Number of plasma units that were properly collected, transferred, tested and stored. The indicators measures the number of plasma units that have been subjected to proper protocol at all stages of the supply Description chain as per the protocol set by BPSP and approved by NBTS. MOHP Data source/ Agency IVA Verification Entity (Years 3,4,5): Upon verification by an IVA, each plasma unit that was properly collected, transferred, tested and stored will be awarded US$13.76. The minimum disbursement threshold will be US$137,600 up to a maximum equal to the allocated Procedure PBC amount. DLI_TBL_VERIFICATION PBC 14 Number of plasma units that were properly collected, transferred, tested and stored. The indicators measures the number of plasma units that have been subjected to proper protocol at all stages of the supply Description chain as per the protocol set by BPSP and approved by NBTS. The World Bank Transforming Egypt's Healthcare System Project (P167000) MOHP Data source/ Agency IVA Verification Entity (Years 3,4,5,6,7): Upon verification by an IVA, each plasma unit that was properly collected, transferred, tested and stored Procedure will be awarded US$107 up to a maximum equal to the allocated PBC amount. DLI_TBL_VERIFICATION Number of clinical screenings of suspected COVID-19 cases by a trained physician/nurse at port of entries, quarantine PBC 15 facilities, community and/or healthcare facilities Description MOHP Data source/ Agency IVA Verification Entity (Year 3): Upon verification by an IVA in a manner acceptable to the World Bank, each clinical screening of suspected COVID- 19 case by a trained physician/nurse at port of entries, quarantine facilities, community and/or healthcare facilities will be Procedure awarded US$39.55. The minimum disbursement threshold will be US$7,909,000. DLI_TBL_VERIFICATION PBC 16 CHWs trained on GBV awareness, prevention and response Description Data source/ Agency IVA Verification Entity See Annex 3 Procedure DLI_TBL_VERIFICATION PBC 17 Percentage of surgical interventions provided in 30 days or less from issue date of operation decree Numerator is the number of surgical interventions provided through the PIESWL within 30 days of the operation decree; Description denominator is the total number of surgeries provided through the PIESWL in the same period. This calculation excludes patients who received liver transplants and patients who had to delay their surgery due to medical necessity. The World Bank Transforming Egypt's Healthcare System Project (P167000) MOHP Data source/ Agency IVA Verification Entity See Annex 3 Procedure DLI_TBL_VERIFICATION PBC 18 Percentage of PTES patients receiving surgical intervention through the PIESWL who are uninsured. Description MOHP Data source/ Agency IVA Verification Entity See Annex 3 Procedure DLI_TBL_VERIFICATION PBC 19 Number of hospitals meeting the National Safety Requirements (NSR) for Surgery, Anesthesia and Sedation. Description MOHP Data source/ Agency IVA Verification Entity See Annex 3 Procedure DLI_TBL_VERIFICATION PBC 20 Financial sustainability of Presidential Initiative to Eliminate the Surgical Waiting List Description MOHP Data source/ Agency IVA Verification Entity The World Bank Transforming Egypt's Healthcare System Project (P167000) See Annex 3 Procedure