The World Bank Cambodia Health Equity and Quality Improvement Project (H-EQIP) (P157291) REPORT NO.: RES38769 DOCUMENT OF THE WORLD BANK RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF CAMBODIA HEALTH EQUITY AND QUALITY IMPROVEMENT PROJECT (H-EQIP) APPROVED ON MAY 19, 2016 TO KINGDOM OF CAMBODIA- MINISTRY OF ECONOMY AND FINANCE HEALTH, NUTRITION & POPULATION EAST ASIA AND PACIFIC Regional Vice President: Victoria Kwakwa Country Director: Mariam J. Sherman Regional Director: Daniel Dulitzky Practice Manager/Manager: Aparnaa Somanathan Task Team Leader(s): Ziauddin Hyder, Nareth Ly The World Bank Cambodia Health Equity and Quality Improvement Project (H-EQIP) (P157291) I. BASIC DATA Product Information Project ID Financing Instrument P157291 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 19-May-2016 30-Jun-2021 Organizations Borrower Responsible Agency Kingdom of Cambodia- Ministry of Economy and Finance Ministry of Health Project Development Objective (PDO) Original PDO To improve access to quality health services for the targeted population groups with protection against impoverishment due to the cost of health services in the Kingdom of Cambodia. Current PDO To improve access to quality health services for the targeted population groups, with protection against impoverishment due to the cost of health services in the Kingdom of Cambodia, and to provide immediate and effective response in case of an eligible crisis or emergency. Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-58130 19-May-2016 26-Aug-2016 09-Nov-2016 30-Jun-2021 30.00 29.78 .06 TF-A9492 28-Jan-2019 23-Feb-2019 23-Feb-2019 30-Jun-2021 6.00 .80 5.20 TF-A2562 19-May-2016 15-Sep-2016 15-Sep-2016 30-Jun-2020 1.00 .71 .29 TF-A3114 19-May-2016 26-Aug-2016 09-Nov-2016 30-Jun-2021 37.00 27.70 9.30 The World Bank Cambodia Health Equity and Quality Improvement Project (H-EQIP) (P157291) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. SUMMARY OF PROJECT STATUS AND PROPOSED CHANGES 1. The Health Equity and Quality Improvement Project (H-EQIP), with a total financing of US$174.2 million, was approved on May 19, 2016 and became effective on November 9, 2016. The project was originally financed by US$30 million IDA Credit; US$94.2 million the Royal Government of Cambodia counterpart financing; and US$50 million Multi-Donor Trust Fund (MDTF) grant, contributed by Australia Department of Foreign Affairs and Trade, Germany KfW and Korea International Cooperation Agency (pooled fund partners). 2. In June 2018, the first additional financing (AF1) to the H-EQIP was processed to add US$6 million grant from the MDTF, bringing the total financing of the project to US$180.2 million. In parallel, the Japan Policy and Human Resources Development (PHRD) Trust Fund (TF0A2562) provided a complementary financing of US$ 1 million to support the strengthening of the health sector monitoring and evaluation (M&E) through complementary financing of US$1 million equivalent. The grant was approved on September 16, 2016 with a closing date of June 30, 2020. A level two restructuring was also proposed during AF1 to add new activities under the Component 3 to include three new disbursement-linked indicators (DLIs) to support enhanced services for cervical cancer screening and treatment, hypertension and diabetes screening and treatment, and long-term family planning as well as to update the project Results Framework and modify some existing DLIs. The PDO was also revised to “to improve access to quality health services for the targeted population groups, with protection against impoverishment due to the cost of health services in the Kingdom of Cambodia, and to provide immediate and effective response in case of an eligible crisis or emergency” to reflect the Contingent Emergency Response Component (CERC) embedded in the project. However, there are no emergency activities to be financed from the PHRD grant and the PDO modification only pertains to the IDA financing. 3. The proposed second additional financing (AF2) to the H-EQIP aims to replenish the financing gap of US$14 million IDA credit created as a result of activating the CERC and reallocating US$2.29 million from Component 1 and sub-component 3.1 to sub-component 3.3. Combined with restructuring, the AF2 also aims to (a) extend the project closing date by 12 months, from June 30, 2021 to June 30, 2022 to allow for the completion of the delayed civil works, particularly the construction of the two provincial referral hospitals (PRHs); and (b) add one new intermediate resultsindicator “Number of hospitals equipped with ventilators for treatment of COVID-19 severe cases”, reflecting the support under the CERC. The proposed AF2 is expected to be approved by the Board on July 30, 2020 bringing the total financing of the project to US$194.2 million. 4. The PHRD grant supports the project with a specific focus on its M&E activities and contributes to the achievement of the PDO by focusing on strengthening the M&E planning, coordination and review processes in the health sector. Specifically, the grant has been supporting the availability of quality data at the Ministry of Health (MOH) to promote evidence-based decision making and to improve monitoring and strengthening of the health management information system. In addition, the grant supports the National Quality Enhancement Monitoring Process (NQEMP) system which was rolled out in May 2017 (six months after the project effectiveness) and involves a quarterly assessment of each health facility in the country by their supervisory authorities that is, operational districts The World Bank Cambodia Health Equity and Quality Improvement Project (H-EQIP) (P157291) (ODs), with an objective scoring on a range of quality and performance indicators, validated by an independent verification process. It reached nationwide coverage in July 2019. After three years of implementation, the NQEMP will introduce at least 25 new clinical vignettes in 2021 to build new knowledge for the health care providers. The Information and Communication Technology (ICT) system will need to be updated to reflect the new tools. 5. Despite initial delays in the rollout of the NQEMP, the PHRD grant has tremendously contributed in improving the monitoring of the quality of services through the training of 246 assessors from ODs on the National Quality Enhancement Monitoring Tools and thereafter, migrating the tool from paper-based to tablet-based ICT system. The grant assisted the MOH to leverage additional financing from the national budget to train additional assessors in rolling out the NQEMP nationwide. It was increasingly clear to the government that such an elaborate system cannot be sustained using simple paper and excel-based tools and thus will benefit from a structured information system. The development of the ICT system started in February 2019, and the field testing continued through April and May 2019. With the support of the PHRD grant, the training of trainers for the ICT system was conducted in May 2019 followed by the cascade training to all the assessors from June to July 2019. 6. As of 29 June 2020, there is no overdue audit report and IFR. MOH has already taken an action on an inactive Designated Account of the PHRD grant by submitting an withdrawal application for advance payment and documenting expenses of the PHRD grant on June 25, 2020. 7. In view of the proposed AF2 and restructuring of the H-EQIP, the task team proposes to extend the closing date of the PHRD TF0A2562 from June 30, 2020 to June 30, 2021. This will help to ensure the maintenance and the update of the ICT system in implementing the NQEMP to collect data measuring the quality of care at the public health facilities nationwide and will contribute to more effective monitoring, planning, supervision and coordination until the end of the project. II. DETAILED CHANGES LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications IDA-58130 Effective 30-Jun-2021 TF-A2562 30-Jun-2020 30-Jun-2021 30-Oct-2021 TF-A3114 Effective 30-Jun-2021 TF-A9492 Effective 30-Jun-2021 The World Bank Cambodia Health Equity and Quality Improvement Project (H-EQIP) (P157291)