REPORT NO.: RES50352 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF SAINT LUCIA HEALTH SYSTEM STRENGTHENING PROJECT APPROVED ON SEPTEMBER 28, 2018 TO SAINT LUCIA HEALTH, NUTRITION & POPULATION LATIN AMERICA AND CARIBBEAN Regional Vice President: Carlos Felipe Jaramillo Country Director: Lilia Burunciuc Regional Director: Luis Benveniste Practice Manager/Manager: Michele Gragnolati Task Team Leader(s): Edit V. Velenyi, Behnaz Bonyadian Dehkordi ABBREVIATIONS AND ACRONYMS AF Additional Financing CERC Contingent Emergency Response Component CPS Country Partnership Strategy DALY Disability-Adjusted Life Years EPHS Essential Package of Health Services ESMF Environment and Social Management Framework FM Financial Management GBV Gender-based Violence GDP Gross Domestic Product GRM Grievance Redress Mechanism GRS Grievance Redress Service HSSP Health System Strengthening Project IDA International Development Association IFR Interim Financial Reports MOHWEA Ministry of Health and Wellness and Elderly Affairs MOHWEA-PIU Ministry of Health and Wellness and Elderly Affairs Project Implementation Unit NPV Net Present Value PBF Performance-Based Financing PDO Project Development Objective PEF Pandemic Emergency Financing Facility PHC Primary Health Care PIU Project Implementation Unit PPSD Project Procurement Strategy for Development RF Results Framework SEAH Sexual Exploitation, Abuse and Harassment SORT Systematic Operations Risk-rating Tool TOR Terms of Reference UHC Universal Health Coverage WHO World Health Organization The World Bank Saint Lucia Health System Strengthening Project (P166783) BASIC DATA Product Information Project ID Financing Instrument P166783 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 28-Sep-2018 31-Oct-2023 Organizations Borrower Responsible Agency Ministry of Finance, Economic Growth, Job Creation and External Affairs,Ministry of Finance, Economic Growth, Job Creation, and External Affairs Project Development Objective (PDO) Original PDO The development objective is to improve the accessibility, efficiency, and responsiveness of key health services. Current PDO The development objective is to improve the accessibility, efficiency, and responsiveness of key health services, and provide a response in the event of eligible crises or emergencies. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-67290 26-Jun-2020 17-Nov-2020 04-Dec-2020 31-Oct-2023 5.00 0 5.00 IDA-63160 28-Sep-2018 27-Nov-2018 15-Jan-2019 31-Oct-2023 20.00 8.69 11.31 TF-B4523 16-Nov-2020 04-Dec-2020 04-Dec-2020 31-Jan-2021 .94 .94 0 The World Bank Saint Lucia Health System Strengthening Project (P166783) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING Introduction 1. This Restructuring Paper seeks Country Director approval of a proposed Level II Restructuring for the Saint Lucia Health Systems Strengthening Project (P166783). A restructuring of the Project is proposed to include: (a) modification of the components’ scope to support the current government’s Universal Health Coverage (UHC) priorities; (b) revision of the component and subcomponent costs to align with the government’s updated priorities; (c) update of the project’s results framework; (d) adjustment of the implementation arrangements; (e) extension of the project closing date by 12 months; and (f) update to the frequency of project reporting. These changes are necessary to ensure that the PDO can be met in the context of the pandemic and to respond to implementation delays, as well as changes in the macro-fiscal and policy environment. Project Background 2. The Health System Strengthening Project (HSSP), initially financed by a US$20 million IDA credit approved by the World Bank’s Executive Directors on September 28, 2018, aimed at improving the accessibility, efficiency, and responsiveness of key health services. Following the declaration of SARS-CoV-2 as a pandemic, the Government of Saint Lucia (GOSTL) requested the activation of the Contingency Emergency Response Component (CERC) under Component 4 of the project in the amount of US$5 million. The request was approved on April 27, 2020, with US$2.5 million financed from the COVID-19 Fast-Track Facility and US$2.5 million from the national Performance-Based Allocation (PBA) under Component 2. Following CERC activation, an Additional Financing/Restructuring was processed and approved on June 26, 2020, to formally reflect and fill the financing gap resulting from the activation of the CERC. The restructuring of the original project reflects changes to the PDO and Results Framework to align with COVID-19 activities. The PDO was updated as follows: “Improve the accessibility, efficiency, and responsiveness of key health services, and provide a response in the event of eligible crises or emergencies.” Saint Lucia also received a US$0.94 million grant through the Pandemic Emergency Financing Facility (PEF), processed as a second Additional Financing and approved on November 25, 2020, to finance the cost overrun of the CERC. 3. The Project is comprised of four components: (a) Design and Implementation of an Essential Health Services Package (EHSP), which is financing the design and roll out of the determined package of health services, including though strengthening necessary administrative, clinical and regulatory systems; (b) Strengthening Service Delivery in Support of the Essential Package of Health Services, which is supporting performance-based financing (PBF) for diabetes and hypertension at the primary health care level, improving supply-side readiness of health facilities, and strengthening public health emergency preparedness and response; (c) Institutional Capacity Building, Project Management and Coordination, which is building the institutional capacity of the Ministry of The World Bank Saint Lucia Health System Strengthening Project (P166783) Health and Wellness and Elderly Affairs (MOHWEA) Project Implementation Unit (MOHWEA-PIU), and supporting project management; and (d) the CERC. Status of Project Implementation and Performance 4. Project implementation has been slower than anticipated. Identified drivers for the delay include the impact of the COVID-19 pandemic, shortcoming in sector policymaking, limited government capacity, and persistent project management challenges. COVID-19 impacted the fiscal and human capacity of MOHWEA to design and implement health sector related reforms, with resources devoted to containing the pandemic in 2020 and the first half of 2021. Project implementation was also hindered by a fragmented project design, unclear policy, and strategy vision for the National Health Insurance Scheme (NHIS), the EPHS; and the PBF scheme. The technical assessments envisaged to support policy reform were also delayed due to capacity gaps. Overall Implementation Progress (IP) and Progress toward achievement of the PDO (DO) ratings in the Project’s December 2021 Implementation Status and Results Report (ISR) were downgraded from Moderately Satisfactory to Moderately Unsatisfactory accordingly. 5. Despite these challenges, significant implementation progress has been made in the last year, resulting in an upgrade to project ratings as of April 2022. Key results to date include the provision of technical assistance under Component 1 to support the development of the UHC White Paper and initiation of support to develop a Health Financing Policy and Strategy; completion of the preparatory activities for the launch of the PBF scheme in four regions under Component 2; hiring of key PIU staff, including a new Coordinator; and activation of the CERC in April 2020 was to provide the resources needed to procure medical equipment and supplies for a timely response to the pandemic. In December 2022, the CERC deadline was extended a second time, by 6-months to provide additional time to finalize remaining procurement activities by June 30, 2023. As of February 10, 2023, the Project has disbursed US$8.69 million (34.8%) of the US$25 million International Development Association (IDA) credits and 100 percent of the PEF grant. IP and DO ratings were upgraded to Moderately Satisfactory in an interim ISR filed in April 2022 and the latest ISR filed in December 2022. 6. Safeguards Performance. Environmental and Social (E&S) Safeguards performance remains assessed as Moderately Satisfactory. The Project’s grievance redress mechanism is fully functional and has been adapted to be responsive to sexual harassment/sexual exploitation and abuse. In addition to the E&S Focal Points, the PIU is in the process of hiring a part-time E&S Specialist, who will split time between HSSP and the Bank-financed OECS Regional Health Project (P168539). As of February 2023, the PIU is finalizing the hiring process to on-board the part-time E&S Specialist by Q2 of 2023. 7. Project Management. Recent hirings of dedicated and experienced PIU personnel have helped to address previous implementation bottlenecks. These include the appointment of a new Project Coordinator (June 2022), as well as the hiring of a Monitoring and Evaluation Specialist, Communications Specialist, Procurement Analyst, and Administrative Assistant. The Project has no financial audit overdue (all previous audit reports were considered satisfactory to the Bank), and remains in compliance with key legal covenants, including safeguards, and financial management reporting requirements. Rationale for Restructuring 8. The Government formally requested a project restructuring in an initial letter dated February 21, 2022, and an updated letter reflecting the requested extension of the closing date on January 9, 2023. The rational for restructuring includes: (a) addressing implementation challenges identified during the midterm review (MTR) The World Bank Saint Lucia Health System Strengthening Project (P166783) completed in July 2021; (b) reflecting changes in the policy direction of the new Government elected in July 2021, including sharper focus on developing a strategy to attain Universal Health Coverage (UHC) agenda, aligned with the macro-fiscal context, resulting from the pandemic; and (c) allowing sufficient time for project implementation, lost to the pandemic and project management challenges, to meet the PDO. 9. The proposed restructuring responds to implementation challenges and solutions identified during the MTR conducted between June and July 2021. These include the following: (a) reducing design fragmentation by sharpening the focus of project components and consolidating activities to better support the UHC agenda; (b) revising the results framework to better capture progress and adjust targets to the current development context; (c) strengthening capacity building to ensure the institutional sustainability of the project activities including project management functions (planning, reporting, and coordination); and (d) adjusting the implementation arrangements with focus on institutional sustainability to strengthen transparency, accountability and project performance. i. Project Design: The current project design is deemed too complex and too ambitious considering the capacity needed to implement major health sector reforms (service delivery, policy-making, and regulatory functions) and the tighter fiscal space resulting from the pandemic. These challenges are magnified by the lack of a broad encompassing UHC policy framework, as well as the lack of a Health Financing Policy and Strategy (HFPS) with clearly defined objectives and targets which would guide the design of an integrated strategic purchasing function and a coherent set of financing and service delivery reforms to implement UHC. Technical assessments and assistance to inform the development of the UHC strategy and the HFPS will be prioritized and fast tracked. Consequently, the project design will be simplified and project activities under the components, reorganized and consolidated to define achievable results, maximize impact, and reduce fragmentation. Targeted support to priority interventions to strengthen the overall health system to support these health sector reforms to may also be expanded. ii. Institutional and Implementation Arrangements: The existing institutional and implementational arrangements will be enhanced to ensure a clearer and stronger transition from the current temporary model to a fully institutionalized model, with a focus on the PBF scheme. Moreover, there is a need to update the project governance arrangement to reflect the de facto governance model as well as changes in the MOHWEA’s organizational arrangements. For example, due to the shift in the policy direction the “envisioned NHI unit” was never created. On the other hand, the PBF unit, currently under the PIU, has introduced a PBF Executive Team, that provides guidance on policy and operational decisions for the PBF Pilot. The role and scope of the PBF Unit and the PBF Executive Team are described and regulated in the POM and the PBF Operation Manual. The PBF OM will be revised by February 28, 2023, to support the launch of the PBF Pilot in Quarter 1 of 2023. Furthermore, following Cabinet Conclusion no. 129 of 2022, as one of the five main deliverables1 for Phase 1 of UHC, the MOHWEA has introduced a UHC Unit to provide policy guidance for the UHC reform agenda and its implementation. Lastly, the Project Steering Committee (PSC) was largely dormant in 2020 and 2021, due to project management challenges. The Terms of Reference for the PSC has been updated to ensure effective project governance. The first meeting of the reconstituted PSC was held on January 26, 2023, based on a progress report to discuss 1 The 5 main deliverables include: (1) Implement HTN/DM screening and treatment under the Performance Based Financing Project (also supported under HSSP); (2) Maternal and Child Health Services be included under Phase 1 of the UHC initiative; (3) Analysis be conducted on the possible inclusion of dialysis and early cancer screening; (4) Registration of the population along with the introduction of health cards (virtual or physical) to the registered population; and (5) Creation of a UHC unit to facilitate implementation of this initiative. The World Bank Saint Lucia Health System Strengthening Project (P166783) implementation status and strategic direction. The institutional and implementation arrangements will be updated to reflect these changes and clarify the relationships between key project implementation stakeholders, their roles, and responsibilities. The updated POM will be ready by March 17, 2023, to reflect the changes from this proposed restructuring. 10. The new GOSTL has a renewed commitment to health sector reforms and the achievement of UHC. i. In 2021, a newly elected Government outlined support for a rejuvenated health policy development and reform agenda in what is described as the Saint Lucia Labour Party (SLP) Manifesto. The new administration is motivated to open necessary fiscal space to reverse the deteriorating health and social conditions, which have been further negatively impacted by the pandemic. The new administration is also committed to improve data analytics for decision-making and invest in preventative health services to contain health care costs and better manage the burden of disease from non-communicable diseases (NCDs). ii. Moving forward, a priority for the GOSTL will be to define what UHC will entail and what the journey will look like – i.e., what can be realistically achieved given the existing fiscal space. Defining UHC for STL will require taking stock of the evidence generated to date, updating fiscal space projections and modeling different scenarios to identify a package of essential services for the population that is affordable and sustainable. Such process is expected to take time and requires support from an extensive network of experts to support the process. Component 1 of the project will focus on supporting an evidence-based policy-making agenda, inter alia, the finalization and adoption of a UHC White Paper and a Health Financing Policy and Strategy. iii. While doing so, the GOSTL is committed to fast-track the implementation of critical health financing reforms to improve results in priority health areas that pose a major burden on the system and the people, such as NCDs. The PBF pilot, which has a state-of-the-art design, is central to the Project’s success and for the UHC agenda. Introducing PBF to the health sector will assist in: (a) improving accountability, governance, and transparency, (b) focusing on strengthening health service delivery through improving health worker performance, including improved productivity, and care quality through a Quality Improvement Program (QIP), and (c) greater targeting and efficiency in the use of public resources for the poorest groups of the population. Component 2 will continue supporting the implementation of the PBF scheme, with emphasis on strengthened data-driven operational decisions leveraging SLUHIS, facility- level planning and reporting functions, and NCD service delivery capacity, including through and introduction of a QIP to improve provider knowledge and patient satisfaction.  An implementation schedule has been developed and will need to be carefully managed, including through the embedded operational evaluation of the pilot. The implementation schedule for the PBF and updated projections for Category 2 expenditures (PBF incentive payments) are critical to determine the extension to the closing date.  To provide a comprehensive set of interventions that can improve NCDs health outcomes, Component 2 will also support demand side interventions, with a focus on improving primary and secondary prevention. 11. A restructuring of the Project is also needed to simplify project activities and align them with the macro fiscal context resulting from the COVID 19 pandemic. The ambitious health financing reforms envisaged under The World Bank Saint Lucia Health System Strengthening Project (P166783) the initial project design were based on fiscal projections prior to the onset of the COVID-19 pandemic. As a result, a recalibration of these activities is required to account for the pandemic’s negative impacts on the macro fiscal context and the limited ability of the government to raise /increase resources for the health sector. The extension period will allow the Government to reassess and accelerate relevant activities to meet the project development objectives by the project closing date. II. DESCRIPTION OF PROPOSED CHANGES 12. The Level II Project Restructuring would consist of the following changes: (a) modification of the components’ scope to support the current government’s UHC priorities; (b) reallocation of credit proceeds across the components to support the updated priorities; (c) update of the Project’s results framework; (d) adjustment of the implementation arrangements; (e) extension of the Project’s closing date by 12 months; and (f) adjustment to the frequency of required project reporting. The safeguards category and safeguards policies triggered would remain unchanged. (a) Modification of the components’ scope: i. Component 1: Supporting Evidence-Based Policy Formulation for UHC (US$4M). The component is simplified, including improved focus, and dropping the former sub-components. Under the revised Component 1, the Project will support capacity building for UHC, including for policy development, regulation, planning, and monitoring/evaluation, thus strengthening stewardship, the policy and regulatory arm. This support is expected to result in: (a) updating the National Health Sector Strategic Plan (NHSSP); (b) development of Health Financing Strategy and Policy (HFSP), including an assessment of financing options for UHC; and (c) drafting of a UHC strategy to provide a coherent and clear framework to guide clinical and financial strategic decision-making. Diagnostic and advisory activities building on previous analytical work, to guide policy development and investment decision related to the health information system will also be conducted to help inform both Component 1 and 2. ii. Component 2: Strengthening Service Delivery at Primary Health Care to Expand UHC (US$13M). This component will support (a) Subcomponent 2.1, Improving Service Delivery of PBF, (b) Subcomponent 2.2, Strengthening Supply and Demand for Health Services for NCDs, and (c) Subcomponent 2.3 Public Health Emergency Preparedness and Response. Under Subcomponent 2.1, Improving Service Delivery of PBF Scheme, the Project will operationalize the PBF pre-pilot launch of the 8 facilities in March 2023 and the scale up to 17 facilities. In addition, Subcomponent 2.1 will finance services to carry out verification and prepare counter-verification reports to ensure the quantity and quality of the services provided by health facilities receiving PBF Payment. The nature of these services is stipulated in the PBF Operations Manual, as well as in the “Performance-Based Financing Counter-Verification Agreement.” No changes are foreseen under Subcomponent 2.2, Strengthening the Supply and Demand of Health Care Services.  Strengthening supply for critical NCDs services will be done through system strengthening activities such as filling supply side gaps identified through a health facility assessment, improving the health information system, and increasing outreach services to reach the most vulnerable population groups. In addition, providers will be equipped with the skills and competencies to implement the latest clinical protocols and ensure a patient centered care system. As part of this component and with the launch of the PBF-scheme, opportunities to introduce a Quality Improvement Program (QIP) have been discussed. An approach has been developed that could be adopted to support the roll-out of the QIP, initially under the PBF Piot to strengthen service The World Bank Saint Lucia Health System Strengthening Project (P166783) quality for the scheme, such as good control of blood pressure, blood sugar and cholesterol, and improved health behaviors through effective counselling. As the PBF scheme matures and the QIP is tested under the pilot, the MOHWEA can build on this experience to mainstream the QIP; to apply it at all levels of care to strengthen service quality for UHC.  Demand side interventions will be added to provide a comprehensive package of interventions to improve NCD-related outcomes. These will include a focus on cost-effective primary and secondary prevention activities, such as awareness raising campaigns in communities and through social media. Subcomponent 2.3, Public Health Emergency Preparedness and Response will remain as is and will continue to support strengthening of surveillance and information systems, laboratory capacity, and preparedness for public health emergencies. iii. Component 3: Institutional Capacity Building, Project Management and Coordination (US$ 3M). This Component will continue financing project implementation activities and needs, including project management, fiduciary tasks and monitoring and evaluation (M&E) associated with supervision of the Project. Greater efforts will be put on building capacity of the MOHWEA to ensure institutional sustainability, including for implementation and maintenance of the PBF scheme which will require greater attention, resources, and capacity building before project closure. iv. Component 4: Contingent Emergency Response Component (US$5.94M). No changes envisioned under this component. As noted above, the CERC has been extended by 6-months with a deadline of June 30, 2023. (b) Changes to Component Costs. The restructuring paper proposes changes to the component costs as follows: reducing the amount allocated to Component 1. Supporting Evidence-based Policy Formulation for UHC, a by US$1.5 million, to a new component total amount of US$4 million; a within component reallocation for Component 2. Strengthening Service Delivery at PHC to Expand UHC, involving a reallocation of US$2 million from Subcomponent 2.3 to Subcomponent 2.2; and doubling the allocations to Component 3 for project implementation and institutional capacity building. These proposed reallocations are reflected in the tables below. Table 1: Proposed reallocation of IDA credit proceeds between components and subcomponents to accommodate the GOSTL’s UHC priorities Project Parent Project Restructured Project components Project cost IDA PEF Project cost IDA PEF Component 1 5.5 5.5 4 4 Component 2 13 13 13 13 Component 3 1.5 1.5 3 3 Component 4 5.94 5 0.94 5.94 5 0.94 Table 2: Proposed Revision of Project Costs by Component and Sub-Component Parent Project Cost Restructured Project Cost Design and Implementation of an Supporting Evidence-Based US$4M Component 1 US$5.5M Essential Benefits Package Policy Formulation for UHC ↓ Subcomponent Review of the Essential Benefits US$1M Dropped N/A 1.1 Package The World Bank Saint Lucia Health System Strengthening Project (P166783) Subcomponent Implementation of the Essential US$4.5M Dropped N/A 1.2. Benefits Package Strengthening Service Delivery in Strengthening Service Component 2 Support of the Essential Benefits US$13M Delivery at PHC to Expand US$13M Package UHC Subcomponent Improving Service Delivery through US$4M Title Unchanged US$4M 2.1. Performance-Based Financing (PBF) Strengthening the Supply Subcomponent Strengthening the Supply of Health US$6.5M US$4.5M and Demand of Health Care 2.2. Care Services ↑ Services Subcomponent Public Health Emergency US$2.5M US$4.5M Title Unchanged 2.3 Preparedness and Response ↓ Institutional Capacity Building, US$3M Component 3 Project Management and US$1.5M Unchanged ↑ Coordination Contingent Emergency Response Component 4 US$5.94M Title Unchanged US$5.94M Component (CERC) (c) Update of project’s results framework: The Results Framework has been revised to (a) ensure that the indicators reflect the simplified project design and capture the updated project components to track progress towards the PDO; (b) replace indicators for activities that have been dropped and indicators with inadequate data quality; and (c) reflect targets based on feasibility analysis for each indicator and the assessment of the MOHWEA’s capacity to make progress on the activities. Detailed changes, including the rationale for new, revised, and dropped indicators are outlined in the Results Framework. (d) Adjustment of the implementation arrangements Changes to Institutional Arrangements. To strengthen the institutional arrangements, a Project Steering Committee will (a) provide strategic guidance to support the development of policy frameworks, institutional and operational aspects of complex health sector reforms; (b) brief the Parliament, Cabinet and Prime Minister’s office as requested on strategic updates, progress review or in response to any queries from government leadership for World Bank projects (c) ensure the timely preparation of the Project Annual Work Plans and Budget and Project Progress Reports; and (d) ensure project implementation adheres to the World Bank guidelines and procedures as well as the law/regulations of Saint Lucia. The Project Steering Committee will meet quarterly to review implementation progress, facilitate key decisions that affect project implementation at both the PIU and Government level, and provide guidance on the management of implementation bottlenecks. Finally, to ensure quality oversight of technical outputs, the Committee will oversee technical sub-committees or working groups with relevant expertise to provide technical feedback and approval of deliverables under the different consultancies. The Bank team highlighted the possible risks with creating many sub-committees as it runs the risk of fragmentation, delays in decision making and implementation. To mitigate this risk, the Bank team has recommended more frequent updates to the Steering Committee and improve overall communication efforts through monthly newsletters and more frequent engagement with relevant Ministry staff. The updated TOR for the Project Steering Committee will be included in the updated the Project Operational Manual and shall be reviewed and updated as necessary to ensure effective project oversight. The legal agreements will also be amended to refer to the Project Steering Committee. Moreover, with PBF being the first phase of the UHC reform, the implementation arrangements take into The World Bank Saint Lucia Health System Strengthening Project (P166783) account the need for close coordination and collaboration between the PBF Coordinator and the UHC Unit to strengthen the link between Component 1 and Component 2. The dotted line represents the coordination function, which aims to maximize the project’s development impact, including sustainability. The updates also highlight the importance of coordinated development of the management information system for the PBF scheme, together with the HMIU, to ensure its scalability and interoperability, and to support data-driven decision-making in the MOHWEA. Figure: Revised institutional arrangements i) Changes to implementation arrangements related to Performance-Based Financing Payments under sub- component 2.1. Under the Project legal agreements, the Recipient, through the MOHWEA, shall hire and maintain throughout Project implementation, an independent Counter-verification Agency (CVA) to be responsible for verifying the quantity and quality of services provided under Part 2.1 of the Project. Signing and effectiveness of the agreement with the Counter-verification Agency is a condition for disbursements of PBF Payments. The Recipient has proposed that verification services will be provided by two national entities: the Recipient’s Office of the Director of Audit and the Saint Lucia Bureau of Standards (SLBS). Following a World Bank Fiduciary assessment of procurement and financial management regulations and policies, the Bank is satisfied that the Office of the Director of Audit and the Saint Lucia Bureau of Standards (SLBS) has the capacity to carry out the verification services. Specifically, the Office of the Director of Audit has a solid grounding within the Constitution and is responsible for both central Government and extrabudgetary units. The Office of Director of Audit conducts all forms of audits including compliance, financial and performance audits and has a dedicated team for performance audits. The Office of Director of Audit continues to be responsible for auditing all World Bank projects in St Lucia and the majority of the The World Bank Saint Lucia Health System Strengthening Project (P166783) audit reports are tabled at the Parliamentary level. It is important to note that the Office of the Director of Audit is independent and has the capacity to deliver effective and important audits, however given scarcity of human resources available, the project could provide “in-kind” support which may include hiring consultants, procurement of software and office equipment. These items would be procured by the PIU based on input requirements defined in a work plan, submitted by the Director of Audit and the Chief Executive of the SLBS. Finally, the assessment concluded that the World Bank will not pay audit fees, given the support is to complement existing capacities and to build overall country systems to boost institutional capacity. The Project will only finance consulting services to be procured by the PIU in accordance with the Bank Procurement Regulations (as these have been defined in the legal agreements). The legal agreements will be updated to reflect this shift in the provider of the verification services for PBF Payments. (e) Extension of the project closing date 13. Due to the implementation delays associated with COVID-19 and previous project management challenges, a 12-month extension of the current closing date from October 31, 2023, to October 31, 2024, is requested. This would be the first extension in closing date and is needed to attain the PDO and full disbursement. Other changes proposed under this restructuring are expected to make implementation more efficient. (f) Update Frequency of Project Reports 14. The number of Project Reports has been modified to twice a year rather than four times a year which was deemed too cumbersome. This change will be reflected in the amended Financing Agreements and in the updated Project Operations Manual. III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Legal Covenants ✔ Implementing Agency ✔ DDO Status ✔ The World Bank Saint Lucia Health System Strengthening Project (P166783) Project's Development Objectives ✔ PBCs ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) Component 1: Design and Component 1: Supporting Implementation of an Essential 5.50 Revised Evidence-Based Policy 4.00 Health Services Package Formulation for UHC Component 2: Strengthening Component 2: Strengthening Service Delivery in Support of the 13.00 Revised Service Delivery at Primary 13.00 Essential Package of Health Health Care to Expand UHC Services The World Bank Saint Lucia Health System Strengthening Project (P166783) Component 3: Institutional Component 3: Institutional Capacity Building, Project 1.50 Revised Capacity Building, Project 3.00 Management and Coordination Management and Coordination Component 4: Contingent Component 4: Contingent 5.94 No Change Emergency Response 5.94 Emergency Response Component Component TOTAL 25.94 25.94 OPS_DETAILEDCHANGES_LOANCLOSING_TABLE LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications IDA-63160 Effective 31-Oct-2023 31-Oct-2024 28-Feb-2025 IDA-67290 Effective 31-Oct-2023 31-Oct-2024 28-Feb-2025 TF-B4523 Closed 31-Jan-2021 14-Apr-2021 OPS_DETAILEDCHANGES_LEGCOV_TABLE LEGAL COVENANTS Loan/Credit/TF Description Status Action Section I. Implementation Arrangements. A. 2. (a). MOHW Project Implementation Unit ("MOHW-PIU"). The Recipient shall maintain at all times until the completion of the Project the MOHW-PIU within MOHW, with staff, terms of reference, mandate and IDA-63160 resources satisfactory to the Association; including a Complied with No Change Project Manager, a PBF Coordinator, a financial management specialist, a procurement specialist, and a monitoring and evaluation specialist, all with experience, qualifications, expertise and terms of reference acceptable to the Association. Section III.B.1(b) of Schedule 2: Notwithstanding the - provisions of Part A above, no withdrawal shall be made Expected soon Revised under Category (2) unless the Association has received The World Bank Saint Lucia Health System Strengthening Project (P166783) adequate evidence that: (i) the first two Management Agreements have been signed and are in effect; (ii) the Service Contract has been signed and is in effect; (iii) the first Verification Report has been completed; and (iv) the PBF Manual has been adopted; all in form and substance satisfactory to the Association. Section III.B of Schedule 2:Original Financing Agreement is amended: under Category (2) until and unless the Association has received adequate evidence that: (a) the four Management Agreements have been signed Proposed SOON and are in effect; (b) the PBF Counter Verification Agreement has been signed and is in effect (c) the PBF OM has been adopted; all in form and substance satisfactory to the Association - Section III.B.1(c) of Schedule 2: Notwithstanding the Complied with No Change provisions of Part A above, no withdrawal shall be made for Emergency Expenditures under Category (3), unless and until the Association is satisfied, and has notified the Recipient of its satisfaction, that all of the following conditions have been met in respect of said expenditures: (i) the Recipient has determined that an Eligible Emergency has occurred, has furnished to the Association a request to include the proposed activities in the Emergency Response Part in order to respond to said emergency, and the Association has agreed with such determination, accepted said request and notified the Recipient thereof; (ii) the Recipient has ensured that all safeguard instruments required for said activities have been prepared and disclosed, and the Recipient has ensured that any actions which are required to be taken under said instruments have been implemented, all in accordance with the provisions of Section I.F of this Schedule; (iii) the entities in charge of coordinating and implementing the Emergency Response Part have adequate staff and resources, in accordance with the provisions of Section I.F of this Schedule, for the purposes of said activities; and (iv) the Recipient has adopted the CERC Manual, in form and substance acceptable to the Association, and the provisions of the CERC Manual remain - or have been updated in accordance with the provisions of Section I.F The World Bank Saint Lucia Health System Strengthening Project (P166783) of this Schedule so as to be - appropriate for the inclusion and implementation of the Emergency Response Part. . The World Bank Saint Lucia Health System Strengthening Project (P166783) . Results framework COUNTRY: St. Lucia Saint Lucia Health System Strengthening Project Project Development Objectives(s) The development objective is to improve the accessibility, efficiency, and responsiveness of key health services, and provide a response in the event of eligible crises or emergencies. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Component 1: Supporting Evidence-Based Policy Formulation for UHC (Action: This Objective has been Revised) Draft Health Financing Policy & Strategy developed for public consultations and published on No Yes MOHWEA website (Yes/No) (Yes/No) Action: This indicator is New Number of people registered under the National Health 0.00 0.00 0.00 60,000.00 80,000.00 100,000.00 Scheme (Number) Action: This indicator has been Marked for Deletion Number of people registered under the 0.00 0.00 0.00 30,000.00 40,000.00 50,000.00 National Health Scheme (women) (Number) The World Bank Saint Lucia Health System Strengthening Project (P166783) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator has been Marked for Deletion Strengthening Service Delivery at Primary Health Care to Expand UHC (Action: This Objective has been Revised) Percentage of persons in the ATP living with Hypertension who are managed by the PBF 0.00 0.00 0.00 0.00 0.00 60.00 facilities, according to OM protocols (Percentage) Action: This indicator has been Revised Percentage of persons in the ATP living with Hypertension who are managed by the PBF 0.00 0.00 0.00 0.00 0.00 60.00 facilities, according to OM protocols (women) (Percentage) Action: This indicator has been Revised Percentage of persons in the ATP living with Diabetes who are managed by the PBF 0.00 0.00 0.00 0.00 0.00 60.00 facilities, according to OM protocols (Percentage) Action: This indicator has been Revised Percentage of persons in 0.00 0.00 0.00 0.00 0.00 60.00 the ATP living with Diabetes The World Bank Saint Lucia Health System Strengthening Project (P166783) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 who are managed by the PBF facilities, according to OM protocols (women) (Percentage) Action: This indicator has been Revised The development objective is to improve the responsiveness of key health services Compliance with 2005 International Health Regulations (IHR) by maintaining a trained Rapid Yes Yes Yes Yes Yes Yes Response Team (RRT) to respond to events that may constitute a public health emergency (Yes/No) Action: This indicator has been Revised Number of designated laboratories with COVID-19 1.00 1.00 diagnostic equipment, test kits, and reagents (Number) Action: This indicator has been Revised PDO Table SPACE The World Bank Saint Lucia Health System Strengthening Project (P166783) Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Component 1. Supporting Evidence-based Policy Formulation for Universal Health Coverage (Action: This Component has been Revised) Essential package of benefits formally adopted and reviewed No No No Yes Yes Yes on an annual basis (Yes/No) Action: This indicator has been Marked for Deletion Primary care service utilization rates (public health sector) 37,320.00 40,000.00 45,000.00 50,000.00 55,000.00 55,000.00 (Number) Action: This indicator has been Marked for Deletion Primary care service utilization rates (public 44,447.00 45,000.00 50,000.00 55,000.00 60,000.00 60,000.00 health sector) (women) (Number) Action: This indicator has been Marked for Deletion Percentage of Primary Health Care (PHC) facilities that have implemented exit surveys with 0.00 0.00 0.00 0.00 0.00 60.00 service users in a one-year period and presenting results to the MOHW (Percentage) Action: This indicator has been Revised Component 2. Strengthening Service Delivery at Primary Health Care Facilities to Expand UHC (Action: This Component has been Revised) The World Bank Saint Lucia Health System Strengthening Project (P166783) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Number of public primary care health facilities equipped for 0.00 5.00 0.00 0.00 0.00 30.00 diabetes and hypertension management (Number) Action: This indicator has been Revised Number of public sector providers registered under the 0.00 0.00 0.00 0.00 0.00 17.00 PBF scheme (Number) Action: This indicator has been Revised Number of persons in the ATP not diagnosed with Hypertension screened at the 400.00 0.00 0.00 0.00 0.00 15,000.00 PBF participating facilities based on national protocols (Number) Action: This indicator has been Revised Number of persons in the ATP not diagnosed with Hypertension screened at the PBF participating 0.00 0.00 0.00 0.00 0.00 7,500.00 facilities based on national protocols (women) (Number) The World Bank Saint Lucia Health System Strengthening Project (P166783) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator has been Revised Number of persons in the ATP not diagnosed with diabetes screened at the PBF 200.00 0.00 0.00 0.00 0.00 10,000.00 participating facilities based on national protocols (Number) Action: This indicator has been Revised Number of persons in the ATP not diagnosed with diabetes screened at the 0.00 0.00 0.00 0.00 0.00 5,000.00 PBF participating facilities based on national protocols (Women) (Number) Action: This indicator has been Revised Percentage of Primary Health Care facilities participating in the Performance Based Financing (PBF) scheme that 0.00 0.00 0.00 0.00 0.00 60.00 have developed an action plan based on the results of the quarterly satisfaction surveys (Percentage) Action: This indicator has been Revised The World Bank Saint Lucia Health System Strengthening Project (P166783) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Number of diabetes and hypertension outreach campaigns successfully 0.00 40.00 conducted by public primary health facilities (Number) Action: This indicator is New Component 4. Contingent Emergency Response Component Number of equipped health facilities with isolation capacity 0.00 1.00 (Number) Action: This indicator has been Revised IO Table SPACE The World Bank Saint Lucia Health System Strengthening Project (P166783)