The World Bank Health System Performance Reinforcement Project (P156679) REPORT NO.: RES42463 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SYSTEM PERFORMANCE REINFORCEMENT PROJECT APPROVED ON MAY 3, 2016 TO THE REPUBLIC OF CAMEROON HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Ousmane Diagana Country Director: Abdoulaye Seck Regional Director: Dina Ringold Practice Manager/Manager: Magnus Lindelow Task Team Leader(s): Yohana Dukhan The World Bank Health System Performance Reinforcement Project (P156679) ABBREVIATIONS AND ACRONYMS CERC Contingency Emergency Response Component CRI Corporate results indicator CRVS Civil Registration Vital Statistics CTN Cellule Technique Nationale DTP Diphtheria, tetanus toxoid and pertussis GFF Global Financing Facility HMIS Health Management Information System HNP Health, Nutrition and Population HSPRP Health System Performance Reinforcement Project IP Implementation progress IRI Intermediate results indicators ISR Implementation Status Report M&E Monitoring and evaluation PBF Performance-based financing PDO Project Development Objective RBF Results-based financing RMNCH Reproductive, maternal, neonatal and child health The World Bank Health System Performance Reinforcement Project (P156679) BASIC DATA Product Information Project ID Financing Instrument P156679 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 03-May-2016 31-Dec-2022 Organizations Borrower Responsible Agency Republic of Cameroon Ministry of Public Health,MINSANTE Project Development Objective (PDO) Original PDO The proposed Project Development Objective (PDO) is to increase utilization and improve the quality of health services with a particular focus on reproductive, maternal, child and adolescent health and nutrition services. Current PDO The new Project Development Objective (PDO) is to: (i) increase utilization and improve the quality of health services with a particular focus on reproductive, maternal, child and adolescent health, and nutritional services for the population of Cameroon, including refugees and refugee host communities, and (ii) in the event of an Eligible Emergency, to provide immediate and effective response to said Eligible Emergency OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-62250 01-May-2018 17-Dec-2018 18-Jun-2019 31-Dec-2022 6.00 2.29 3.41 The World Bank Health System Performance Reinforcement Project (P156679) IDA-D3000 01-May-2018 17-Dec-2018 18-Jun-2019 31-Dec-2022 30.00 0 29.03 IDA-57900 03-May-2016 14-Sep-2016 13-Dec-2016 31-Dec-2022 100.00 46.56 54.11 TF-A2177 03-May-2016 14-Sep-2016 13-Dec-2016 31-May-2021 27.00 6.59 20.41 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Project Summary 1. The Health System Performance Reinforcement Project (HSPRP) is a USD 163 million operation, comprised of USD 106 million IDA credit, USD 27 million Global Financing Facility grant and USD 30 million IDA18 Refugee Sub-window grant. The HSPRP was approved in May 2016; became effective on December 13, 2016 with an original project closing date of May 31, 2021. It is an IPF project supporting the scale-up of Performance-Based Financing (PBF) at the national level in the health sector. This project includes an Additional Financing (USD 36 million) approved by the Board on May 1, 2018 and became effective on June 18, 2019, with a revised project closing date of December 31, 2022. 2. With the Additional Financing, the revised Project Development Objective (PDO) is to increase utilization and improve the quality of health services with a particular focus on reproductive, maternal, child and adolescent health, and nutritional services for the population of Cameroon, including refugees and refugee host communities, and (ii) in the event of an Eligible Emergency, to provide immediate and effective response to said Eligible Emergency.” The project is comprised of two components that aim to improve performance of the health sector: (i) strengthening of health service delivery; and (ii) institutional strengthening for improved health system performance. 3. The May 2019 mid-term review mission conducted a complete review of the implementation and results of HSPR in the view to monitor progress and take decisions on course corrections to reinforce the achievement of the PDO in its remaining years. This review provides the basis for the proposed restructuring and proposes a revision of the results framework and an extension of the closing date of the Global Financing Facility (GFF) Trust Fund to December 31, 2022 to align it to the revised closing date of the project. With the recent activation of the Contingency Emergency Response Component (CERC), this restructuring also includes a reallocation of funds between disbursement categories. B. Project Status 4. The rating of the PDO has been rated Moderately Satisfactory (MS) in the last two Implementation Status Reports (ISRs) dated July 28, 2019 and February 4, 2020 given slow progress in some of PDO level indicators (e.g number of children under 24 months being weighted for growth monitoring in the three Northern regions and East) but more importantly in a number of intermediate level indicators (e.g percentage of pregnant women receiving at least 4 antenatal care visits in the 3 Northern regions and East, number of adolescent girls aged 10-19 years benefiting from multi-sectoral services supported by the GFF investment case, number of consultations provided to the poor The World Bank Health System Performance Reinforcement Project (P156679) and vulnerable free of charge, percentage of facilities with 100 percent tracer drugs available in targeted health facilities on the day of the visit). 5. The rating for the overall implementation progress (IP) of the project remained in February 2020 Moderately Unsatisfactory (MU). This rating was justified by the ongoing challenges faced, since March 2018, in the renewal of the staff of the CTN-PBF, which also resulted in difficulties in procurement, financial management, environmental and social safeguards. This rating is expected to remain to MU in the next ISR (August 2020) given the low performance of the CTN-PBF in financial management. 6. The audit status of the project is up to date. The 2019 audit report of the project has been submitted to the Bank on June 12, 2020. The reports comply with World Bank audit guidelines and international auditing standards. A set of recommendations has been sent to the CTN-PBF on July 6, 2020. As of July 8, the disbursement rate on the project is 34 percent but this rate is expected to increase significantly in the coming months with the implementation of the additional financing activities. There is a 15 months inactive designated (DA-DD) with a balance of XAF 1,398,646,382 (eq USD 2,439,365.17) not accounted for. The team is following up with the PIU to clear this situation by September 2020. C. Rationale for restructuring 7. The restructuring follows the official request No 000001038 made by the government of Cameroon on March 19, 2020. This is in line with the Bank’s guidance that allows deferral of restructuring by six months after CERC activation. The restructuring proposes the following revisions to improve the implementation and results of the HSPRP: (i) Reallocate funds disbursement categories following the activation of the CERC component to ensure that there are funds to support the COVID-19 response activities. The replenishment of the CERC will be sought through an Additional Financing which will be prepared in September FY21; (ii) Revise the closing date of the GFF Trust Fund (TF-A2177) of May 31, 2021 to align it with the revised date of the Af of the HSPRP closing date of December 31, 2022; (iii) Revise the results framework to improve the relevance of the monitoring and evaluation (M&E) to track changes supported by the project, align indicators with the new list of CRIs and add an indicator to reflect CERC results. II. DESCRIPTION OF PROPOSED CHANGES 8. The restructuring paper proposes the three changes below: (i) Reallocation of funds between disbursement categories 9. The restructuring proposes the following changes to amend the disbursement table for the Credit (page 18) in the Additional Financing for the Health System Performance Reinforcement Project Financing Agreement: The World Bank Health System Performance Reinforcement Project (P156679) Reallocation of 5,000,000 EUR from Category 1 (“Performance-based payments under Parts A.1, A.2(a), A.4 and Part C.1 of the Project”) to Category 3 (“emergency expenditures under Part D of the Project”) to support the COVID-19 response activities of the national COVID-19 response plan. Proposed changes in the allocation of the amount of Credit to each category Category Original amount Re-allocated amount Revised Amount of the Percentage of of the Credit (expressed in Euros) allocated Grant expenditures to Allocated amount Allocated be financed (expressed in (expressed in (expressed in (inclusive of taxes) Euros) Euros) SDR) (1) Performance-Based 5,000,000 -5,000,000 0 17,300,000 100% of Payments under Parts Performance- A.1, A.2(a), A.4 and Part Based Payments C.1 of the Project (2) Goods, consultants’ 0 3,500,000 100% services and Operating Costs for the Project except Parts A.1, A.2(a), A.4 and Part C.1 of the Project (3) Emergency Expenditures 0 +5,000,000 5,000,0001 0 100% under Part D of the Project TOTAL AMOUNT 5,000,000 5,000,000 20,800,000 10. The HSPRP Additional Financing, through the CERC activation on March 27, 2020 has provided a critical funding package to finance the rehabilitation of health facilities, purchase medical equipment, other commodities and supplies required to deal with the emergency. A first batch of medical equipment which includes ventilators, thermoflash, defibrillators, COVID-19 testing kits and protective equipment has been delivered to the Government of Cameroon in April and May 2020 through a UNDP procurement funded by the World Bank and the Global Fund. Additional batches are expected to be ordered and delivered in the coming weeks. (ii) Revision of the closing date of the GFF Trust Fund (TF-A2177) 11. The restructuring proposes to revise the initial closing date of the GFF Trust Fund (TF-A2177) of May 31, 2021 to December 31, 2022 to align it with the revised date of the AF of the HSPRP. (iii) Revision of the results framework 12. The restructuring proposes the following revisions to the results framework:  Revision of PDO-level indicators: Indicator Action Rationale People who have received essential health, New This indicator and its subset indicators are marked as “New. It will nutrition, and population (HNP) services (CRI, now be tagged in the system as corporate results indicator. Number) 1The US$5 million amount in Euro is as indicated in the Financing Agreement. The US$ 6 million is provided by the system at the exchange rate prevailing at the time of the Loan agreement. The World Bank Health System Performance Reinforcement Project (P156679) People who have received essential health, Delete This indicator has been deleted and re-created above with the right nutrition, and population (HNP) services (CRI, tag. Number) Children 12-23 months fully immunized in the 3 Delete This indicator will be dropped since there is no national survey data Northern regions (Far North, North and to track them regularly. Adamawa) and the East (Percentage) Birth attended by a skilled professional in the 3 Delete This indicator will be dropped since there is no national survey data Northern regions (Adamawa, North and Far to track them regularly. North) and the East (Percentage) Children under 24 months being weighed for Delete Since it is a subset of the nutrition services in PDO indicator 1, this growth monitoring in the 3 Northern regions indicator will be deleted and moved to the section on intermediate (Adamawa, North and Far North) results indicator. Direct project beneficiaries Delete these two indicators will be dropped due to the difficulties Female beneficiaries Delete encountered in measuring them and because they are no longer part of the list of Corporate Results Indicators. Refugees who have received health care Revise This indicator has been edited to have the name of the regions (curative and preventive) at health facilities in consistent with the other indicators. the three Northern regions (Adamawa, North and Far North) and the East Number of acceptors of modern contraception New this indicator will capture the reproductive health dimension in the PDO; it is the number of acceptors of the following modern contraceptives in the PBF portal (pill, injectable and implant). The target for this indicator will be set to 1,292,020. Number of acceptors of modern contraception New this indicator captures the adolescent health dimension in the PDO among adolescents and the target will be set to 100,865.  Revision of intermediate results indicators (IRIs): Indicator Action Rationale People who have received essential health, Delete This indicator and its subset indicators have been deleted and re- nutrition, and population (HNP) services (CRI, created in the PDO section above with the right tag. Number) Number of pregnant women receiving at least 4 Revise It is suggested to measure indicators as numbers instead of antenatal care visits in the 3 Northern regions percentage since the latter require survey data. Hence, “Number” and the East (Number) will be used for this indicator for which data is available in the PBF portal. The target for this indicator will be set to 814,656. Adolescent girls 10-19 years benefiting from Delete This indicator is vague and difficult to measure. multisectoral services supported by the GFF Investment Case Women 15-49 using modern contraceptive Delete Percentage requires survey so it is suggested to use ‘Number’ for methods in the 3 Northern regions and the East which data is available in the PBF portal (pill, injectable, implant are (Percentage) reported). This indicator will be replaced by the Number of acceptors of modern contraception in the PDO indicator section to capture reproductive health dimension in the PDO. Children aged 6-59 months who received a Revise The previous target was underestimated and has been met. It will be vitamin A supplement in the last six months” revised from 504,286 to 3,128,788. Number of children 24 months being weighed New This indicator will be moved from the PDO indicator section since it is for growth monitoring in the three Northern a subset of the nutrition services in PDO indicator 1. The target will regions (Adamawa, North and Far North) be set to 3,689,641. Patients/people referred to the health facilities Revise The target has already been reached and will be revised from 343,890 by community health workers to 1,403,217. The World Bank Health System Performance Reinforcement Project (P156679) Number of COVID-19 designated health care New This indicator will reflect the activities financed under the CERC facilities with required equipment for treatment component. The target will be set to 11 as per the approved COVID- of critical patients as per approved national 19 response plan. protocol III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Reallocation between Disbursement Categories ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ PBCs ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ The World Bank Health System Performance Reinforcement Project (P156679) 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) Strengthening of Health Service Strengthening of Health 130.00 Revised 124.00 Delivery Service Delivery Institutional Strengthening for Institutional Strengthening for Improved Health System 23.00 No Change Improved Health System 23.00 Performance Performance Strengthening emergency, sexual Strengthening emergency, and reproductive health services, sexual and reproductive health and water, sanitation and services, and water, sanitation hygiene and nutrition service 10.00 No Change and hygiene and nutrition 10.00 delivery for refugee and host service delivery for refugee and populations in the northern and host populations in the East regions northern and East regions Contingent Emergency Response Contingent Emergency 0.00 Revised 6.00 Component Response Component TOTAL 163.00 163.00 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-57900 Effective 31-May-2021 31-Dec-2022 IDA-62250 Effective 31-Dec-2022 IDA-D3000 Effective 31-Dec-2022 TF-A2177 Effective 31-May-2021 31-Dec-2022 30-Apr-2023 OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) The World Bank Health System Performance Reinforcement Project (P156679) Current Proposed IDA-62250-001 | Currency: EUR iLap Category Sequence No: 1 Current Expenditure Category: PERF-BASED PAYMNT PRT A1,A2a,A4,C1 5,000,000.00 0.00 0.00 100.00 100.00 iLap Category Sequence No: 2 Current Expenditure Category: GD,CS,TR,OC EXCEPT PRT A1,A2a,A4,C1 0.00 0.00 0.00 100.00 100.00 iLap Category Sequence No: 3 Current Expenditure Category: EMERGENCY EXPENDITURES PRT D 0.00 0.00 5,000,000.00 100.00 100.00 Total 5,000,000.00 0.00 5,000,000.00 . The World Bank Health System Performance Reinforcement Project (P156679) . Results framework COUNTRY: Cameroon Health System Performance Reinforcement Project Project Development Objectives(s) The new Project Development Objective (PDO) is to: (i) increase utilization and improve the quality of health services with a particular focus on reproductive, maternal, child and adolescent health, and nutritional services for the population of Cameroon, including refugees and refugee host communities, and (ii) in the event of an Eligible Emergency, to provide immediate and effective response to said Eligible Emergency Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline End Target Increase utilization and improve the quality of health services People who have received essential health, nutrition, and 0.00 6,020,987.00 population (HNP) services (CRI, Number) Action: This indicator is New People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) (CRI, 0.00 4,216,408.00 Number) Action: This indicator is New Number of children immunized (CRI, Number) 0.00 737,048.00 Action: This indicator is New Number of women and children who have received basic 0.00 4,570,560.00 nutrition services (CRI, Number) Action: This indicator is New Number of deliveries attended by skilled health personnel 0.00 713,379.00 (CRI, Number) The World Bank Health System Performance Reinforcement Project (P156679) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline End Target Action: This indicator is New People who have received essential HNP services (Number) 0.00 6,020,987.00 Action: This indicator has been Marked for Deletion Children 12-23 months fully immunized in the 3 Northern regions 68.00 80.00 and the East (Percentage) Action: This indicator has been Marked for Deletion Births attended by a skilled professional in the 3 Northern 37.60 55.00 regions and the East (Percentage) Action: This indicator has been Marked for Deletion Average score of the quality of care checklist (Percentage) 30.00 50.00 Children under 24 months being weighed for growth monitoring in the 3 northern regions (Adamaoua, North, Far north) and the 0.00 1,646,480.00 East (Number) Action: This indicator has been Marked for Deletion Direct project beneficiaries (Number) 0.00 8,267,467.00 Action: This indicator has been Marked for Deletion Female beneficiaries (Number) 0.00 4,216,408.00 Action: This indicator has been Marked for Deletion Number of refugees who have received healthcare (curative and preventive) at health facilities in the three Northern regions 0.00 600,000.00 (Adamawa, North and Far North) and the East (Number) Rationale: Action: This indicator has been Revised This indicator has been edited to have the name of the regions consistent with the other indicators. The World Bank Health System Performance Reinforcement Project (P156679) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline End Target Number of acceptors of modern contraception in the three Northern regions (Adamawa, North and Far North) and the East 4,232.00 1,292,020.00 (Number) Rationale: This indicator will capture the reproductive health dimension in the PDO; it is the cumulative number of acceptors of the Action: This indicator is New following modern contraceptives in the PBF portal (pill, injectable and implant). Number of acceptors of modern contraception among adolescents in the three Northern regions (Adamawa, North 0.00 100,865.00 and Far North) and the East (Number) Rationale: Action: This indicator is New This indicator captures the adolescent health dimension in the PDO. PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Strengthening of Health Service Delivery People who have received essential health, nutrition, and 0.00 6,020,987.00 population (HNP) services (CRI, Number) Action: This indicator has been Marked for Deletion People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) (CRI, 0.00 4,216,408.00 Number) The World Bank Health System Performance Reinforcement Project (P156679) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Action: This indicator has been Marked for Deletion Number of children immunized (CRI, Number) 0.00 737,048.00 Action: This indicator has been Marked for Deletion Number of women and children who have received basic 0.00 4,570,560.00 nutrition services (CRI, Number) Action: This indicator has been Marked for Deletion Number of deliveries attended by skilled health personnel 0.00 713,379.00 (CRI, Number) Action: This indicator has been Marked for Deletion Number of pregnant women receiving at least 4 antenatal care visits in the three Northern regions (Adamawa, North and Far 0.00 814,656.00 North) and the East (Number) Rationale: Action: This indicator has been Revised “Number” will be used for this indicator instead of "Percentage" for which data is available in the PBF portal Adolescent girls 10-19 years benefiting from multisectoral 0.00 150,000.00 services supported by the GFF Investment Case (Number) Action: This indicator has been Marked for Deletion Women 15-49 using modern contraceptive methods in the 3 12.80 22.00 Northern regions and the East (Percentage) Action: This indicator has been Marked for Deletion Number of children aged 6-59 months who received a vitamin A 0.00 3,128,788.00 supplement in the last six months (Number) Action: This indicator has been Revised The World Bank Health System Performance Reinforcement Project (P156679) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Number of children under 24 months being weighed for growth monitoring in the three Northern regions (Adamawa, North, Far 0.00 3,689,641.00 North) and the East (Number) Rationale: Action: This indicator is New This indicator will moved from the PDO indicator section since it is a subset of the nutrition services in PDO indicator 1. Number of consultations provided to the poor and vulnerable 0.00 1,502,057.00 free of charge (Number) Patients/people referred to the health facilities by community 0.00 1,403,217.00 health workers (Number) Action: This indicator has been Revised Percentage of the national population covered by the PBF 25.00 95.00 program (Percentage) Strengthening emergency, sexual and reproductive health services, and water, sanitation and hygiene and nutrition service delivery for refugee and host populations in the northern and East regions Number of children and pregnant women dewormed (Number) 0.00 3,542,000.00 Number of refugee children and pregnant women dewormed 0.00 637,000.00 (Number) Institutional Strengthening for Improved Health System Performance Percentage of facilities with 100% tracer drugs available in 20.00 40.00 targeted health facilities on the day of the visit (Percentage) Percentage of reported maternal deaths audited in PBF districts 0.00 25.00 (Percentage) Contingent Emergency Response Component (Action: This Component is New) The World Bank Health System Performance Reinforcement Project (P156679) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Number of COVID-19 designated healthcare facilities with required equipment for treatment of critical patients as per 0.00 11.00 approved national protocol (Number) Rationale: Action: This indicator is New This indicator will reflect the COVID-19 response activities financed under the CERC component. IO Table SPACE The World Bank Health System Performance Reinforcement Project (P156679)