62772 v1 Document of THE WORLD BANK Report No: RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF DECENTRALIZED HEALTH SYSTEM DEVELOPMENT PROJECT MDTF-NS GRANT NO. TF057324 TO THE GOVERNMENT OF NATIONAL UNITY REPUBLIC OF THE SUDAN June 9, 2011 1 2 Regional Vice President: Obiageli Katryn Ezekwesili Country Director: Ian Banon Sector Manager / Director: Ritva Reinikka/Eva Jarawan Task Team Leader: Isabel Soares ABBREVIATIONS AND ACRONYMS MDTF-NS MULTI-DONOR TRUST FUND-NORTH SUDAN (NATIONAL) PDO PROJECT DEVELOPMENT OBJECTIVE HMIS HEALTH INFORMATION MANAGEMENT SYSTEM RH REPRODUCTIVE HEALTH OC OVERSIGHT COMMITTEE ITN INSECTICIDE-TREATED NET OPC OUTPATIENT CONSULTATION ANC ANTENATAL CARE NHA NATIONAL HEALTH ACCOUNTS EOC EMERGENCY OBSTETRIC CARE MWMP MEDICAL WASTE MAGAMENT PLAN SHHS SUDAN HOUSEHOLD SURVEY 3 REPUBLIC OF THE SUDAN CONTENTS Page PROJECT DATA................................................................................................................ 5 SUMMARY ........................................................................................................................ 7 PROJECT STATUS ………………………………………………………………………7 PROPOSED CHANGES ………………………………………………………………… 9 ANNEX 1: RESULTS FRAMEWORK AND MONITORING ....................................... 11 4 a. Project Data Restructuring Status: Restructuring Type: Level II (Extension of closing date) Last modified on date : August 30, 2010 1. Basic Information Country Sudan Task Team Leader Isabel Cristina Soares Sector Manager/Director Eva Jarawan Country Director Ian Bannon Original Board Approval Date August 29, 2006 Original Closing Date: December 31, 2009 Current Closing Date June 30, 2011 Proposed Closing Date [if applicable] June 30, 2012 EA Category B-Partial Assessment Revised EA Category B-Partial Assessment EA Completion Date August 12, 2008 Revised EA Completion Date Revised Financing Plan (US$) Original Revised Source (P098483) (P123495) Government of National Unity, Sudan 13.0 million 5.2 million Muli-Donor Trust Fund- North Sudan (MDTF-NS) 6.0 million 12.0 million Total 19.0 million 15.2 million Borrower Organization Department Location Ministry of Finance and Sudan National Economy Implementing Agency Organization Department Location Federal Ministry of Health Planning Dept Sudan, Khartoum 5 6 5. Disbursement Estimates (US$ m) Actual amount disbursed as of 05/31/2011 Fiscal Year Annual Cumulative 2011 0.448 7.802 2010 2.568 7.354 2009 2.406 4.786 2008 0.787 2.380 2007 1.593 1.593 Total 7.802 6. Policy Exceptions and Safeguard Policies Does the restructured project require any No exceptions to Bank policies? Does the restructured project trigger any new safeguard policies? If yes, please select from the No checklist below and update ISDS accordingly before submitting the package. 7a. Project Development Objectives/Outcomes Original/Current Project Development Objectives/Outcomes To improve access to basic health services by conflict-affected and underserved populations in four target states while establishing the basis for reform, sustainable financing, and development of the decentralized health system. 7b. Revised Project Development Objectives/Outcomes [if applicable] 7 Sudan MDTF-National Decentralized Health System Development Project (DHSDP) Restructuring Paper b. Summary 1. This is a level 2 restructuring which encompasses a cumulative extension of the closing date by 30 months as well as a revision of the results framework targets, for which RVP approval is sought. The proposed changes involve: (i) The extension of the closing date from June 30, 2011 to June 30, 2012. This represents a 30 month cumulative extension, from the original closing date of December 31, 2009. (ii) The revision of targets of the Project Development Objective (PDO) indicators. The data sources are the Sudan Health Management Information System (HMIS) for outpatient consultations and the specific Reproductive Health database1 for the antenatal care and birth attended by skilled health staff. The proposed changes are detailed in Annex 1. c. Project Status 2. In October 2006, the MDTF-NS OC approved a grant amount of USD 6 million and a government counterpart financing commitment of USD 13 million. The project became effective in January 2007, with a closing date of 31 December 2009. The project was subsequently restructured in May 2009 with an additional grant of USD 6 million (bringing the total MDTF-NS grant financing to USD 12 million), and the closing date was extended to 30June 2011. In addition, the restructuring intended to treat the remaining undisbursed government financing as parallel support thus limiting the risk of non achievement of project objectives due to lack of counterpart financing. The approved restructuring thus aimed to narrow the project scope and revise its targets, and key performance indicators were modified to take into account the narrowed scope of activities. 3. The project development objective is to improve access to basic health services by conflict-affected and underserved populations in four target states while establishing the basis for reform, sustainable financing, and development of the decentralized health system. The project has five outcome indicators and five intermediate outcome indicators. 4. The project has made moderately satisfactory progress on three of the five outcome indicators, namely: number of outpatient consultations per person per year, % of pregnant women who attended at least one antenatal care consultation; and no. of primary health care workers trained. In regards to % of total births attended by skilled staff, although there has been progress – in 2010, the % of total births attended increased 1 Data referring to major (or vertical) programs are often collected by the program, rather than by the Health Management Information System (HMIS). The project provides support to the Reproductive Health dept at state level to collect data from the health facilities targeted by the project on antenatal care and births attended by skilled health staff. 8 from 16% in Qrt1, to 19% in Qrt2, 26% in Qrt3 and 29% in Qrt4, 23% for the whole year – the results are still far below the target established by the additional financing for mid June 20112. Finally, the indicator % of households who possesses at least one insecticide- treated net (ITN), has been fully achieved under the initial project. Table 1 below provides further details, and the justification for the revised end of project targets is mentioned below. Table 1 – Project Outcome Indicator Results: Baseline Progress/Targets Project Outcome Revised end of Initial AF AF Target Current Indicators project target (2006) (2009) (June 2011) (Dec 2010) (June 2012) Outpatient consultations 0.20 0.30 0.25 0.30 (OPC) per person per year % pregnant women 59% 70% 64% 65% attending at least one ANC Births attended by skilled 49% 55% 23% 30% staff (% of total births) % households who 18% 42% possesses at least one insecticide-treated net (ITN) Number of health 0 40 200 930 1,000 personnel (incl. midwives) receiving training 5. The project has also made satisfactory progress on the five intermediate outcome indicators – as shown in Table 2 below: (i) the distribution of 179,100 ITNs was fully achieved under the initial project; (ii) preliminary results from the National Health Accounts (NHA) study are available and the full report is expected to be finalized by August 2011; and (iii) per capita value of support to targeted health facilities and midwives is currently calculated to be US$ 0.42 per capita for CY 2010. As for the refurbishing of health infrastructure, all construction/rehabilitation of health facilities under the initial project has been completed and handed over; contracts for civil works under the additional financing have been signed, and works have commenced for all four midwifery schools and for the rehabilitation of surgical units and maternity wards in the six targeted rural hospitals; finally, contracts for procuring emergency obstetric medical equipment for seven rural hospitals have been signed and initial payments made, and delivery was expected by the end of June 2011. The NHA, the construction/renovation and equipment of health facilities, and the construction of training facilities contribute to achieve the institutional building part of the PDO “… while establishing the basis for reform, sustainable financing and development of the decentralized health system”. 2 The project targets the most underserved states and, within these the most underserved localities. The proportion of birth attended by skilled health staff in these remote areas is certainly much lower that the national (and even state) proportions found in the Sudan Household Survey (SHHS) 2006. 9 Table 2 – Intermediate Outcome Indicators: Progress Baseline Intermediate Outcome Indicators AF Target Current (2006/AF) (June 2011) (Dec 2010) Long-lasting insecticide-treated malaria nets 0 179,100 179,100 purchased and/or distributed (number) (a) Annual per capita USD value of drugs, 0.17 0.40 0.42 consumables, and operation support provided to target facilities and midwives National Health Accounts completed No Yes In progress Health facilities constructed, renovated and/or 0 18 18 equipped (number) (b) Midwifery schools constructed and equipped 0 4 In progress (number) (c) Rural hospitals upgraded and equipped for 0 3 6 in progress EOC (number) (c) Notes: a. The distribution of ITNs was one-time activity and was completed under the initial project. b. The rehabilitation/construction and equipping of training and PHC facilities was part of the initial project and was fully achieved by the Sept 2010. c. Under the additional financing, four midwifery schools are planned to be constructed & equipped; and the maternity wards and surgical units in six rural hospitals are planned to be rehabilitated and equipped with emergency obstetric medical equipment. 6. Overall implementation progress remains Moderately Satisfactory. There are no unresolved fiduciary issues. The Project has hired an internal auditor in response to the Bank recommendation to help rectify the control weaknesses noted in some states. Recruitment is underway to fill the financial management officer position. Procurement arrangements and institutional roles and responsibilities remain unchanged. As of April 30, 2011, the cumulative disbursements from the grant account totaled US$ 7.8 million, or 65% of the total grant amount. Most of the remaining balance is committed and is expected to be disbursed by the end of 2011. 7. The Medical Waste Management Plan (MWMP) is being addressed in a satisfactory way: safety & protective has been procured and small-scale incinerators have been constructed and installed in all primary health care facilities targeted by the project. Training on the use of the protective equipment and incinerator has been provided to involved Health staff. Pending Safeguards issues – namely the implementation of the MWMP also in the rural hospitals targeted by the project – is also being address: safeguards assessments have been conducted in each hospital, and procurement of appropriate incinerators and other safety equipment is ongoing. 10 d. Proposed Changes 8. The project was restructured in 2009 to introduce an additional financing. The initial baseline and targets were based on the 2006 Sudan Household Survey (SHHS) and these data were used for the additional financing phase due to unavailability of other data at that time. Data from the 2009 SHHS are not yet available, however, data from 2008/09 have become available – namely from the Health Management Information System for outpatient consultations and from the Reproductive Health Dept for antenatal care and births attended by skilled health staff – and these are far more in line with the current progress as of December 2010. Therefore the proposed changes. The PDO will remain unchanged. 9. The original closing date was extended to June 30, 2011 in order to allow the implementation of the new activities under the additional financing. It is now proposed to extend the closing date to June 30, 2012. This extension would enable the project to consolidate some of the project’s components, particularly the village midwives’ performance incentive schemes. The extension would also provide greater opportunity to ensure the project’s sustainability through wider consultations with stakeholders. 11 Annex I: Results Framework and Monitoring COUNTRY: Project Name Revisions to the Results Framework Comments/ Rationale for Change PDO Current (PAD) Proposed change To improve access to basic Continued health services by conflict affected and underserved populations in four target states while establishing the basis for reform, sustainable financing, and development of the decentralized health system PDO indicators Current (PAD) Proposed change Outpatient consultations per person Continued Indicator. per year End of project target to change from 0.30 to 0.35 Percentage pregnant women who Continued Indicator. attended at least one antenatal care End of project target to change from Refer to text above for further consultation 70% to 65% details. Births attended by skilled health staff Continued Indicator (% of total births) (skilled health staff End of project target to change from = doctor, nurse, midwife, trained 55% to 30% village midwife) Percentage households who possess at Fully achieved under initial project least one insecticide-treated net (ITN) Number of health personnel Continued (including midwives) receiving training Direct Project Beneficiaries Continued Population data updated as per the Census 2009 Intermediate Results indicators Current (PAD) Proposed change Long-lasting insecticide-treated Fully achieved under initial project malaria nets purchased and/or distributed (number) Per capita USD value of Continued drugs/consumables provided to target health facilities and midwives National Health Accounts completed Continued Health facilities constructed, Fully achieved under initial project renovated and/or equipped (number) Midwifery schools constructed and Continued equipped (number) Rural hospitals upgraded and Continued equipped for EOC (number) 12 REVISED PROJECT M&E ARRANGEMENTS Progress Target Values Responsibility Core Unit of Baseline Data Source/ PDO Level Results Indicators as of Dec June June Frequency for Data Comments Measure (2006) Methodology 2010 2011 2012 Collection Outpatient consultations per Custom 0.20 0.25 0.25 0.35 Quarterly Health DHSDP It refers to annual person per year Management values Information System (HMIS) Percentage pregnant women % 59 64 64 65 Quarterly Reproductive DHSDP who attended at least one Health (RH) Dept antenatal care consultation database Births attended by skilled % 49 23 23 30 Quarterly RH Dept database DHSDP health staff (% of total births) (skilled health staff = doctor, nurse, midwife, trained village midwife) Percentage households who % 18 42 HH Survey and DHSDP Fully achieved possess at least one ITN HMIS under initial project Number of health personnel Number 0 930 930 1,000 Quarterly Progress Reports DHSDP (including midwives) receiving training Beneficiaries: Direct Project Beneficiaries Number 1,019,983 1,057,207 1,057,207 1,088,077 Ad hoc Population DHSDP Census 2009 Unit of Progress Target Values Responsibility Core Intermediate Results Baseline Data Source/ Measure as of June June Frequency for Data Comments Indicators (2006) Methodology ment Dec 2010 2011 2012 Collection Long-lasting insecticide- Number 0 179,100 Quarterly Progress Reports DHSDP Fully achieved treated malaria nets under initial purchased and/or distributed project (number) Per capita USD value of Custom 0.17 0.40 0.40 0.42 Quarterly Progress Reports DHSDP drugs/consumables provided to target health facilities and midwives National Health Accounts Y/N N N N Y Quarterly Progress Reports DHSDP NHA data completed available; report yet to be submitted Health facilities constructed, Number 0 18 Quarterly Progress Reports DHSDP Fully achieved renovated and/or equipped under initial (number) project Midwifery schools Number 0 0 0 4 Quarterly Progress Reports DHSDP Construction in constructed and equipped progress (number) Rural hospitals upgraded Number 0 0 0 6 Quarterly Progress Reports DHSDP Construction in and equipped for EOC progress (number) 14 15