Document of The World Bank Report No: ICR00003894 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-44700 TF-93574) ON A CREDIT IN THE AMOUNT OF SDR 18.5 MILLION (USD 30.0 MILLION EQUIVALENT) AND A MULTI-DONOR TRUST-FUND GRANT IN THE AMOUNT OF USD 124.37 MILLION EQUIVALENT TO THE KINGDOM OF CAMBODIA FOR A SECOND HEALTH SECTOR SUPPORT PROGRAM December 29, 2016 Health, Nutrition and Population Global Practice East Asia and Pacific Region CURRENCY EQUIVALENTS (Exchange Rate Effective March 29, 2008 [PAD]) Currency Unit = KHR KHR 3,950 = USD 1.00 USD 1.00 = SDR 0.61 (Exchange Rate Effective June 30, 2016 [Closure]) Currency Unit = KHR KHR 4,057 = USD 1.00 USD 1.00 = SDR 0.71 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS 3YRPs Three-Year Rolling Plans AF Additional Financing AOP Annual Operational Plans CBO Community Based Organizations CDHS Cambodia Demographic Health Survey CSES Cambodia Socio Economic Survey DBF Department of Budget and Finance DPs Development Partners DPHI Department of Planning and Health Information HCMC Health Center Management Committees HEF Health Equity Fund H-EQIP Health Equity and Quality Improvement Project HMIS Health Management Information System HSP2 Second Health Strategic Plan HSP3 Third Health Strategic Plan HSSP Health Sector Support Project HSSP2 Second Health Sector Support Program ICR Implementation Completion and Results Report IDA International Development Association IPD Inpatient Department ISR Implementation Status and Results Report JAPR Joint Annual Performance Review JPIG Joint Partnership Interface Group M&E Monitoring and Evaluation MBPI Merit-Based Performance Incentive MDTF Multi Donor Trust Fund MOH Ministry of Health MTR Mid-Term Review NAHC National Annual Health Congress NGOs Non-Governmental Organizations NNP National Nutrition Plan NPV Net Present Value NSDP National Strategic Development Plan ODs Operational Districts ODO Operational District Office OPD Outpatient Department PAD Project Appraisal Document PDO Project Development Objective PHD Provincial Health Department POC Priority Operating Cost PR Project Restructuring RF Results Framework RGC Royal Government of Cambodia RH Referral Hospital RMCH Reproductive Maternal and Child Health RTC Regional Training Center SAO Special Operating Agency SDGs Service Delivery Grants SWAp Sector-Wide Approach SWiM Sector-Wide management Senior Global Practice Director: Timothy Grant Evans Global Practice Manager: Toomas Palu Task Team Leader: Somil Nagpal ICR Team Leader: Somil Nagpal CAMBODIA Second Health Sector Support Program CONTENTS Data sheet ...................................................................................................................... iii A. Basic Information...................................................................................................... iii B. Key Dates .................................................................................................................. iii C. Ratings Summary ...................................................................................................... iv D. Sector and Theme Codes .......................................................................................... iv E. Bank Staff ................................................................................................................... v F. Results Framework Analysis ...................................................................................... v G. Ratings of Project Performance in ISRs ................................................................. xix H. Restructuring (if any) ............................................................................................... xx I. Disbursement Profile .............................................................................................. xxii 1. Project Context, Development Objectives and Design ............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 5 3. Assessment of Outcomes .......................................................................................... 14 4. Assessment of Risk to Development Outcome......................................................... 29 5. Assessment of Bank and Borrower Performance ..................................................... 30 6. Lessons Learned ....................................................................................................... 33 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 34 Annex 1. Project Costs and Financing .......................................................................... 35 Annex 2a. Outputs by Component ................................................................................ 37 Annex 2b. Indicators by PDO ....................................................................................... 47 Annex 3. Economic and Financial Analysis ................................................................. 56 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 59 Annex 5. Beneficiary Survey Results ........................................................................... 60 Annex 6. Stakeholder Workshop Report and Results................................................... 60 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 61 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 68 Annex 9. List of Supporting Documents ...................................................................... 71 Project documentation: ................................................................................................. 71 Additional References: ................................................................................................. 72 MAP .............................................................................................................................. 73 Data sheet A. Basic Information Cambodia Second Country: Cambodia Project Name: Health Sector Support Program Project ID: P102284 L/C/TF Number(s): IDA-44700, TF-93574 ICR Date: 12//2016 ICR Type: Core ICR ROYAL Lending Instrument: SIL Borrower: GOVERNMENT OF CAMBODIA USD 30.00M (IDA) Original Total and USD 80.00M Commitment: (MDTF) USD 30.00M (IDA) USD 28.17M (IDA) Revised Amount: and USD 124.37 Disbursed Amount: USD 124.37M (MDTF) (MDTF) Environmental Category: B Implementing Agencies: MINISTRY OF HEALTH (MOH) Cofinanciers and Other External Partners: AUSTRALIA: Australian Agency for International Development (AusAID) / Department of Foreign Affairs and Trade (DFAT) UK: British Department for international Development (DFID) KOREA: Korea International Cooperation Agency (KOICA) GERMANY: Kreditanstalt für Wiederaufbau (KfW) UNFPA UNICEF B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 07/16/2007 Effectiveness: 01/19/2009 01/19/2009 10/11/2010 (PR1) 09/24/2012 (PR2) 10/01/2013 (AF1) Appraisal: 05/02/2008 Restructuring(s): 06/04/2014 (PR3) 09/11/2014 (AF2) 10/30/2015 (AF3) Approval: 06/19/2008 Mid-term Review: 09/14/2011 11/14/2011 Closing: 06/30/2014 06/30/2016 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Satisfactory Risk to Development Outcome: Moderate Bank Performance: Satisfactory Borrower Performance: Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Satisfactory Implementing Quality of Supervision: Satisfactory Moderately Satisfactory Agency/Agencies: Overall Bank Overall Borrower Satisfactory Satisfactory Performance: Performance: C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Quality at Entry Project at any time Yes None (QEA): (Yes/No): Problem Project at any Quality of No None time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 24 24 Compulsory health finance 4 4 Health 44 44 Other social services 4 4 Sub-national government administration 24 24 Theme Code (as % of total Bank financing) Administrative and civil service reform 17 17 Child health 17 17 Health system performance 33 33 Participation and civic engagement 16 16 Population and reproductive health 17 17 E. Bank Staff Positions At ICR At Approval Vice President: Victoria Kwakwa James W. Adams Country Director: Ulrich Zachau Ian C. Porter Global Practice Manager: Toomas Palu Fadia M. Saadah Task Team Leader: Somil Nagpal Toomas Palu ICR Team Leader: Somil Nagpal ICR Primary Author: Patrick Eozenou F. Results Framework Analysis Project Development Objectives (from the Legal Agreement) To support the implementation of the Government's Health Strategic Plan 2008-2015 in order to improve health outcomes through strengthening institutional capacity and mechanisms by which the Government and Program Partners can achieve more effective and efficient sector performance. Revised Project Development Objectives (as approved by original approving authority) The three Project Restructurings (PR1, October 2010; PR2, September 2012; PR3, June 2014) and the three Additional Financings (AF1, October 2013; AF2, September 2014; AF3, October 2015) retained the original PDO. (a) PDO Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Outcome Percentage of births delivery by trained personnel indicator 1 Value 58.0 85.0 87.0 85.2 (quantitative or qualitative) (2008, NSDP) (2008, NSDP) (2015, AF3) (2016, NAHC) Date achieved 12/31/2008 12/31/2013 06/30/2016 05/31/2016 Comment (incl. Target 98 percent achieved. The original target (85 percent) was achieved in % achievement) 2014. The target was revised to 87 percent after AF3. Outcome Percentage of births delivery by trained personnel at health facility indicator 2 Value 39.0 80.0 85.0 80.35 (quantitative or qualitative) (2008, NSDP) (2008, NSDP) (2015, AF3) (2016, NAHC) Date achieved 12/31/2008 12/31/2013 06/30/2016 05/31/2016 Comment (incl. Target 95 percent achieved. The original target (80 percent) was achieved in % achievement) 2014. The target was revised to 85 percent after AF3. Outcome Percentage of currently married women using a modern contraceptive indicator 3 method Value 26.0 49.0 39.0 41.0 (quantitative or qualitative) (2008, NSDP) (2008, NSDP) (2014, AF2) (2016, HMIS) Date achieved 12/31/2008 12/31/2013 12/31/2015 12/31/2015 The NSDP target was revised in 2014 down to 39 percent because the original target was deemed overly ambitious and to align the target with that of the Comment (incl. government’s own strategic plan. This indicator was then dropped from the % achievement) PDO indicators in 2014 at AF2 because the data was assessed as non-reliable. The HMIS actual value in 2015 exceeds the revised target (105 percent achieved). Outcome Percentage (and number) of children under one year immunized with DPT- indicator 4 HepB3 Value 84.0 95.0 98.0 94.8 (quantitative or qualitative) (2008, HSP2) (2008, HSP2) (2015, AF3) (2016, NAHC) Date achieved 12/31/2008 12/31/2013 06/30/2016 05/31/2016 Target 96 percent achieved. The original indicator “percentage of children under 1 fully immunized” was Comment (incl. revised after PR1 to “percentage (and number) of children under one year % achievement) immunized with DPT-HepB3”. The baseline (84 percent) and target value (95 percent) were updated at AF1 to be consistent with the 2008 HSP2. The end target value was further revised at AF3 after the project extension to 98 percent. Outcome Percentage of HIV+ pregnant women receiving Antiretroviral drugs for indicator 5 PMTCT Value 27.0 68.0 58.0 (quantitative or - qualitative) (2008, HSP2) (2008, HSP2) (2016, HMIS) Date achieved 12/31/2008 12/31/2013 - 12/31/2015 Comment (incl. This indicator was dropped in 2014 at AF2 because the Project did not finance % achievement) HIV/AIDS interventions covered by other donors. Outcome TB cure rate indicator 6 Value 90.0 >85.0 >85.0 89.0 (quantitative or qualitative) (2008, HSP2) (2008, HSP2) (2014, AF1) (2016, HMIS) Date achieved 12/31/2008 12/31/2013 12/31/2014 12/31/2015 Comment (incl. This indicator was dropped in 2014 at AF2 because the Project did not finance % achievement) TB interventions covered by other donors. Outcome Number of malaria cases treated at public health facilities per 1,000 indicator 7 population Value 4.1 3.7 2.9 2.26 (quantitative or qualitative) (2010, JAPR) (2010, JAPR) (2014, AF1) (2016, HMIS) Date achieved 12/31/2008 12/31/2013 12/31/2014 12/31/2015 The end target was revised downward in 2013 at AF1 because the original target was assessed as overly ambitious and to align the target with that of the Comment (incl. % achievement) government’s own strategic plan. The indicator was then dropped in 2014 at AF2 because the Project did not finance Malaria interventions covered by other donors. Outcome Percentage (and number) of children age 6-59 months who receives two indicator 8 doses of Vitamin A supplement every 6 months (R1, R2) Value 89.0 96.0 96.0 81.5 (quantitative or qualitative) (2008, HSP2) (NNP) (2015, AF3) (2016, NAHC) Date achieved 12/31/2008 12/31/2014 06/30/2016 05/31/2016 This indicator was added in 2010 at PR1 and revised from “Percentage (and Comment (incl. number) of children aged 6–59 months who received 2 doses of vitamin A % achievement) supplement within the last 12 months” to “Percentage (and number) of children age 6-59 months who receives two doses of Vitamin A supplement every 6 months (R1, R2)” in 2015 at AF3. Outcome Percentage of children aged 12-59 months who received mebendazole indicator 9 Value 71.0 90.0 97.0 (quantitative or - qualitative) (2010, JAPR) (2010, JAPR) (2016, HMIS) Date achieved 12/31/2008 12/31/2013 12/31/2015 Comment (incl. This indicator was added in 2010 at PR1and then dropped in 2014 at AF2 % achievement) because coverage is similar to Vitamin A coverage. Outcome Percentage of pregnant women receiving iron folate supplementation indicator 9 Value 80.0 90.0 85.0 82.17 (quantitative or qualitative) (2008, HSP2) (2010, JAPR) (2015, AF3) (2016, HMIS) Date achieved 12/31/2008 12/31/2013 06/30/2016 12/31/2015 Target 97 percent achieved. Comment (incl. % achievement) This indicator was added in 2010 at PR1 and revised in 2014 at AF3 to align the target with that of the government’s own strategic plan. Outcome Percent of poor population covered by Health Equity Funds indicator 10 Value 57.0 100.0 100.0 (quantitative or NA qualitative) (2008, DPHI) (2015, AF3) (2016, NAHC) Date achieved 12/31/2008 - 06/30/2016 05/31/2016 Target 100 percent achieved. Comment (incl. % achievement) This intermediary result indicator was added in 2010 at PR1 and then moved to PDO in 2014 at AF2. (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Strengthened Health Service Delivery Indicator 1 Percentage of population with access to full MPA This indicator was dropped in 2010 at PR1. Project Results Indicators were Comment (incl. % achievement) streamlined at the request of MoH to focus on key Project-related outcomes which were measurable using existing MoH systems. Indicator 2 Percentage of population with access to at least CPA2 This indicator was dropped in 2010 at PR1. Project Results Indicators were Comment (incl. % achievement) streamlined at the request of MoH to focus on key Project-related outcomes which were measurable using existing MoH systems. Indicator 3a Consultations (new cases) per person per year (all) Value 0.54 0.6 (quantitative or - - qualitative) (2010, JAPR) (2010, JAPR) Date achieved 12/31/2008 12/31/2013 - - Comment (incl. This indicator was dropped in 2014 at AF2 because the Project was not % achievement) accountable for all consultations, just priority groups. Indicator 3b Consultations (new cases) per person per year (under 5 years old) Value 1.1 1.5 1.52 (quantitative or - qualitative) (2010, JAPR) (2010, JAPR) (2016, NAHC) Date achieved 12/31/2008 12/31/2013 - 05/31/2016 Comment (incl. % achievement) Target surpassed Percentage (and number) of pregnant women attending at least 2 antenatal Indicator 4 care consultation Value 81.0 94.0 90.0 93.0 (quantitative or qualitative) (2008, NSDP) (2008, NSDP) (2015, AF3) (ISR, Seq. 11) Date achieved 12/31/2008 12/31/2013 06/30/2016 05/31/2016 Comment (incl. Target surpassed. % achievement) The target for this indicator was revised in 2015 at AF3. Indicator 5 Percentage of deliveries by C-section Value 2.0 3.2 (quantitative or - - qualitative) (2008, NSDP) (2008, NSDP) Date achieved 12/31/2008 12/31/2013 - - Comment (incl. This indicator was dropped in 2014 at AF2 to avoid creating incentives for % achievement) unnecessary procedures. Indicator 6 Case detection rate of smear (+) pulmonary TB (%) Value 69.0 70.0 (quantitative or - - qualitative) (2008, NSDP) (2008, NSDP) Date achieved 12/31/2008 12/31/2013 - - Comment (incl. This indicator was dropped in 2014 at AF2 because the Project does not finance % achievement) TB interventions. Percentage of families living in high malaria endemic areas (<1km from Indicator 7 forest) of 20 provinces have sufficient (1 net / 2 persons) treated bed nets (LLIT / ITN) Value 75.0 90.0 (quantitative or - - qualitative) (2008, JAPR) (2011, NSDP) Date achieved 12/31/2008 12/31/2013 - - Comment (incl. This indicator was dropped in 2014 at AF2 because the Project did not finance % achievement) Malaria interventions covered by other donors. Indicator 8 DHF case fatality rate reported by public health facilities Value 0.68 <0.6 0.5 0.25 (quantitative or qualitative) (2008, NSDP) (2011, NSDP) (2015, AF3) (2016, NAHC) Date achieved 12/31/2008 12/31/2013 06/30/2016 05/31/2016 Comment (incl. % achievement) Target surpassed. Percentage of children under 5 years with pneumonia receiving correct Indicator 9 antibiotic treatment at public facilities Value 48.0 65.0 (quantitative or - - qualitative) (CDHS, 2005) (2008, HSP2) Date achieved 12/31/2005 12/31/2013 - - This indicator was revised from “Percentage of children under 5 years with cough or difficulty breathing who sought treatment by public health provider [IMCI-CS]” to “Percentage of children under 5 years with pneumonia receiving Comment (incl. % achievement) correct antibiotic treatment at public facilities” in 2010 at PR1. The indicator was then dropped in 2014 at AF2 because measurement is conducted only every five years. Percentage of children under 5 years with diarrhea having received ORT Indicator 10 and Zinc at public health facilities Value 58.0 95.0 (quantitative or - - qualitative) (CDHS, 2005) Date achieved 12/31/2005 12/31/2013 - - This indicator was revised from “Percentage of children with diarrhea having received ORT” to “Percentage of children under 5 years with diarrhea having Comment (incl. received ORT and Zinc at public health facilities” in 2010 at PR1. % achievement) The indicator was then dropped in 2014 at AF2 because measurement is conducted only every five years. Indicator 11 Percentage of disease outbreak responses in timely manner Value NA (quantitative or NA - - qualitative) Date achieved - - - - Comment (incl. % achievement) This indicator was dropped in 2010 at PR1. Indicator 12 Percentage of adults with diabetes treated at public health facilities Value 3.5 0.55 (quantitative or - - qualitative) (2008, NSDP) (2008, NSDP) Date achieved 12/31/2008 12/31/2013 - - This indicator was revised from “Incidence of diabetes reported from public health facilities” to “Percentage or number of adults with diabetes treated at public health facilities” in 2010 at PR1. Comment (incl. % achievement) The indicator was then dropped in 2014 at AF2 because the Project did not cover treatment of diabetes at all public health facilities nor as part of HEF package. Indicator 13 Percentage of Essential Drugs (15 items listed) at HCs that faced stock- outs Value 12.87 <5 (quantitative or - - qualitative) (2010, JAPR) (2008, NSDP) Date achieved 12/31/2008 12/31/2013 - - Comment (incl. The indicator was then dropped in 2014 at AF2 because it was not within % achievement) control of the project. Indicator 14 Percentage of Government health expenditure at provincial level and below Value 29.8 (quantitative or NA - - qualitative) (2008, DBF) Date achieved 12/31/2008 - - - Comment (incl. The indicator was then dropped in 2014 at AF2 because it was not within % achievement) control of the project. Indicator 15 Percentage of referral hospitals implementing Health Equity Funds Value 61.0 85.0 100 (quantitative or NA qualitative) (2008, DPHI) (2015, AF3) (2016, NAHC) Date achieved 12/31/2008 - 06/30/2016 05/31/2016 Target surpassed. The indicator was revised in 2010 at PR1 from “Coverage (OD and population) Comment (incl. % achievement) of HEFs” to “Percentage of referral hospitals implementing Health Equity - Funds”. The target for this indicator was set in 2015 at AF3 (85 percent). Indicator 16 Percentage of Health Centers implementing Health Equity Funds Value 13.0 61.0 91.0 (quantitative or NA qualitative) (2008, DPHI) (2015, AF3) (2016, NAHC) Date achieved 12/31/2008 06/30/2016 05/31/2016 Target surpassed. The indicator was revised in 2010 at PR1 from “Coverage (OD and population) Comment (incl. % achievement) of HEFs” to “Percentage of referral Health Centers implementing Health Equity Funds”. The target for this indicator was set in 2015 at AF3 (61 percent). Indicator 17 Number of cases receiving Health Equity Fund assistance Value 152,000 8,464,456 (quantitative or NA 6,800,000 qualitative) (2016, NAHC) Date achieved 12/31/2008 - 06/30/2016 05/31/2016 Comment (incl. % achievement) Target surpassed. Number of Outpatient Department visits (OPD) receiving Health Equity Indicator 18 Fund assistance Value 312,713 2,098,272 (quantitative or NA 5,500,000 qualitative) (2016, NAHC) Date achieved 12/31/2009 - 06/30/2016 05/31/2016 Target surpassed Comment (incl. % achievement) 7,346,365 by 05/31/2016 (Source: 2016 NAHC) Number of Intpatient Department visits (IPD) receiving Health Equity Fund Indicator 19 assistance Value 102,205 159,996 (quantitative or NA 720,000 qualitative) (2016, NAHC) Date achieved 12/31/2009 - 06/30/2016 05/31/2016 Comment (incl. Target surpassed % achievement) 869,743 by 05/31/2016 (Source: 2016 NAHC) Indicator 20 Number of deliveries receiving Health Equity Fund assistance Value 15,629 230,348 (quantitative or NA 190,000 qualitative) (2016, NAHC) Date achieved 12/31/2008 - 06/30/2016 05/31/2016 Target surpassed Comment (incl. % achievement) 230,348 by 05/31/2016 (Source: 2016 NAHC) Indicator 21 Number of individuals insured under CBHI schemes Value 79,873 (quantitative or NA - - qualitative) (2008, NSDP) Date achieved 12/31/2008 - - - Comment (incl. The indicator was dropped in 2014 at AF2 because Project does not support % achievement) CBHI, just HEFS. Indicator 22 Government health expenditure per capita Value 7.75 USD per cap. (quantitative or NA - - qualitative) (2008, HSP2) Date achieved 12/31/2008 - - - Comment (incl. The indicator was dropped in 2014 at AF2 because it was not within control of % achievement) the project. Ratio of MOH secondary midwives per 10,000 population per location * Country ratio Indicator 23 * Provincial average * Provincial median Value * Country ratio: 1.35 (quantitative or * Provincial average: 1.40 NA - - qualitative) * Provincial median: 1.74 Date achieved 12/31/2009 - - - Comment (incl. The indicator was dropped in 2014 at AF2 because no target values and a better % achievement) indicator for secondary midwives was proposed (Indicator 24). Indicator 24 Percentage of health center having at least one secondary midwife Value 56 85 85 100 (quantitative or qualitative) (2014, AF2) (2014, AF2) (2015, AF3) (2016, HMIS) Date achieved 12/31/2008 12/31/2014 06/30/2016 05/31/2016 Comment (incl. Target surpassed % achievement) The indicator was added in 2014 at AF2. Indicator 25 Number of HC with staffing level recommended by MPA Guidelines Value (quantitative or NA NA NA NA qualitative) Date achieved - - - - Comment (incl. % achievement) The indicator was dropped in 2010 at PR1. Indicator 26 Number of RH with staffing level recommended by CPA Guidelines Value (quantitative or NA NA NA NA qualitative) Date achieved - - - - Comment (incl. % achievement) The indicator was dropped in 2010 at PR1. Indicator 27 Percentage of external funds for health included in AOPs Value (quantitative or NA NA NA NA qualitative) Date achieved - - - - The indicator was revised in 2010 at PR1 from “Percentage of external funds for health included in 3YRPs and AOPs” to “Percentage of external funds Comment (incl. for health included in AOPs”. % achievement) The indicator was dropped in 2014 at AF2 (Very process oriented and data not available). Indicator 28 Percentage of RH, ODO and PHD offices with computerized HMIS Value (quantitative or NA NA NA NA qualitative) Date achieved - - - - Comment (incl. % achievement) The indicator was dropped in 2010 at PR1. Indicator 29 Percentage of functioning HCMCs Value (quantitative or NA NA NA NA qualitative) Date achieved - - - - Comment (incl. The indicator was dropped in 2014 at AF2 (not within control of the project and % achievement) data not available). Percentage of private entities licensed: - Polyclinics Indicator 30 - Consultation cabinets - Maternity clinics - Dental clinics - Pharmacies… Value 56.0 (quantitative or >95.0 - - qualitative) (2010, JAPR) Date achieved 12/31/2008 12/31/2014 - - Comment (incl. % achievement) The indicator was dropped in 2014 at AF2 (not supported by the Project). Indicator 31 Percentage of licensed private Pharmacies and Depots Value (quantitative or NA 100% - - qualitative) Date achieved - 12/31/2014 - - Comment (incl. The indicator was added in 2013 at AF1 and dropped in 2014 at AF2 (not % achievement) supported by the Project). Technical content and results-focus of AOP process improves based on Mid- Indicator 32 Term Review (MTR) and Final Evaluation. Value Improvement (quantitative or PAD Assessment since Mid Term - - qualitative) Review Date achieved - 12/31/2014 - - Comment (incl. % achievement) The indicator was dropped in 2014 at AF2 (no specific way to measure). Number and percentage of MOH central institutions and provinces Indicator 33 submitting AOP and 3YRPs according to schedule and in MOH format Value 79% (quantitative or >95% - - qualitative) (2008) Date achieved 12/31/2008 12/31/2014 - - Comment (incl. The indicator was dropped in 2014 at AF2 (very process oriented and levels % achievement) already very high). AOP resource allocation of program budgets reflecting HSP2 and JAPR Indicator 34 priorities (1. RMCH; 2. CDs; and 3. NCDs) MCH: 3.9% MCH: Increase Value CDs: 20.2% CDs: Maintain (quantitative or - - qualitative) NCDs: 0.5% NCDs: Increase Date achieved 12/31/2008 12/31/2013 - - Comment (incl. % achievement) The indicator was dropped in 2014 at AF2 (No targets. Relevance not clear). Rate of Program execution for Indicator 35  pooled DP  Government funds  pooled DP: NA Value 95%  Government (quantitative or - - qualitative) funds: 105% 95% (2009, JAPR) Date achieved 12/31/2008 12/31/2014 - - Comment (incl. The indicator was dropped in 2014 at AF2 (regularly monitored as part of % achievement) implementation support). Indicator 36 Share of operating cost budget reaching contracting ODs Value (quantitative or 0 40% - - qualitative) Date achieved 12/31/2008 12/31/2013 - - Comment (incl. The indicator was dropped in 2014 at AF2 (difficult to measure, not entirely in % achievement) control of the project, and adds relatively little value). Proportion of ODs implementing SDGs and internal contracting meeting at Indicator 37 least 80% of their performance targets Value (quantitative or 0 100% 100% 100% qualitative) Date achieved 12/31/2008 12/31/2014 06/30/2016 06/30/2016 Target achieved Comment (incl. 100% of ODs implementing SDGs and internal contracting meeting at least 80% % achievement) of their performance target by 03/30/2014 (ISR Seq. 8) and also by 06/30/2016 (ISR Seq. 11) Financial Management Improvement Plan (FMIP) developed and Indicator 38 Implemented Value FMIP (quantitative or NA - - qualitative) implemented Date achieved - 12/31/2014 - - Comment (incl. The indicator was dropped in 2014 at AF2 (very process oriented and no longer % achievement) relevant). Indicator 39 Number of MOH staff receiving POC payments financed by the program. Value (quantitative or 0 NA - - qualitative) Date achieved 12/31/2008 - - - Comment (incl. % achievement) The indicator was dropped in 2014 at AF2 after the POC scheme was cancelled. Annual health planning summits (JAPR and JAPA) conducted with wide Indicator 40 stakeholder participation Value JAPA and JAPR (quantitative or NA - - qualitative) conducted Date achieved 12/31/2014 - - Comment (incl. % achievement) The indicator was dropped in 2014 at AF2. Percentage of HSP2 indicators that have Indicator 41 * baselines * targets Value 70.6% 100% (quantitative or - - qualitative) NA TBD Date achieved 12/31/2008 12/31/2014 - - Comment (incl. % achievement) Indicator dropped at AF2. Indicator 42 Selected key HSP2 indicators disaggregated by location and sex Value (quantitative or NA NA - - qualitative) Date achieved - - - - Comment (incl. % achievement) Indicator dropped at AF2. Indicator 43 Health personnel receiving training through the program (number) Value 166,042 (quantitative or NA NA NA qualitative) (ISR Seq.11) Date achieved - - - 12/31/2015 Although no target was explicitly established, this indicator is considered Comment (incl. % achievement) “achieved” since December 2015 with 166,042 health personnel trained (Source: ISR Seq.11, 06/20/2016) Health facilities constructed, renovated, and/or equipped through the Indicator 44 program. Value (quantitative or 0 506 699 699 qualitative) Date achieved (12/31/2007) (12/31/2015) 06/30/2016 06/30/2016 Target surpassed 699 by 05/31/2016 (ISR, Seq. 11), including: * 53 additional delivery rooms * 15 referral hospitals Comment (incl. % achievement) * 1 LINAC * 1 clean room * 103 solar lighting * 193 water improvement * 263 sanitation improvement G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 04/03/2009 Satisfactory Satisfactory 1.56 2 03/25/2010 Satisfactory Moderately Satisfactory 2.87 3 03/01/2011 Satisfactory Moderately Satisfactory 11.58 4 03/24/2012 Moderately Satisfactory Moderately Satisfactory 11.58 5 02/06/2013 Moderately Satisfactory Moderately Satisfactory 16.33 6 10/22/2013 Moderately Satisfactory Moderately Satisfactory 17.74 7 04/27/2014 Moderately Satisfactory Moderately Satisfactory 25.46 8 11/22/2014 Satisfactory Satisfactory 25.46 9 06/05/2015 Satisfactory Satisfactory 27.57 10 01/29/2016 Moderately Satisfactory Satisfactory 27.57 H. Restructuring (if any) ISR Ratings at Amount Disbursed at Restructuring Board Approved Restructuring Reason for Restructuring & Restructuring Dates PDO Change Key Changes Made (USD millions) DO IP Level 2 Restructuring (PR1) RGC decision to cancel the MBPI scheme and to replace it with the establishment of POC. 10/11/2010 S MS 2.87 No changes proposed in the PDO. The Results Framework is updated to reflect agreements with the MOH and HSSP2 partners. Level 2 Restructuring (PR2) Amendment of the Grant Agreement to reflect the full availability of trust fund resources under Australian Agency for International Development (AusAID) and the United Kingdom Department for 09/24/2012 MS MS 11.58 International Development (DFID). No changes proposed in the PDO or in the Results Framework. The financing percentage for POC is changed to reflect the fact that POC payments under HSSP2 have been stopped as of July 1, 2012 Additional Financing (AF1 / P146271) Scale up of the project following additional receipts from DFID and AusAID into the Multi Donor Trust Fund (MDTF) for a total 10/01/2013 MS MS 16.33 amount of USD 13.44 million, raising the total MDTF envelope to USD 99.5 million. The AF is used to support the scale up of existing activities. No changes proposed in the PDO or in the Results Framework. Level 2 Restructuring (PR3) 06/04/2014 MS MS 25.46 Request from RGC to extend the closing date from June 30, 2014 to December 31, 2015, to allow adequate time for implementation completion of the civil works and delivery of medical equipment. The Financing and Grant Agreements are amended to reflect this change. No changes proposed in the PDO or in the Results Framework. Additional Financing (AF2 / P150472) Additional donor receipts into the MDTF (from the Government of Australia and the Korea International Cooperation Agency (KOICA). These funds provide additional grant financing of USD 12.69 million increasing the total 09/11/2014 MS MS 25.46 MDTF envelope to USD 112.23 million and the total financing envelope for HSSP2 to USD 142.23 million. The PDO remains unchanged. The Results Framework is revised to include only targets that can be attributed to the Program’s activities and that can be measured. Additional Financing (AF3 / P154911) Additional donor receipts into the MDTF (from the Governments of Australia and Germany). These funds provide additional grant financing of USD 12.69 million increasing the total MDTF envelope to USD 124 million and the total financing envelope for 10/30/2015 S S 25.57 HSSP2 to USD 154.37 million. Closing date for the Project is extended from December 31, 2015 to June 30, 2016, and closing date for the MDTF is extended from June 30, 2016 to December 31, 2016. The AF is used to cover a financing gap for a period of 10 months for the SDGs, and to scale up HEF Grants nationwide. I. Disbursement Profile 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. At appraisal, Cambodia was a low-income country, ranked 129 out of 177 countries on the UN Human Development Index. With an annual growth rate of about 2%, the total population reached about 14 million in 2008. Most of the population (80%) lived in rural areas. Per capita gross national income (GNI) was about USD 670 in 2008 (in current terms using the Atlas method). The poverty headcount under the national poverty line was about 30% in 2008. Economic growth however was high, averaging about 8% per year between 1998 and 2008. 2. The economy and the health system were largely destroyed after the international and domestic conflicts of the 1970s. Reconstruction efforts began in the 1980s, but progress was slow. Reforms to rebuild the health system were initiated in the 1990s after the signature of the Paris Peace Accords in 1991. Cambodia lost up to 90 percent of their trained health staff during the Khmer Rouge regime; moreover, the subsequent civil conflict that lasted until 1998 made provision of health service difficult. Since then, Cambodia has made substantial progress in rebuilding its health system. 3. Improvements in health outcomes in the 2000s was steady, but despite these significant trends, Cambodia lagged other countries in the region. Life expectancy increased by 9 years between 1998 and 2008, and both infant and under 5 mortality were declining and on track to meet the MDG targets. Significant health inequalities persisted however among the population. 4. Like many other developing countries, health financing was dominated by out-of- pocket expenditures in Cambodia (60% of total health expenditure). One important driver of the maldistribution of health gains was the impact of financial barriers on access to health services by the poor. Moreover, the cost of health care was reported as one of the most important cause of new impoverishment in Cambodia (Biddulph, 2004). 5. The World Bank had been actively engaged in the health sector since 1996. The previous Health Sector Support Project (HSSP) allowed the World Bank to build strong relationships with the Government and other development partners, and the institution was positioned to be a key player in Cambodia’s health sector development. 1 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) 6. To support the implementation of the Government's Health Strategic Plan 2008- 2015 in order to improve health outcomes through strengthening institutional capacity and mechanisms by which the Government and Program Partners can achieve more effective and efficient sector performance. 7. This evaluation’s interpretation of the Program’s objectives breaks down the PDO in three components: a. PDO1: Improve health outcomes b. PDO2: Institutional capacity strengthening i. Strengthening human resources ii. Strengthening health system stewardship functions c. PDO3: Strengthening mechanisms by which the Government and DPs can achieve more effective and efficient sector performance i. Strengthening health service delivery network ii. Improving financial protection 8. Key performance indicators are itemized in Annex 2b and organized around each PDO component according to their category (impact, outcome, output). Key impact indicators for example relate to the first component of the PDO “Improve health outcomes”, and are extracted from the high level HSP2 goals which appear in Table A (Program Results Framework) of the PAD. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification The PDO remained unchanged through PR1, PR2, AF1, PR3, AF2, and AF3. 1.4 Main Beneficiaries, 9. The primary beneficiaries are the total population, but women and children are a priority group, through reproductive and child health, as well as the poor and ethnic minority groups living in remote rural areas. Key intermediate beneficiaries of the project include health providers who were meant to benefit from pre and in- service training and from additional resources through performance based financing to improve service quality and efficiency. Other secondary beneficiaries included MOH policy makers, program planners and managers who benefit from system strengthening, increased autonomy at the decentralized level, and from capacity building activities. 1.5 Original Components (as approved) Box: Original Components The Project has a health system strengthening focus, with components that are aligned to the Government’s HSP2. Component 1: Strengthening Health Service Delivery through: 2 - (i) the provision of Service Delivery Grants and contracting for health services at provincial level and below; and - (ii) strengthening health services management supervision and public health functions at provincial and district level; and - (iii) investments for the improvement, replacement, and extension of the health service delivery network. Component 2: Improving Health Financing which supported - (i) health protection for the poor through the consolidation of health equity funds under common management and oversight arrangements and expansion of health equity fund coverage; and - (ii) supporting the development of health financing policies and institutional reforms. Component 3: Strengthening Human Resources focused on - (i) strengthening pre- and in-service training and supporting enrollment where shortfalls existed; - (ii) strengthening human resource management in the Ministry of Health; and - (iii) support the Merit Based Performance Incentive (MBPI) scheme for health managers and key technical staff participating in the implementation of the HSP2 at central and provincial level. Component 4: Strengthening Health System Stewardship Functions by supporting: - (i) development of policy packages identified, strengthening the institutional capacity (in particular meeting the demands from Decentralization and Deconcentration); - (ii) private sector regulation and partnerships; and - (iii) governance and stewardship functions of the national programs and centers overseeing the three HSP2 strategic programs. Table 1: Total Estimated Financing by Component Local Foreign Total USD USD USD million million million Overall Program Cost 79.6 30.4 110.0 A. Strengthening Health Service Delivery 50.6 14.4 55.0 B. B. Improving Health Financing 9.9 4.1 14.0 C. Strengthening Human Resources 9.0 3.5 12.5 D. Strengthening Health System Stewardship Functions 20.1 8.4 28.5 Source: PAD, Annex 5. 3 1.6 Revised Components (No revised components) 1.7 Other significant changes 10. First Project Restructuring (Level 2, October 2011). A restructuring was proposed in October 2010 to reflect the RGC decision to cancel the MBPI, Priority Mission Group and all other salary supplement and incentives schemes with effect from January 1, 2010, and to replace it with the establishment of Priority Operating Costs (POC). No changes were proposed in the PDOs, Program components, or implementation arrangements. The proposed changes related to (i) replacing the Project indicator related to MBPI with an indicator related to POC, (ii) updating the Project financing tables and counterpart contributions, as well as reallocating the unallocated expenditure category, and (iii) updating the Results Framework and related indicators and targets to reflect agreements with the MOH and HSSP2 partners. 11. Second Project Restructuring (Level 2, September 2012). The MDTF Grant Agreement was amended to reflect the full amount of Trust Fund resources available under AusAID and DFID. To guard against exchange rate risks, the original MDTF Grant Agreement was signed for USD 52.09 million (i.e 65% of the original commitment of USD 80 million). The additional Trust Fund resources at PR2 include the remaining of the original commitment (USD 27.9 million) and an additional contribution from AusAID equivalent to USD 6.09 million. The total Trust Fund resources amounted to USD 86.09 million after PR2. No changes were proposed in the PDOs, Program components, or in the Results Framework. The Financing and the Grant Agreement were however amended to reflect the following changes:  Change in the deadline for Joint Annual Operational Plan and Appraisal, to be held no later than November of every year, instead of September.  HEF Grants eligibility extended to Community Based Organizations (CBOs) in addition to NGOs, in order to consolidate and expand the coverage of health care benefits packages to the poor.  Each Project Report to cover a period of six months and to be furnished to the Association not later than 90 days, instead of 45 days, after the end of the period covered by the report.  The thresholds for procurement to be carried out by the PHDs and SOAs raised to USD 20,000 per contract for goods, and to USD 40,000 per contract for civil works.  The financing percentage for Priority Operating Costs was changed to reflect the fact that POC payments under HSSP2 were stopped as of July 1, 2012. 12. First Additional Financing (October 2013). The first Additional Financing reflects the scale up of the project following additional receipts into the MDTF for a total amount of USD 13.44 million, raising the total MDTF envelope to USD 99.5 million. No changes were proposed in the PDOs, Program components, or in the Results Framework 4 13. Third Project Restructuring (Level 2, June 2014). The third Project Restructuring (i) extended the Program closing date by 18 months at the request of the Government (from June 30, 2014 to December 31, 2015) to allow for adequate time for implementation completion of the civil works and procurement and delivery of medical equipment; and (ii) amended the Financing and Grant Agreements to reflect these changes. No changes were proposed in the PDOs, Program components, or in the Results Framework 14. Second Additional Financing (September 2014). The second Additional Financing reflected additional donor receipts into the MTDF consisting of USD 8.86 million from AusAID, and USD 4.5 million from the Korean International Cooperation Agency (KOICA). The additional grant financing of USD 12.69 million increased the total MDTF envelope of the Program to USD 112.23 million and the total financing envelope to USD 142.23 million. No changes were proposed in the PDOs or in the Program components. The Program’s Results Framework was revised to only include targets that could be attributed to the Program's activities and could be measured. In some cases, the type of indicator was also revised, such as from PDO level to intermediate level, and vice-versa. All relevant core IDA indicators were included. Indicators and targets remained aligned with those of the government’s own health strategic plan results framework. 15. Third Additional Financing (October 2015). The third Additional Financing was conducted to allow for (i) extension of the Project closing date from December 31, 2015 to June 30, 2016 and extension of the closing date of the MDTF from June 30, 2016 to December 31, 2016; (ii) additional donor contributions to the MDTF from AusAID (USD 6.26 million equivalent) and the Government of Germany (USD 6.51 million equivalent); and (iii) to reallocate Credit funds between categories of expenditure to adjust for overdraws. The additional grant financing of USD 12.67 million equivalent increased the total MDTF envelope of the Program to USD 124.37 million and the total financing envelope to USD 154.37 million. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry Soundness of the background analysis 16. The Program objectives were highly relevant to the country’s context. The improvement in health status of all Cambodians has been recognized by the RGC as a priority for investing national resources in the social sector. The PDOs were directly aligned with the objectives of the Second Health Strategic Development Plan (2008- 2015) which aim at increasing demand and ensuring equitable access to quality health services for all the population, especially for the poor, the women and the children. Achieving these high level goals directly contributes to poverty alleviation and socio- economic development. The PDOs were also fully consistent with the country’s broader development agenda as defined by the National Strategic Development Plan Update (2009-2013) and the Third National Strategic Development Plan (2014-2018). 5 17. The Program objectives were also aligned with the Country Assistance Strategy (2005-2008) and the World Bank Health Nutrition and Population (HNP) Strategy. The Country Assistance Strategy was developed jointly by the World Bank, the Asian Development Bank (ADB), DFID, and the United Nations, calling for increased investments in sectors relevant to the achievement of the MDGs. For the health sector, this translated into supporting Cambodia’s commitment to provide affordable health services for the poor, improving service utilization and service quality, reducing the burden of communicable diseases, and enhancing sector capacity and performance. The World Bank HNP “Healthy Development” strategy was focused around strengthening health systems and results. 18. The preparation of HSSP2 drew extensively from existing analytical and sector work such as the Health Sector Strategy Review (2003-2007), a Public Expenditure Tracking Survey Report in the Health Sector (2007), a Contracting Review (2007), a Midwifery Review (2007), a Poverty Assessment (2006) and an Equity Report (2007). All served as key inputs during project preparation. Annear et al. (2008) for example, identified the principal issues in health planning for Cambodia as being (i) the improvement of public health service delivery quality, (ii) the reduction of out-of- pocket payments, (iii) increasing the utilization of public facilities, and (iv) providing better access to services for the poor. All these four elements were taken into account during the preparation of the Project design. 19. The design of HSSP2 also incorporated a number of lessons from HSSP. After ADB decided to withdraw from the health sector in Cambodia, the Bank built a partnership with several other donors (including AusAID, DFID, AfD, BTC, UNICEF and UNFPA) to form a stronger sector-wide partnership for the new project. All of the successful initiatives in HSSP were continued in HSSP2 (performance based contracting with district health services, HEFs, strengthening health service delivery network). Skills and capacities built in MOH and the PMU during HSSP have been used during the implementation of HSSP2, and financial and operational management systems further strengthened. Assessment of Project Design 20. The design of HSSP2 expanded on the previous HSSP project. While the objective of strengthening health service delivery and institutional capacity was pursued to consolidate the progresses made under the previous project, improving health financing mechanisms and financial protection for the poorest as well as strengthening human resources were new focus areas under HSSP2. Support to health financing was an integral part of HSP2 in a context where the country was characterized by an unusually high reliance on out-of-pocket spending (about two thirds of total health expenditure). Moreover, the MOH’s Health Workforce Strategic Plan 2006 -2015 had identified human resources as a major constraint to improving service delivery outcomes in the health sector. 6 21. HSSP2 was designed to consolidate existing innovative pilot experiments which proved successful both on the supply and demand side of the health sector. On the supply side, the support to the SDGs provided by HSSP2 was meant to foster the adoption of internal contracting principles within the Government system to improve service delivery after MOH had already begun experimenting with sub-contracting district health service delivery through NGOs since 1998. On the demand side, Health Equity Funds had emerged as locally generated projects developed by various international NGOs to assist MOH in providing health services at district level with a focus on facilitating financial access to health services for the poor. Based on the successful experience in implementing these schemes, support for HEFs became an integral part of the National Poverty Reduction Strategy and the Health Strategic Plan, and the early HEF pilots quickly drew the attention of donors and policy makers. 22. The design of HSSP2 followed the sector-wide management (SWiM) approach which was in essence a flexible form of Sector-Wide Approach (SWAp) aiming at striking a balance between increased donor alignment with Government priorities and some degree of flexibility regarding funding and implementation mechanisms to preserve the participation of development partners who might otherwise not be able to be involved. In 1999 the RGC decided to pursue a SWAp to support the health sector. Subsequently, MOH adopted a modified version of sector coordination arrangements which was labelled SWiM and which provided more flexibility to development partners. Under the SWiM, the common strategic framework to achieve national goals and objectives was maintained, but pooled funding and the adoption of common implementation arrangements would not be mandatory. Adequacy of government’s commitment 23. MOH prepared the HSP2 through a participatory process with donors and NGOs, following a sector review to identify key problems. MOH also committed to developing comprehensive annual plans and budgets, linked to three-year rolling plans (3YRPs). The RGC had also shown strong support for the SWiM endorsing the principles of the Paris Declaration on Aid Effectiveness. The SWiM approach emerged as a modified version of a wider SWAp and aligned Development Partners’ effort behind MOH leadership and under a common strategic framework to achieve the national goals and objectives set in the Health Strategic Plans. 24. Transitional arrangements for implementation were conducted smoothly between HSSP and HSSP2. The HSSP Secretariat key functions were maintained with the extension of the Project Director and Project Coordinator’s positions. Other contract from previously employed consultants were also extended in the Secretariat’s administration, M&E, finance and procurement units. Additional positions were created to support implementation arrangements such as a pooled fund management officer, a discrete fund management officer and an infrastructure specialist. 7 Assessment of risks 25. Overall the risk rating for the Program was substantial, and the risk assessment covered a wide range of potential challenges at country level and at Program level, such as weak governance systems, weak institutional capacity to implement the Program in a decentralized context, the quantity and quality of civil works and goods, procurement risk, corruption risk, and weak financial management and controls environment. Table 2 below show the Country Policy and Institutional Assessment scores between 2005 and 2015. The rating for transparency, accountability and corruption in the public sector deteriorated from a low base during the period covered by the Program. Table 2. CPIA scores 2005-2015 26. Mitigation measures were appropriate and included: (i) providing technical support and capacity building; (ii) monitoring and physical verification, use of an International Procurement Agent (IPA); (iii) strengthening FM and procurement arrangements; (iv) the implementation and monitoring of a Good Governance Framework; (v) the establishment of preventive controls during the operation and (vi) external audits arrangements. Given the level of institutional risk assessment, adopting the SWiM approach can also be seen as a way to cautiously avoid the risk of placing the non- mandatory pooled funds on budget, by using a separate funding mechanism, and by working to gain leverage with the government and to manage risks. 2.2 Implementation 27. Effectiveness, MTR, Restructuring. The Program became effective on January 19, 2009. The Program MTR was conducted in November 2011 to align the process with the HSP2 mid-term review led by the Department of Planning and Health Information of MOH. The MTR influenced the fine tuning of program support and implementation. The Program closed on June 30, 2016, two years after the original closing date. The first extension of the closing date was approved at the request of RGC to allow adequate time for implementation completion of the civil works and delivery of medical equipment (PR2, June 11, 2014). The second extension took place because additional 8 financing was approved (AF3, October 30, 2015) to bridge the gap between the end of HSP2 implementation and the preparation of HSP3. 28. Program implementation of HSSP2 was planned to closely follow existing Government systems and procedures as much as possible. HSSP2 implementation was aligned with the National Planning Process which consists of (i) Joint Annual Planning Appraisal, (ii) Mid-Year Reviews, and (iii) Joint Annual Performance Reviews. Annual plans were developed and updated by using national planning and budgeting instruments (AOPs and 3YRPs). The AOP activities supported by the Program were implemented by the respective health sector implementing units, including central health departments, national programs and provincial health departments (PHDs) and operational districts (ODs). 29. The governance of HSSP2 was overseen by the Health Sector Steering Committee (HSSC) under chairmanship of MOH. The HSSC included high level officials of the MOH and other relevant line ministries and agencies, and provided policy guidance and implementation oversight of HSP2, including the endorsement of the sector AOP. A Secretary of State for Health was appointed as the Program Director to provide executive oversight on the overall Program implementation, and a Deputy Director General for Health was responsible for routine coordination of the Program supported by a Program Secretariat. The Program Secretariat was staffed with consultants and was responsible for facilitating the Program implementation with regard to the preparation of procurement plans and disbursement, semi-annual progress reports, providing information ahead of the Joint Annual Performance Reviews, maintaining communication with implementation units at the central and decentralized levels, as well as with the HSSP2 partners. 30. Phases of restructuring and additional financing were approved to preserve the continuity of engagement in the health sector. Some part of the apparent complexity of the HSSP2, including three rounds of additional financing, (AF01: 10/01/2013; AF02: 09/11/2014; AF03: 10/30/2015), can be attributed to the strong perceived support from the World Bank’s partner entities to continue this engagement in the health sector until a follow on project was possible. These rounds of additional financing through MDTF funding, allowed the sectoral engagement to continue even during a period of challenges in the overall engagement of the World Bank in the country (in the period from August, 2011 until the new CEN was approved by the Board in May, 2016). HSSP2, thus, became the only World Bank lending program in Cambodia that did not face any interruption in financing. 31. Factors outside of Government Control. Cambodia was negatively affected by the 2008 global financial crisis when real GDP growth dropped from a level of about 10 percent in 2007 to close to zero percent in 2009. Floods in 2011 and 2013 also affected Program implementation by reducing agricultural income, by increasing the water- borne burden of disease and by hampering access to health facilities. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 9 M&E Design 32. The M&E framework for HSSP2 was designed to be aligned with the Health Strategic Plan M&E framework. A selection of key Program indicators was drawn primarily from the HSP2 since there was a broad agreement amongst donors on the importance of adopting a single, common results and monitoring framework reflecting the Government’s priorities in the sector. 33. The results framework (RF) consisted of two sets of indicators: one related to Program results (see Table A in Annex 3 of the PAD), and one related to Project results (see Table B in Annex 3 of the PAD, where the term Project refers specifically to the pooling partners) 1 . The Program RF is used to monitor aggregate health sector performance and to track progress towards health outcomes. The Project RF included the Program RF (Table A) and, in addition, indicators aimed at measuring (i) improved policy, planning and implementation, (ii) improved financing at front line service delivery, (iii) use of performance results to improve planning and management, (iv) broad commitment and ownership of the sector wide process, and (v) improved sector governance (Table B). The Program RF had eight high level goals (impact level) and 30 outcome and output indicators, eight of which are proxies (outcome level) for monitoring the high level health indicators (impact level). In addition, the Project RF comprised 18 indicators. While the PAD explicitly states that the RF indicators against which the World Bank is held accountable are the 18 indicators in Table B of the pAD. 34. There is some degree of discrepancy between the broad ambition of the program and the selection criteria for some indicators in the Results Framework. While HSSP2 has only provided support to parts of the activities aligned with HSP2, it is mentioned in the PAD (p. 93, paragraph 248) that “the success of the program should be judged by looking at HSP2 as a whole, rather than on the specific areas supported with the pooled account”. Yet several outcome indicators were dropped because the underlying interventions were not financed by the program. 35. Several of the 30 Program Results indicators (Table A in PAD) did not have targets, and some did not have baseline. Out of the 48 original indicators, 18 were dropped at PR1, 12 were added, and 12 revised. During AF2, one indicator was revised, one was added, and 33 were dropped. Finally, at AF3, 14 indicators got revised, and one new indicator was added to the list. During the course of the project, indicators were dropped because they were assessed not relevant, or because of data collection and measurement issues. 1 Support provided through common management arrangements to the HSP2 was defined as “Program”. The term “Project” refers to the pooling partners which included AusAID, DFID, the World Bank, KOICA and KFW. 10 36. The original 18 Project Results indicators were “streamlined” first after PR1 (12/19/2010) and a second time after AF2 (09/11/2014) in order to further align the Results Framework with the Government’s own health strategic plan Results Framework, and in order to focus on indicators and targets that are measurable using existing MOH systems. In addition, four of the IDA “Core Indicators” for health were added. From the original list of 18 Project Results indicators, eight were dropped at PR1, and nine were dropped at AF2. Only one indicator (Proportion of ODs implementing SDGs and internal contracting meeting at least 80% of their performance target) remained. Before AF2, the indicators reported in the ISRs were the Project Results indicators. After AF2, the indicators reported were the Program Results indicators, plus the remaining Project Results indicators that were not dropped (one from the original PAD, and four core IDA indicators). One important motivation underlying the revision of the original dual Results Framework were the lessons learned from the 2011 Aid Effectiveness Assessment Report (Vaillancourt et al., 2011). In particular, it was deemed difficult for MOH to fully assume its sector stewardship role as long as DPs insisted on multiple M&E frameworks, indicators and reporting systems (Lesson 5 in the report). M&E Implementation 37. M&E was implemented as planned, using data coming from a variety of sources, including from HMIS, survey data (CSES, CDHS), LQAS, and participatory assessments. The MOH department of Planning and Health Information was responsible for the HMIS, and the Ministry of Planning for the CSES. With HSSP2 support, the HMIS was improved, moving from manual data collection of data to a fully computerized system, and with the inclusion of private sector data. A new software was purchased in 2010 to improve the quality and timeliness of data and its analysis. Some areas for further improvement remain, such as data quality, rationalization of indicators included in the HIS, capacity building for data analysis and data use, as well as timeliness of the data production stream. M&E Utilization 38. Joint Annual Performance Reviews were conducted annually to review and benchmark progress in the implementation of HSP2 and to determine the impact of HSP2 on improved health status. These Joint Annual Performance Reviews then formed the basis for annual planning in the Annual Operational Plans (AOPs). The AOPs were then used to promote decentralized planning through provincial plans. Community scorecards were implemented by NGOs at the beginning of the project but the pilot experiment was stopped due to difficulties in bringing it to scale. 39. Joint semi-annual Performance Reviews were also conducted to monitor progress made against annual targets. The purpose of these semi-annual reviews was to speed up implementation for indicators that were unlikely to meet their annual targets. 2.4 Safeguard and Fiduciary Compliance 11 Safeguard Compliance 40. The Program triggered four safeguard policies: Environmental Assessment (OB/BP 4.01), Pest Management (OP 4.09), Involuntary Resettlement (OB/BP 4.12), and Indigenous People (OB/BP 4.12). To address these safeguard policies, the Government prepared an Environmental and Social Management Framework (ESMF) comprising (a) an updated Environmental Management Plan with details on pesticide mitigation measures related to human and environmental impacts; (b) an updated Framework for Land Acquisition Policy and Procedures describing mechanisms for handling involuntary resettlement; and (c) an Indigenous People’s Planning Framework prepared in consultation with ethnic minorities. 41. Compliance with safeguard was assessed as moderately satisfactory between effectiveness and 2013, and as satisfactory from 2013 until Program closure. The only safeguard compliance rated as moderately satisfactory since effectiveness was the Indigenous People safeguard, due to delays from the Government in conducting consultations. All other safeguard compliances were rated satisfactory throughout all ISRs. Fiduciary Compliance 42. Fiduciary risks were deemed high during Program preparation. The design of mitigation policies was a high priority for the team which drew lessons from World Bank’s past reviews of projects as well as from more detailed assessments of projects in which mis-procurement were revealed. Appropriate control mechanisms were incorporated in the Financial Management and Procurement Arrangements and in the Good Governance Framework. 43. Financial Management. Project financial management at central level was carried out by a Financial Management Group (FMG). An accounting firm was hired to provide training on general accounting procedures and on the use of an accounting software. Capacity building at the subnational level was also supported at district and province levels. With the support of HSSP2, PwC provided capacity building to the internal audit department of MOH, and internal auditing manuals were developed. Looking forward, internal audit functions will be the responsibility of the internal audit department. Despite being intense and time consuming exercises, the Quarterly Integrated Technical and Financial Audit reports were effective tools to address technical and financial management issues in a timely manner. 44. Financial management was downgraded to “Moderately Satisfactory” at the third ISR, and then to “Moderately unsatisfactory” during the fifth ISR (01/23/2013) due to delays in the submission of IFRs and inaccurate cost projections. MOH had also not adequately addressed FM issues identified in audit reports. The timely submission of the financial audit reports improved and were unqualified since April 2014 (7th ISR) which resulted in an upgraded rating to “Moderately Satisfactory”. Further improvements in monitoring the implementation of the auditor’s recommendation 12 resulted in an upgraded rating to “Satisfactory” by June 2015 (9th ISR). The processing of funding extension requests between July 2014 and June 2016 translated into some interruptions of funding which affected Program implementation. The RGC managed, however, to fulfill its commitment to finance the funding gap in HEFs during the first semester of 2016. 45. Procurement. A specific HSSP2 procurement department within the MOH was in charge of all bids financed under the Program for both pooled funds and discrete funds. The procurement activities were carried out by an International Procurement Agent (IPA) which adhered to the RGC’s Standard Operating Procedures (SOP) for Externally Assisted Projects. The RGC and the World Bank agreed to exit the IPA arrangements after the expiry of their contract. An international procurement consultant was then hired to support the MOH procurement department in executing the remaining procurement tasks related to HSSP2 implementation. Overall, procurement was conducted according to procedures. There were however occasional delays due to, for example, price escalation and shortage of construction labor. The RGC approved and adopted a revised Standard Operating Procedures and Procurement Manual in May 2012 for HSSP2 procurement tasks. 46. Procurement was downgraded to “Moderately Satisfactory” during the 4th ISR (March 2012) due to delays by MOH in providing technical specifications and consultant recruitment. Continued delays in addressing technical inputs for some procurement packages and procurement delays in general resulted in keeping the rating to “Moderately Satisfactory” until closure. 2.5 Post-completion Operation/Next Phase 47. A new project building on the lessons learned from HSSP2 was approved by the World Bank Board on May 19, 2016. The project development objectives of the Health Equity and Quality Improvement Project (H-EQIP) for Cambodia is to improve access to quality health services for targeted population groups with protection against impoverishment due to the cost of health services in the country. The project will consolidate the HSSP2 achievements by focusing on: (a) strengthening quality of health service delivery by expanding the current SDGs into a mechanism for providing performance-based financing to different levels of the Cambodian primary and secondary health system based on achievement of results; and (b) by improving financial protection and equity, through continued support and expansion of the HEF system, and with RGC co-finance of the cost of health services for the poor. In addition, the third component will aim at ensuring sustainable and responsive health systems, by supporting a program of activities designed to improve supply-side readiness and strengthen the institutions that will be implementing project activities. Project design followed core principles aligned with those of HSSP2 such as the support of a broader government program (HSP3), a focus on results, and a continued ambition to mainstream implementation arrangements to make greater use of Government’s systems. 13 48. The implementation arrangements are also based on lessons learned from HSSP2, as well as from the PFM reforms ongoing in the country. The implementation agency for the project will be the MOH through the Department of Planning and Health Information (DPHI) and the Department of Budget and Finance (DBF). 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation Relevance of Objectives Rating: Substantial 49. The Program objectives were, and continue to be, highly relevant to the country’s sectoral context. The improvement in health status of all Cambodians was recognized by the RGC as a priority for investing national resources in the social sector. The PDOs were directly aligned with the objectives of the Second Health Strategic Development Plan (2008-2015) which aimed at increasing demand and ensuring equitable access to quality health services for all the population, especially for the poor, women and children. Achieving these high level goals directly contributed to poverty alleviation and socio-economic development. These objectives remain relevant with respect to the (draft) Third Health Strategic Plan 2016-2020 (HSP3). The overarching goal of HSP3 is “improved health outcomes of the population, with increased financial risk protection in access to quality health services”. 50. The Program objectives were also fully consistent with the country’s broader development agenda as defined by the National Strategic Development Plan Update (2009-2013) and the more recent Third National Strategic Development Plan (2014-2018) which provided the foundation for investing in health as a means to develop human capital and build a more productive workforce for the social and economic development of Cambodia. Improving access to quality health services and increasing financial protection coverage are also two key objectives of the recently adopted Sustainable Development Goals (SDGs), especially with respect to goal 3.8 on Universal Health Coverage (UHC). Relevance of Design Rating: Substantial 51. The Program components were also very relevant to the operational framework of HSP2. Strengthening health service delivery, improving health care financing, strengthening human resources, and strengthening health system governance were four of the five strategic areas of HSP2. Moreover, the focus on RMNCH, on communicable diseases control and on non-communicable diseases also corresponded to the three priority health program areas of HSP2. 52. The logic of the results chain was sound and addressed key weaknesses of the Cambodian health system from the supply side and from the demand side. 14 Improvements in the availability and quality of physical infrastructure and of human resources, coupled with management reforms offering more autonomy in exchange of greater accountability of performance at the decentralized level were meant to strengthen the supply side of the health system. Improvements in financial protection of the poor through the consolidation of HEF schemes addressed some of the main demand side constraints. 53. The use of a pooled funding mechanism and of a Sector Wide Management Approach (SWiM), including common management and monitoring practices, strengthened wider stewardship of the sector and institutional capacity for MOH, as well as reduced the transaction costs generated by donor fragmentation. 3.2 Achievement of Project Development Objectives 54. This evaluation’s interpretation of the Program’s objectives breaks down the PDO in three components: a. PDO1: Improve health outcomes b. PDO2: Institutional capacity strengthening i. Strengthening human resources ii. Strengthening health system stewardship functions c. PDO3: Strengthening mechanisms by which the Government and DPs can achieve more effective and efficient sector performance i. Strengthening health service delivery network ii. Improving financial protection 55. A summary of indicator achievement broken down by PDO component is given in Table 3 below. This table includes an assessment of indicators that were included in the Results Framework during Program implementation but which were dropped at some point 2 . The summary table for indicator achievement is based on the more detailed Table in Annex 2b where all indicators are broken down according to their PDO component and according to the type of indicator (impact, outcome, output). Overall, 89% of the measured indicators were achieved or surpassed. 2 As long as the indicator is measured and can be assessed against original target values. 15 Table 3: Indicators summary table for efficacy rating PDO1 PDO2 PDO3 Strengthening mechanisms to Strengthening institutional High level HSP2 goals achieve more effective and capacity efficient sector performance 2a: Human resources 3a: Health service delivery Improve Health Outcomes 2b: Health system stewardship 3b: Financial protection IMPACT Outcomes Outputs Outcomes Outputs Surpassed* 3 0 1 14 7 Achieved* 1 3 8 3 2 * Not achieved 2 0 2 1 0 Dropped but measured 0 2 9 5 3 Dropped / not measured 2 6 9 6 6 Total (measured) 6 3 11 18 9 % achieved (among measured) 67% 100% 82% 94% 100% * Includes the number of indicator that were dropped, but measured through the HMIS. Project efficacy is rated Substantial PDO 1. Improve health outcomes: Substantially Achieved 56. Cambodia has made remarkable progress towards achieving the MDGs which were the higher level outcomes to which the Program contributed. Maternal, infant and under five mortality fell on average by about nine percent per year between 2005 and 2014. Over the same period, neonatal mortality fell by almost five percent annually, and stunting by about three percent. Most of the high level impact goals figuring in the Program Results framework have been achieved or surpassed and the end of the project period. The original HSP2 targets for chronic undernutrition and for maternal mortality were not met in 2015, but the improvement in these indicators is positive and accelerates during the course of the projects if the average annual changes are compared with those preceding the project period. 57. Two indicators have not been achieved but are trending positively with an acceleration of progress between 2010 and 2014. The target for maternal mortality for example was 140 deaths per 100,000 live births in 2015, with the actual value 170 based on the 2014 CDHS results. Given that the observed average rate of reduction in maternal mortality between 2010 and 2014 was about -4.7% per year, one could expect the 2015 value to lie around 162 which would represent a potential achievement given that the target would represent 86% of the actual value. TB death rate is also trending positively towards its target value (32 per 100,000) from 75 per 100,000 at the beginning of the Program to 55 per 100,000 in 2015. 58. Several factors have driven these achievements, including economic growth. Income growth alone however does not account for all the progress achieved in health outcomes. Figure 1 below for example shows a predicted under five mortality rate based on a fixed effect panel regression model using income and a (non-linear) time 16 trend as explanatory variables3. We can see that while the simple fixed effect model captures the declining trend in under five mortality, it underestimates the decline between 2004 and 2014. The gap between the actual data points and the predicted series increases with years during the period span of the Project, suggesting that income alone is not a sufficient factor to explain the observed improvement in health outcomes. The observed increase investments in physical infrastructure, improvements in the quality of health service provided, and increase in essential health service utilization by the Cambodian population, including the poorest, are also important plausible contributing factors behind these trends. Figure 1: Predicted and actual under 5 mortality 120 100 HSSP2 Under 5 mortality rate 80 60 40 20 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 Fixed Effect Model WDI 59. The large improvements in health outcomes observed over the period 2008-2014 have allowed Cambodia to catch up with average regional outcomes. Table 4 below shows that for key selected health outcomes, the ratio between Cambodia and the EAP average has reduced between 2008 and 2014. 3 Annex 3 shows similar figures for maternal mortality and for life expectancy. 17 Table 4: Health outcomes regional comparison 60. Important inequalities in health outcomes do persist however. Improvements in health outcomes are not equally distributed across the 24 provinces of the country for example. Table 5 below gives the level achieved in infant mortality as well as the average annual rate of change in the indicator between the years for which DHS surveys were conducted. Table 5: Levels and changes in infant mortality across provinces PDO 2. Strengthening institutional capacity: Modestly Achieved 61. Overall, all 86% of all measured indicators have been achieved. All of the (3) outcome indicators were achieved, and 82% of the 11 output indicators were also achieved (Table 3). Strengthening Human Resources: Modestly achieved 62. The Project contributed to increase the coverage and to improve the distribution of secondary midwives across the country and in all provinces. Despite the fact that the secondary midwives’ coverage ratio indicator was dropped from the RF at AF2, 18 HMIS data show that the nationwide coverage ratio increased by 37% from 1.35 to 1.85 secondary midwife per 10,000 population. The distribution of these key health personnel has also been appropriate with all health centers in the country having at least one secondary midwife at the end of the Project (against a target of 85%). 63. The Project also contributed to substantially increase the number of pre-service and in-service training provided to public health staff. National examinations for pharmacists, dentists and nurses were introduced as planned, and these factors have played a key role in improving health service quality. 64. Progress in other domains such as Health Professional Registration and Licensing, scaling up the public sector workforce against population growth and the development of policy regarding private sector regulation have however been slower. These elements were highlighted in the Health Workforce Development Plan (HWDP) 2006-2015. The mid-term review of the HWDP recommended for example that urgent attention is given to the further development of mechanisms and processes to regulate and ensure quality and adequacy of the health workforce, with the institution of a formalized governance framework to oversee the accreditation of institutions. 65. The introduction of performance based incentives schemes for public health managers and technical staff did not succeed. The MBPI scheme represented one of the main elements behind the Program strategy to strengthen human resources, but it was cancelled by the Government of RGC in January 2010 leading to the first restructuring of the Project. The MBPI scheme was replaced by another merit based incentive scheme called Priority Operating Costs (POC). The POC scheme was then subsequently ended in July 2012. 66. A Value for Money Assessment (VFM) for training and supervision activities was conducted in 2012 and highlighted several components with low value for money. The MOH model used for preparing training facilitators to deliver courses using Training of Trainer (TOT) at the sub-national level combined with leadership from key facilitators from national agencies was shown to be cost-effective. Operational district integrated supervision of health centers was assessed as providing good value for money. At the level of Provincial Health Departments however, integrated supervision activities were assessed as low value for money. Moreover, the evaluation identified weaknesses in the MOH training continuum which include: (i) identification of training needs based on a national prioritized training plan (absent); (ii) effective targeting of the MOH cadre that requires training (weak to absent); (iii) and assessment of the impact of training against identified health indicators (absent). Because of these major gaps in the MOH training continuum, HSSP2 Pooled Fund training expenditure was assessed overall as low value for money. Strengthening Health System Stewardship Functions: Substantially Achieved 67. The Program has contributed to strengthening institutional capacity and to support MOH policies and regulations in critical areas identified in the Health 19 Strategic Plan. Assessing and quantifying the extent to which the Program has effectively contributed to strengthen MOH’s stewardship functions is rendered difficult by the fact that only one of the initial 21 RF indicators related to Strengthening Health System Stewardship has been retained throughout the course of the Project (see Annex 2b). Overall however, out of the seven indicators that were measured, all were surpassed. HEFs were scaled up over the life of the program and became Cambodia’s most significant social security scheme. The program also supported the development, implementation and regulation enforcement for quality standards through the regular quality of care assessments. Finally, in order to increase accountability of health providers to citizens, the program provided technical support to the National Center for Health Promotion. Areas of technical support included health promotion, nutrition, and behavior change surrounding food and hygiene for pregnant women and post-delivery. 68. At the subnational level, the Program contributed to increase the autonomy of provincial and district level agents at the operational level ensuring more efficient service delivery. HSSP2 supported the national policy on public service delivery through the transition of contracting of NGOs under HSSP to MOH internal contracting of Special Operating Agency (SOA) for SDGs under HSSP2. This move translated directly into increased autonomy of public service providers. HSSP2 provided support in the area of internal contracting through the conversion of ODs and Provincial Referral Hospitals (PRHs) into Special Operating Agencies (SOAs) as well as through the transfer of performance based Service Delivery Grants (SDGs) from the central level to the local level (ODs and PRHs). The resulting increased management autonomy, coupled with the development of a solid web-based HMIS system, a stronger electronic Patient Management and Registration System (PMRS), and with increased staff incentives for front line health personnel have also contributed positively to the provision of more efficient service delivery. 69. Efforts to strengthen the local budgeting process through the AOPs have been pursued, but improvements in overall efficiency of health expenditures remains possible. Training, supervision and outreach activities at central and provincial level were supported by HSSP2, but the JPIG partners continued to express concerns about the disconnect between subnational budgeting and the AOP process. Initially, each AOP would constitute the first ingredient in the MOH three-year rolling plan (3YRP). Subsequently, the government introduced the Budget Strategic Plan (BSP) with a medium-term horizon to incorporate the sector AOP. The BSP, together with the Public Investment Program constitutes the principal strategy for medium to long term planning which is aligned with the National Strategic Development Plan (NSDP). The link between these national plans, the Medium Term Expenditure Framework and the AOP needs to be strengthened. External financing for example is not fully captured in the government budget and is not classified using the government’s chart of accounts. Subnational level planning is also not fully integrated in the BSP. 70. Initial activities to strengthen private sector regulation and partnership have been supported by the Program, but overall there is still scope for reinforcing the regulatory mandate of MOH. During the course of the project, MOH has made 20 progress in developing standards for public and private training institutions, and developing a licensing system for health professionals. The completion of the National Laboratory and Drug Quality Control, meeting strict international pharmaceutical and environmental standards, has also strengthen MOH’s capacity to monitor counterfeit and sub-standard drugs use in the country. Despite these improvements, regulation of private service providers, especially private-for-profit health care providers remain a major challenge. While only authorized practitioners are allowed to operate in the public sector, the enforcement of licensing and registration procedures is still incomplete. The MOH took an initial step towards establishing a proper accreditation system for health providers by developing a Master Plan for Quality Improvement in Health (2010-2015). 71. Progress in the domain of increasing effective sector coordination have been made, but there is still a need to make the governance strategy more explicit. Overall, HSSP2 and the JPIG have contributed to decrease the degree of fragmentation in a sector characterized by high fragmentation among the development partners, thereby increasing harmonization and improving alignment of priorities. The establishment of a pooled funding mechanism, as well as the Joint Partnership Arrangement between RGC and the HSSP2 Development Partners have improved the alignment and consistency of activities supported in the sector. HSSP2 also acted as a convening platform to harmonize the voice of the JPIG partners in their policy dialogue with RGC and MOH. The conduct of joint supervision missions and six-month joint review meetings (JRM) as well as joint quarterly management meetings (JQM) and joint technical and financial audits have also translated into more effective coordination across the sector. The HSP2 2011 mid-term review (MTR) however highlighted the fact that visualizing and appraising the specific strategies and decisions taken in relation to governance as a cross-cutting strategy was difficult. The MTR report noted that lack of clarity and visibility of the governance agenda, and lack of regular reporting on progress achieved are clear limiting factors for the implementation of this cross- cutting strategy. In addition, the 2011 Sector-Wide Management (SWiM) Assessment drew similar conclusions in pointing out the absence of a clear articulation of the SWiM vision, goals, objectives, performance indicators, implementation arrangements and accountability mechanisms. PDO 3. Strengthening mechanisms by which the Government and Program Partners can achieve more effective and efficient sector performance: Substantially Achieved 72. Overall, all 96% of all measured indicators have been achieved. 94% of the (18) outcome indicators were achieved, and all of the nine output indicators were also achieved (Table 3). Strengthening Health Service Delivery: Substantially Achieved 73. Supporting the transition from pilot experiences in contracting health services from international NGOs into scaled up internal contracting arrangements has 21 been a major achievement of HSSP2. Established in 2009 by government decree, Special Operating Agencies (SOAs) are decentralized MOH administrative units which provide district health managers with greater autonomy in decision making and additional resources to be used for staff incentives and to cover operating costs, in exchange for stronger accountability for performance. Internal contracts were signed between the central MOH and the provinces (as commissioners), and between the commissioners and the district level (SOAs). MOH defined and monitored the performance agreements with the contracts stipulating the specific roles and responsibilities of the respective parties, with performance targets and associated bonuses. Additional funds channeled through the Service Delivery Grants (SDGs) were paid 80% in advance, with 65% for staff incentives, and the remainder for operating costs. The remaining 20% represented an SOA performance bonus payment and was paid upon verification of services delivered. The government counterpart contribution to SDGs increased from ten percent in year one of program implementation to reach 40% in 2013. After the 2011 MTR, MOH requested HSSP2 support to fully scale up SOAs nationwide. 74. HSSP2 support to the three strategic health program areas was successful, although Non-Communicable Diseases (NCDs) remain an underfunded priority area. All outcome and output indicator targets for RMNCH and for Communicable Disease Control have been achieved or surpassed. HSSP2 has for example contributed to the success of reducing the dengue case fatality rate from 1.2% to 0.25% in 2016. The percentage of births delivered by trained staff in facility has also increased from 39% in 2009 to more than 80% in 2016. It is difficult to assess however the extent to which the Program has contributed to supporting NCDs control given the absence of relevant indicators being monitored by the M&E system. AOP resource allocations of program budgets for NCDs have increased from 0.5% in 2008 to 2% in 2014. At the same time, NCDs represent about 57% of the total burden of diseases in Cambodia in 2015 (IHME, 2015). 75. HSSP2 has also contributed to strengthening the health service delivery network. The final number of health facilities constructed, renovated or upgraded (699) surpassed the original target of 300. The construction and renovation and equipping of the BEmONC and CEmONC facilities has been almost entirely due to HSSP2 funding. This large increase has most likely contributed to reducing MMR, although geographical spread remains inequitable. Maintenance and the use and repair of clinical equipment remains a challenge. 76. While utilization of public health facilities has increased, the percentage of the population being ill or injured and seeking care first in private facilities instead of public facilities is also increasing (see Figure 2 below). This is a signal that the quality of services provided in public facilities remains a concern. This also suggests that private sector regulation should be kept high on the MOH reform agenda. 22 Figure 2: Type of first contact health provider Percentage of ill or injured population who sought treatment, by place of treatment 70.0 60.0 50.0 40.0 30.0 20.0 10.0 2005 2010 2014 First public (Total) First private (Total) First public (Rural) First private (Rural) Source: CDHS 2005, 2010, and 2014. Improving Health Financing: Substantially Achieved 77. Supporting the scale up of Health Equity Funds (HEFs) nationwide has been another major achievement under HSSP2. The HEF system has become Cambodia’s most significant social security scheme, covering the poorest 20% of the total population (approximately 3 million). This system is funded by government taxation revenues and by pooled donor funding. The system was designed to reduce the financial barriers to accessing health services for the poor. HEFs are autonomous district-based schemes that reimburse public health facilities for the cost of user-fee exemption provided to the identified poor. A subsidy for transportation costs and food required during health seeking episodes is also provided. HEF beneficiaries are identified either through the national (Ministry of Planning) Identification of Poor Households Program (IDPoor), or through post-identification at Referral Hospital level. 23 Figure 3: Total HEF member visits by facility types and year Source: Annear et al. (2016) 78. A substantial body of evidence has shown that HEFs have increased access to health services for the poor, raised utilization levels at government facilities, acted as a significant source of additional revenue for public facilities, and reduced debt for health care4 . A recent analysis of the Cambodia Socio Economic Survey has also shown that HEF reduced the amount (but not the incidence) of out-of-pocket expenditure on health by 35% on average, with a larger effect for the poorer households. Another recent report on HEF member service utilization has shown that HEF recipients have greater access to hospitalization services than the rest of the population, and have similar utilization rates at HC level. 79. Relying on several rounds of CSES data, we can see that while impoverishment due to OOP for the total population has decreased steadily since 2007, the incidence of catastrophic payments has been on the rise between 2011 and 2013 (Figure 4). While this recent trend has touched all the population covered by the survey, it seems that the increase in the share of households spending 25% or more of their budget on health OOP was driven mostly by the better off households who are more likely to resort to private facilities (Figure 5). 4 Annear et al. (2016) National coverage and health service utilization by Health Equity Fund members, 2004-2015. 24 Figure 4: Financial protection indicators Financial Protection Indicators (% population) 14.0 12.7 11.5 12.0 10.2 10.0 8.5 8.3 8.0 6.8 5.8 5.4 6.0 4.7 5.0 4.9 4.0 3.0 2.6 2.1 2.0 3.3 2.7 2.3 2.2 0.3 1.8 0.5 0.0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Catastrophic payments (15%) Catastrophic payments (25%) Impoverishment ($1.90) Figure 5: Changes in catastrophic payments (25% threshold) 12 Incidence of catastrophic payments (25% threshold) 11 10 9 8 7 6 5 4 3 2 1 0 Poorest 20% Q2 Q3 Q4 Richest 20% Source: CSES 2008 and 2013. Hollow (solid) circles are 2008 (2013) values. The dashed orange line represents the national average in 2008 (%). The solid orange line represents the national average in 2013 (%). 3.3 Efficiency 80. Given the broad objectives of the Program, the economic analysis provided in the PAD does not provide an explicit calculation of the External Rate of Return (ERR) / Internal Rate of Return (IRR), or the expected Net Present Value (NPV) of the Program. While the Program contributed to finance inputs, activities, and interventions in specific areas, it also provided a broad platform to align the efforts and 25 objectives of MOH and development partners regarding resource allocation in the health sector. It is mentioned in the PAD that “given this logic, the success of the Program should be judged by looking at HSP2 as a whole, rather than on the specific areas supported with the pooled account”. 81. Economic efficiency. Following the logic underlined in the PAD, we attempt to estimate the NPV of the Program in light of the overall achievement in health outcomes. We first start by estimating what health outcomes would be by estimating a simple model using country level fixed effects, a nonlinear time trend, and GDP per capita as the main predictors. This is our simplified counterfactual scenario. We then value the incremental gains in health outcomes observed above and beyond what this simple model would predict. These incremental health gains are then valued using the estimated Value of Life Year (VLY) parameter derived by the Lancet Commission on Investing in Health for the East Asia and Pacific region5. Depending on the assumed value for a discount factor used over the duration of the project, we estimate the NPV of the Program to lie between USD 220 million (using a seven per cent discount factor) and USD 930 million (using a three per cent discount factor). This corresponds to benefits to costs ratios ranging from 2.5 to 6.2. 82. Leveraged resources and alignment of development partners with MOH. Another important aspect of HSSP2 contributing to the overall economic efficiency was the capacity of the Program to leverage multi donor resources into a pooled fund, and to align resources and objectives to the Government’s priorities and strategic plan. While the initial financing envelope for HSSP2 was USD 110 million at appraisal (including USD 30 million from IDA), the overall financing at the end of the Program amounted to USD 213 million, including pooled fund contributors, discrete funders, and the Government of Cambodia counterpart contribution. Feedback collected during the ICR mission interviews suggested a common view that HSSP2 had served as an effective harmonization platform both for the strategic dialogue between the development partners and MOH, as well as among the development partners themselves, and in terms of management and supervision of the Program implementation. The pooled funded program has been seen as an improvement over more traditional bilateral approaches or stand-alone projects. This was mainly due to the common management and implementation structure. The pooled funding approach has been seen as a vector of economies of scales and of reduced transaction costs which allowed some development partners to maximize the return on their investments in the sector. 83. Performance based contracting influence the overall efficiency of the system by changing incentives at the margin. While the vast majority of personnel working in SOAs are regular civil service employees, with their base pay and benefits directly funded by MOH budget allocation, part of the SDGs received in relation to performance outcomes were used to fund salary top-ups in order to incentivize 5 See Jamison et al. (2013) Global Health 2035: a world converging within a generation. Lancet 382(9908), pp. 1898-1955. 26 improvement in the quality of service provision. The 2015 Level 2 Quality of Care Assessment suggests that SOAs appear to have higher quality of care services compared to non-SOAs. Similarly, HEF revenues to facilities represented a marginal increase in revenues for facilities representing on average about five percent of the full cost of the health system. These only provided marginal incentives for facility managers to improve the quality of service delivery, including the poor. 84. Implementation Efficiency. The ICR assessment for implementation efficiency is mixed. Many of the key activities financed under HSSP2 have improved the coverage and quality of high impact interventions for children and women such as family planning; antenatal, delivery and postpartum care; breastfeeding, immunization and integrated management of childhood illnesses (IMCI). The civil work and medical equipment procurement have also been prioritized based on assessments of basic and emergency obstetric and neonatal care. According to a Value-for-Money Assessment conducted in 2012, the overall MOH model for preparing and delivering training courses at the sub-national level proved to be cost-effective and efficient. Operational district integrated supervision was also assessed to provide good value for money. However, most of the other training and supervision activities evaluated showed low value for money. Initial implementation of SDGs also faced a variety of difficulties including delayed transfers, lack of clarity in administrative procedures, unclear guidelines on target setting and limited engagement of PHDs Commissioners. The implementation of outreach activities faced several challenges with budget allocations falling short of the AOPs and of the need, and with inefficiencies stemming from the conduct of fragmented “vertical” outreach activities. The activities conducted focused on closest and easy to reach villages to meet the service coverage targets, instead of benefiting the most remote communities. Finally, non-communicable diseases remained underfinanced with respect to the burden of diseases (45% of DALYs in 2005 and 57% in 2015) even though NCDs were one of the three priority national Programs in HSP2. 85. The multiplication of funding extension requests at the end of the project increased transaction costs and generated interruptions in funding flows which affected service delivery. During the implementation, especially from 1st July, 2014 to 30th June, 2016, there have been several interruptions of funding due to different stages of request for extension of HSSP2 from the Ministry of Economy and Finance to the HSSP2 Partners. The Interruptions of funds, especially during the last stages of HSSP2 have had adverse impact on program implementation. Better planning and avoiding the multiplication of extension requests would have minimize the risk of abrupt interruption of funding, leading to the interruption of key activities such as the implementation of HEF to help the poor to access to health care service. 27 3.4 Justification of Overall Outcome Rating Rating: Satisfactory 86. The overall outcome of this project is Satisfactory. Even though a split rating was initially applied to evaluate the achievement of objectives through the main phases of the Project (effectiveness to PR1, PR1 to AF2 and AF2 to closure), the final assessment by PDO subcomponents does not change between the different phases so we present ratings pertaining to the whole course of implementation. Table 3: Rating Summary Ratings RELEVANCE: Relevance of Objectives Substantial Relevance of design Substantial EFFICACY: Expected Impact: Substantial Improved health status Expected Outcomes: Strengthening institutional capacity  Strengthening human resources Modest  Strengthening health system stewardship Substantial functions Strengthening mechanisms to achieve more effective and efficient sector performance  Strengthening health service delivery Substantial  Improving health financing Substantial EFFICIENCY Satisfactory Overall Outcome SATISFACTORY 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts 87. The scaling up of HEFs has been seen as Cambodia’s most significant social security scheme. Approximately three million poor Cambodians are now enrolled in the HEF. The poor are identified by local government authorities through routine interviews that consider household assets and vulnerabilities. The poor are identified with an “ID poor card” that grants them access to subsidized services available at public health facilities. When members of poor households are hospitalized, they are also provided with reimbursement for transportation and a food allowance of for the patient’s caretaker. As a result of scaling up HEFs, fewer households are falling into debt to pay for health care. Two recent surveys show that household debt for health care has fallen across the country, but that effect is more pronounced in areas where HEFs provide support. HEFs reduced out-of-pocket expenditures by the poor on health care by 29 percent and reduced the amount of their health-related debt by a quarter. 28 (b) Institutional Change/Strengthening 88. The establishment and strengthening of SOAs have fostered a new mindset in public service delivery, where citizens are seen as customers, and results are more important than bureaucratic systems. SOAs are seen as ministry-led semi- autonomous government bodies controlled by performance targets setting and management contracts. These entities still receive funding through the national budget, but they are also granted a certain degree of autonomy over finance and managerial decision making. While in theory any ministry can seek to establish SOAs, most existing SOAs are health agencies, which underlines the leading role of the health sector in implementing internal contracting schemes at scale in Cambodia. (c) Other Unintended Outcomes and Impacts (positive or negative) 89. HSSP2 represented a vehicle for continued engagement with the RGC during a period in which the overall World Bank portfolio had substantially reduced in Cambodia. The World Bank froze new lending to Cambodia in 2011 over mass evictions at the capital's Boeung Kak lake. The discontinuation of new IDA lending led to a reduction in portfolio size both by commitments and by number, as closing projects were not replaced by new commitments. As the World Bank Board agreed in July 2016 to restart lending the current IDA portfolio consists of two investment operations for a total commitment of US$53 million in the education and health sectors. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 90. No beneficiary survey was specifically undertaken under HSSP2. 4. Assessment of Risk to Development Outcome Rating: Moderate 91. Risk to health outcomes is low. The Cambodian economy is growing steadily by approximately seven percent annually and has recently graduated to lower-middle income status. The Government is showing strong political commitment to consolidate and expand the set of extensive health reforms initiated in the 1990s. The RGC has recently adopted a new Health Strategic Plan (HSP3 2016-2020). Government funding which has increased significantly over the recent years is expected to remain sustained. A new health sector support project (H-EQIP) has been prepared to improve access to quality health services for targeted population groups. 92. Risk to financial protection outcomes is moderate. One explicit objective of the new H-EQIP project is to provide protection against impoverishment due to the cost of health services through a dedicated component to improve financial protection and equity. This component will provide support to consolidate the HEFs which are now covering the entire poor population in rural areas. Further consolidation of the HEF scheme will include deeper appropriation by RGC, expansion of the target population to include vulnerable groups, and expansion of the benefit package with efforts to improve the quality of care. 29 93. Governance risk is substantial. Governance of the health sector remains constrained by a limited ability of the Government to manage and coordinate multiple initiatives and by weak regulation of public and private sector providers. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance 94. HSSP2 represented a continuous sectoral engagement for the World Bank in Cambodia. The health sector was one of the only sectors through which the World Bank was supporting Cambodia during the period of loan freeze (2011-2016). Moreover, within the health sector in Cambodia, the World Bank represented an element of continuity during HSSP2 by being, with Australia, the only development partners supporting the Program throughout its whole duration. The Bank has been a trusted partner to the Royal Government of Cambodia (RGC) over the last 13+ years. Each of the country’s strategic health plans, since the first one (2002-2007), has been supported closely by a Bank-financed project, often co-financed with trust funds and informed by strategic analytical work. The Bank engagement has evolved from support to initial policy intervention pilots on contracting for service delivery (initially from NGOs) and the highly successful Health Equity Funds (HEFs) that were mainstreamed under HSSP2 with nationwide coverage. 95. The Bank has been at the forefront of alignment and harmonization efforts of development partners’ support to RGC. The performance of the Bank in these convening, coordination and joint implementation roles (including as an MDTF administrator) has secured the trust of partners who see the Bank as the most appropriate entity to pool and manage funds, and to lead knowledge work that would support further attainment of project’s development objectives. (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Satisfactory 96. The design and preparation of HSSP2 was technically sound and highly relevant to the health sector priorities identified in the Second Health Strategic Plan. HSSP2 can be seen as a natural continuation building on the lessons learned from the previous project and from the pilot experiments conducted in Cambodia such as service contracting to NGOs and pilot HEF and CBHI schemes. The overall ambition of HSSP2 was to consolidate, scale up, and mainstream through Government systems the experiments that proved successful at pilot scale. The adopted SWiM approach also proved to be a flexible compromise between a more stringent Sector Wide Approach and stand-alone projects. In a context of high fiduciary risk, the Good Governance Framework provided detailed, comprehensive and appropriate risk mitigation actions which applied to all activities funded by the pool account. Social and environmental safeguard policies were also appropriately addressed. 30 97. While the HSSP2 M&E framework and indicators were aligned with those of HSP2, the original design proved too complex and unnecessarily lengthy. Several important adjustments were made to the Results Framework during the project with several indicators dropped, others revised and some with target adjustments. The total number of indicators was 68 at PR1, 54 at AF2, and 22 at AF3. (b) Quality of Supervision Rating: Satisfactory 98. During the seven-year period of project implementation, the project had four different TTLs, but the nature of the supervision (frequency and quality) remained constant and appropriate. Supervision missions were conducted jointly with the other development partners contributing to the pooled fund, and the Joint Review Mission Reports were similarly structured around Program components and development impact. These reports were of good quality, candid, and ISR performance ratings were supported by evidence. Supervision of fiduciary and safeguard policies was appropriate. 99. The World Bank has adequately fulfilled its management and fiduciary roles as the manager of the development partners’ pooled fund through the HSSP2 MDTF. A 2016 DFAT Partners Performance Assessment attributed the World Bank a rating of 5 (“Good, satisfies criteria in almost all areas”) out of a 6 points scale for (i) being results focused and delivering on time, (ii) undertaking sound monitoring and evaluation reporting, and (iii) promoting sustainability where applicable. The assessment also attributed a rating of 5 for efficiency (“Maximize value for Money”) with World Bank policies and procedures, including fraud, corruption and procurement policies and processes, evaluated as adequate to mitigate fiduciary risks during HSSP2 implementation and to ensure procurements are value for money. Collaboration, communication and responsiveness was also rated 5, as well as “Policy alignment, risk management and innovation”, and “Effective partner personnel”. (c) Justification of Rating for Overall Bank Performance Rating: Satisfactory 5.2 Borrower Performance (a) Government Performance Rating: Satisfactory 100. The RGC remained committed to this Program and to supporting the achievement of its development objectives. This commitment manifested itself through the provision of counterpart funding, although with some delays, and through the Government request to scale up proven successful activities such as the SDGs and HEFs. Government’s commitment to HEFs and SDGs rose steadily from 10% in the first year of the project to over 40% of the budget in 2014 and in subsequent years. 101. The provision of counterpart funding took place with some delays, but the RGC increased its counterpart funding during the course of the Program. Delayed 31 provision of counterpart funding resulted in ISR rating of “Moderately Unsatisfactory” in 2013 at ISR 5 and 6. The performance of the RGC in this domain was however upgraded to “Satisfactory” when the full share of counterpart funds allocated for 2013 was released and when MEF confirmed and disbursed the 2014 allocation to HEFs and SOAs. 102. Transition of HSSP2 Secretariat functions to MOH were an explicit objective of the Program, but was never fully implemented. Progress on moving HSSP2 toward a sector-wide approach with greater alignment and use of country systems remained a challenge. It was estimated in 2012 that a full transition as originally planned would have been unlikely due to human resource constraints which prevented MOH to follow World Bank/JPIG recommendations to transfer fiduciary staff to the Department of Budget and Finance (DBF). Some HSSP2 Secretariat functions were transitioned to MOH units, however. (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory 103. Various delays affected implementation performance at the start of the Program. Slow disbursement at startup, delays in civil work procurement and delays in Secretariat transitions and in processing contracts affected implementation effectiveness and resulted in a rating of “Moderately Unsatisfactory” for overall project management at ISR 5 (01/2013). The rating was however upgraded to “Moderately Satisfactory” during the following ISR, and to “Satisfactory” during the last ISR (June 2016) due to the completion of all key activities and to significant effort shown to ensuring a smooth transition into the new H-EQIP project mechanisms. Clear transition plans were developed and new manuals and guidelines were drafted. (c) Justification of Rating for Overall Borrower Performance Rating: Satisfactory 32 6. Lessons Learned 104. The SWiM approach followed by the World Bank and by development partners in Cambodia proved to be a successful intermediary approach towards getting closer to Government systems for aid delivery. The establishment of a pooled funding mechanism with solid fiduciary guarantees and the alignment with the RGC’s Health Strategic Plan has been an attractive value proposition for development partners looking to maximize the impact of their support to the health sector. The SWiM approach put in place effective tools to improve coordination and management of the sector, establishing new and different partnership dynamics between the government and donors. Whether or not this type of sector wide approach has been effective in reducing transaction costs for the government or for donors is however difficult to determine since objective data to support such assessment is lacking. Given the degree of fiduciary risk assessed during project preparation, a full sector wide approach would have been a riskier choice. 105. Experimentation and evaluation are key ingredients for a successful scale up of effective policy interventions. HSSP2 can be seen as a logical follow up program from HSSP with the consolidation of successful policies both for the demand side (HEFs) and for the supply side (SOAs/SDGs) of the health system. Likewise, H-EQIP can also be gauged as a natural evolution from HSSP2 with a continued focus on strengthening health service delivery and improving financial protection, but with a strong emphasis on improving the quality of care. 106. The harmonization of development partner management and implementation systems is an important aspect of aid effectiveness which can support government ownership and sector governance. However, when these harmonization efforts are not accompanied by a reduction in parallel systems, structures and reporting requirements of individual development partners can also increase the partner Government’s transaction costs. 107. Marginal changes in incentives (salary top-ups), together with clear and verifiable performance contracts are powerful and cost effective tools to improve the overall efficiency of the health systems. Performance based incentives were introduced through SOAs and SDGs, but the bulk of SOA’s budget remained funded by line item government finance (50% to 70%). 108. HSSP2 stands out in the health sector in Cambodia, as well as within the World Bank’s portfolio, for its continuity of engagement with the RGC. Health was the only sector where the WB’s financing engagement with RGC did not get interrupted for well over a decade and continues unabated with the new project until 2021. Within the country’s health sector, too, this engagement stands out with WB being a partner managing pooled funds where the composition of the pool has itself been changing. from a set of donors who have themselves been changing. The Bank has been at the forefront of alignment and harmonization efforts of development partners’ support to RGC. 33 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies: No major issues were raised by the MOH. All comments received were addressed and summarized under Annex 8. (b) Cofinanciers: No major issues were raised by the co-financiers. All comments received were addressed and summarized under Annex 8. (c) Other partners and stakeholders (e.g. NGOs/private sector/civil society) 34 Annex 1. Project Costs and Financing (a) Project Cost by Component (IDA + MDTF, in USD Million equivalent) Appraisal Actual as Estimate Actual percentage of PR2 AF1 AF2 AF3 Components (USD Exp. AF3 (09/2012) (10/2013) (09/2014) (10/2015) millions and (06/2016) allocation %) Component 1: 54.99 58.04 61.77 65.28 69.42 84.83 Strengthening Health [50%] [50%] [48%] [46%] [45%] [56%] 122% Service Delivery Component 2: 13.93 14.70 21.45 30.63 38.63 40.70 Improving Health [13%] [13%] [17%] [22%] [25%] [27%] 105% Financing Component 3: 12.47 13.16 14.65 14.65 14.65 2.41 Strengthening Human [11%] [11%] [11%] [10%] [9%] [2%] 16% Resources Component 4: Strengthening Health 28.59 30.18 31.67 31.67 31.67 24.88 79% System Stewardship [26%] [26%] [24%] [22%] [21%] [16%] Functions TOTAL Project Costs 110.0 116.08 129.53 142.23 154.37 152.54 98.8% (b) Financing Appraisal Actual Actual as Estimate PR2 AF1 AF2 AF3 Source of Funds (06/2016) percentage of (USD (09/2012) (10/2013) (09/2014) (10/2015) (USD millions) AF3 allocation millions) AUSTRALIA: Australian Agency for International Development (AusAID) / 30.00 36.09 43.89 52.75 57.72 57.72 100% Department of Foreign Affairs and Trade (DFAT) UK: British Department for International 50.00 50.00 55.64 55.64 55.64 55.64 100% Development (DFID) KOREA: KOICA 0.00 0.00 0.00 4.50 4.50 4.50 100% GERMANY: KfW 0.00 0.00 0.00 0.00 6.51 6.51 100% TOTAL MDTF 80.00 86.09 99.53 112.23 124.37 124.37 100% International Development 30.00 30.00 30.0 30.0 30.0 28.17 93.9% Association (IDA) TOTAL 110.0 116.08 129.53 142.23 154.37 152.54 98.8% (MDTF + IDA) Source: World Bank PR2, AF1, AF2 and AF3 documents, and MOH Financial Reports. 35 Annex 2a. Outputs by Component As per the PAD description, there were thirteen intermediate outputs identified and divided by the four project components, with three corresponding to the first component, two corresponding to the second component, three corresponding to the third component, and five corresponding to fourth component. Outputs Planned Achieved COMPONENT 1. Strengthening Health Service Delivery: 1.1. Service  Support Service Delivery Grants and The program supported Service Delivery Grants to ODs and PRHs, which had been upgraded to Delivery Grants contracting to Operational Districts and the status of Special Operating Agencies (SOAs), to support the objectives of the HSP2 in and Contracting Referral Hospitals increasing utilization of quality health services by the whole population. SDGs were allocated to ODs and PHDs in accordance with their Annual Operational Plan (AOP) and through the  A program of technical support provided to mechanism of Service Delivery Management Contracts. They were managed by the DPHI for help strengthen core functions in PHDs and overall management and coordination, and for planning and resource allocation formula and ODs, including: planning; budgeting; monitoring; and by the DBF for overseeing the program-based budget for OD use in tandem financial management; contracting; with the SDGs. Contracts were dependent on the achievement of satisfactory quality scores performance management; and, monitoring using MOH quality assessment tools, and based on agreed service delivery targets to be and evaluation. financed partially by the SDGs.  Internal and External monitoring: technical Over the lifetime of the program, SDGs were scaled up from 30 ODs and PHDs as SOAs, to 40 and financial management performance SOAs, with six additional SOAs being added in 2009, and the remaining four being added in supported through contracting of 2016. There was an increase in Government financing from 10% at the start of the program to independent teams by MOH to validate 40%. performance and financial transactions. Technical support was provided to SOAs to help set up appropriate targets and to facilitate the transition from contracting under HSSP1 to SDGs under HSSP2, following the guidelines of the SDG Operational Manual. Capacity-building was a core of the SDG design, with a necessary capacity building assessment, along with necessary appropriate actions to build capacity in the case that a lack of capacity was observed, as part of the SDG eligibility assessment. Technical support was also provided for the opening of commercial bank accounts at the PHD and OD levels for receiving SDGs and bonuses, and a package of technical support was 37 provided to help strengthen core functions in PHDs and ODs, including: planning; budgeting; financial management; contracting; performance management; and, monitoring and evaluation. At the central level, the project supported the Department of Administration and Finance to manage, coordinate, and monitor internal contracting arrangements at Central, Provincial and District levels. The program also provided technical support to the Service Delivery Monitoring Group (SDMG), an inter-departmental working group at MOH (members from various departments (DPHI, DBF, DHS and HRD), which was set up at the beginning of the project to manage monitoring of SOA performance at the central level, develop tools for assessing eligibility for SDGs and HEFs and monitoring SDGs. By March, 2014 and at the end of the program, 100% of ODs were implementing SDGs and internal contracting was meeting at least 80% of their performance targets (ISR Seq. 11). 1.2. Strengthening  Support incremental operating costs for HSSP2 has supported these priorities for central programs, PHDs, and ODs through the AOP health services management, public health, integrated process, mostly through financing of training, supervision, and outreach activities. Support was management, supervision, and capacity strengthening guided by priorities established in the MOH’s AOP cycle for both the central and provi ncial supervision and activities, based on provincial AOP and level, with 100% of MOH central institutions and provinces submitting AOPs and 3YRPs public health guidelines set out in the Program according to schedule and format by February, 2014 (ISR Seq. 7). All PHDs also prepared functions at Operational Manual, for provinces not AOPs, beginning in 2009 (ISR Seq. 2) As of December, 2013, the AOP process was recorded as provincial and initially receiving SDGs. having “improved” in terms of technical content and results -focus of the AOP process, based on district level the MTR and Final Evaluation (ISR Seq.6). Support was also provided to priority reproductive,  Support to priority reproductive, maternal maternal and child health elements of selected provincial and OD AOPs, as well as to the and child health elements of selected gender mainstreaming committee at MOH. A gender mainstreaming committee at MOH was provincial and OD AOPs to be provided supported through UNFPA discrete funds. through discrete Partner support until such time as these locations are eligible for SDGs Financial support was provided for the convening of the Annual Health Congress, attended by through the pooled account. all PHDs, selected ODs, and local governors for sector supervision and planning and the JAPR process. Additionally, SDGs were also designed to strengthen Government systems for financing and managing service delivery at the sub-national level by linking closely with the Government’s budget and AOP processes, the ongoing process of decentralization and deconcentration (D&D), new Government service delivery initiatives, and the shift from external contracting (of NGOs) to internal contracting (using MOH staff). 1.3. Improving the  Support investments to fill in the gaps The program supported investments to fill in the gaps identified in the Health Coverage Plan health service identified in the Health Coverage Plan (HCP), including the construction of: delivery network (HCP). o 121 new health centers (12 of which were under both HSSP and HSSP2 support) 38 o five new health posts  Support in quantifying necessary investment o one new referral hospital (Tbeng Meanchey referral hospital in Preah Vihear costs through: (a) supporting the review and province under both HSSP and HSSP2 support) update of hospital and health center designs, o 79 additional delivery rooms in health centers (b) finalizing the Health Infrastructure o 15 maternity wards for hospitals Investment and Maintenance Plan, (c) o 12 non-communicable disease clinics at referral hospitals. establishing a database for standard costs o one pharmacy store in Preah Vihear OD for works and goods, and (d) strengthening o landscape improvement of O’Chrov referral hospital; and capacity for asset management. o two regional medical training centers o a radiation bunker and installation of the Linear Accelerator at Khmer Soviet Friendship Hospital o National Laboratory for Drug Quality and Control and installation of the same This was supported by: 1) the hiring of a civil construction design supervision firm and technical support on the preparation, design, planning, supervision of construction, and 2) development of maintenance plans, to be used by OD and HC staff. The program target of 399 health facilities constructed, renovated, and/or equipped through the project was surpassed with 699 by May, 2016 (ISR Seq. 11). Social and environmental safeguards were taken into account in the design and construction of health facilities, including safeguards for health care waste management, water supply, proper resettlement of populations for civil works when necessary, and for indigenous populations. Areas with high numbers of indigenous populations were prioritized in the overall civil works plan to increase access to health services. Additionally, the program supported procurement of goods, primarily including: office furniture, office equipment, drugs, medical instruments and equipment and vehicles. The program supported monitoring of drug stock management at the Department of Drugs and Food (DDF) and the development of a standards list and medical equipment for HCs and RHs. For medical equipment, the program supported provision of training and/or proper installation where necessary. HSSP2 support was provided toward co-financing of contraceptive commodities, as well as programs for de-worming of school children. UNICEF support was provided to the procurement of nutrition commodities to prevent or manage severe or acute malnutrition among children (F75, F100, ReSoMal, RUTF and micro-nutrient powder supplementation). 39 The program saw improvements in service delivery, with the target for people with access to a basic package of health, nutrition, or reproductive health services surpassing its target. As of May, 2016, a cumulative total of 8,464,456 cases had been supported by HEFs (against a target of 6,500,000) (ISR Seq. 11). Additionally, targets were achieved by more than 85% for percentage of births delivered by trained personnel (85.2% achieved by 5/31/2016 with a target of 85% as of 12/31/2013) and percentage of children under one year immunized with DPT- HepB3 (94.8% achieved by 5/31/2016 with a target of 95% as of 12/31/2013) (2016 NAHC). The indicator for percentage of children aged 6-59 months who received two doses of Vitamin A supplement every six months surpasses it’s target of 80%, with 81.5% achievement by May, 2016 (2016 NAHC), as did the indicator for percentage of pregnant women receiving iron folate supplementation (90.3% achieved by June, 2016; target 85%; HMIS), and percentage of pregnant women attending at least two antenatal care consultations (93% achieved by May, 2016; target 90%) (ISR Seq. 11). 2,239,784 pregnant women were attending at least two antenatal care consultations by 2014, surpassing a target of 1,900,000 (2014 PMR). Overall, consultations for new cases per person per year for those under five surpassed its target of 1.5, with an achievement of 1.52 (2016 NAHC). By May, 2016, 100% of health centers were implementing IMCI services (target of 90%) (2016 NAHC). COMPONENT 2. Improving Health Financing: 2.1. Improving  Support operating and management costs, The program financed the HEF Grants, managed by eligible NGOs operating HEFs, financing Health Protection and costs associated with identification of the direct benefits for the poor, including user fees and associated costs as defined in the HEF for the Poor the poor, outreach and community benefit package. Over the life of the program, the HEFs were scaled up nationwide and participation of the NGOs operating HEFs, expanded to all ODs and RH, as well as to HCs based on priority ODs (marked by high poverty and the HEF Implementer. rates and slum areas). By the end of the program, and by March, 2016 HEFs had expanded to 100% of the IDpoor (URC and 2016 NAHC), 100% of RHs, and 91% of HCs (2016 NAHC).  Finance the HEF Grants managed by The number of cases, OPD, IPD, and deliveries receiving HEF assistance also all surpassed eligible NGOs operating HEFs, financing their targets by May, 2016 (2016 NAHC). By May, 2016, 8,464,456 cases had been financed the direct benefits for the poor, including using HEF assistance (against an end-project target of 6,500,000), broken down by 7,346,365 user fees and associated costs as defined in OPD cases (end-project target 5,500,000), 869,743 IPD cases (target 720,000), and 230,348 the HEF benefit package, and scaling up delivery cases (target 190,000) (2016 NAHC). over the lifetime of the program.  Support the HEF monitoring, supervision The program also supported operating and management costs of the HEFs, costs associated with and oversight role of the DPHI. the post-identification of the poor, and outreach and community participation of the NGOs operating HEFs. The HEF Implementer (HEFI), University Research Company, was supported by USAID through and MoU with MOH, with support of World Bank and other partners. The 40 program also supported costs for HEF monitoring, supervision, and the oversight of DPHI within MOH. 2.2. Support to  Support to development of Government The Program provided technical support to the development of Government health care Health Financing health care financing policies and financing policies and institutional reforms, based on the Government’s Strategic Framework Policies and institutional reforms, based on the for Health Financing. This included: 1) financial support to improving health services costing, Institutional Government’s Strategic Framework for building capacity for and linking health financing information to the AOP process, and 2) Capacity Health Financing. This included: building institutional capacity for implementing health financing policies both on central and (a) improving the collection of health provincial level through trainings, workshops, and supervision activities. Workshops and financing information such as trainings were also supported to review the HEFs and implementation of health financing National Health Accounts and policies, organized by the PDHI within MOH. health services costing; (b) integrating health financing information, costing results and other evidence in health financing policies, including medium-term planning and budgeting processes; (c) aligning DP resources with sector priorities; and (d) building institutional capacity for implementing health financing policies both on central and provincial level. COMPONENT 3. Strengthening Human Resources: 3.1. Strengthening  Support and strengthen training institutions The program supported and strengthened training institutions and pre-service training Training and pre-service training programs in the programs in Regional Training Centers (RTCs). Support was provided for the construction Institutions and Technical School of Medical Care, the of two new RTCs (Battambang and Steung Treng), training fees, teaching fees, and Programs Regional Training Centers (RTCs), and the preceptors at RTCs, as well as for translation feed and procurement of small goods and University of Health Sciences. services. Additionally, national examinations were introduced for pharmacists, dentists, and nurses.  Capacity strengthening needs assessment on Training Institutions and Programs, as well Support was also provided to the Department of Human Resources Development for the as on needs for infrastructure improvement, development of training requirements in AOPs, 3YRPs of RTCs. Additionally, a Value for including buildings, classroom and teaching Money assessment (2012) was conducted and provided important recommendations to materials, and office equipment, and strengthen planning, monitoring, impact of training, and supervision. Based on this, there support to identified areas thereafter. was a move to prioritize training, and technical support was also provided for workshops, trainings, and supervision for RTCs. 41  Support the improvement and revision of the pre-service curriculum, including The Program also reviewed and expanded specific in-service training programs, and supported support to strengthening skills and learning from scale-up of training activities for priority areas. Trainings of trainers, trainings, competencies of trainers and developing a and follow-up were provided in targeted areas, including reproductive health, CDC and core group of Master Trainers for each dengue prevention. For the purpose of streamlining programs, support for the Avian and training intuition at HC level linked to Human Influenza Control and Preparedness Emergency Project (P100084: AHICPEP 2008- RTCs. 2014), previously being supported by the World Bank, was transferred to the HSSP2 pooled funds in 2014, based on the CDC’s AOP.  Establish at least two Training Skills Centers in two RTCs as sites for training of trainers and training of preceptors in hospitals providing training to medical students.  Review and expand specific in-service training programs, and support learning from scale-up of training activities for priority areas.  Support to build upon training programs developed by the NIPH trainings and broad degree levels for management, with GTZ support.  Support to the Department of Human Resources Development for development of training requirements in AOPs, 3YRPs of RTCs. 3.2. Strengthening  Support to key human resource management The program supported improvements for technical skills and competencies of the health Human Resource areas, including licensing of professionals in workforce, through capacity building trainings and workshops for central-level national Management both public and private sectors, self- programs, MOH departments, PHDs, and RTCs. Technical support was also provided for regulation of medical professionals, ethics improving staff distributions and retention, with a priority given to personnel essential to health and code of conduct for health professionals, sector priorities, and financial support was provided for trainings of staff at RTCs. better alignment and strengthening of human resource planning and personnel Over the course of the program, 166,042 health personnel were trained (ISR, Seq. 11 06/20/2016). management, and recruitment and In terms of human resources capacity, the program exceeded its target of training secondary midwives and the percentage of health centers with a secondary midwife rose from 53 percent in 42 deployment of staff, including locally 2011 to 100 percent by the end of the program (Latest HMIS data for Jan-June 2016). At the time managed contracted staff. of AF3, it was deemed that the existing staff at HFs was sufficient to effectively implement the HEFs and SDGs, including those in new ODs.  Modest financial support for building effective national organizations, professional The program also strengthened performance management and quality improvement through associations and councils, as described in the performance incentives through the SDGs and additional revenues from HEFs, as well as through MOH Second National Health Workforce the interim support of the Merit-Based Performance Incentive Scheme and the Priority Operating Plan 2006-2015, and linking these to Costs System (POC). The performance of staff receiving SDG and POC schemes was managed regional and international organizations. through the performance management mechanism, the Performance Management and Accountability System (PMAS), on which technical support was provided to the Personnel Department. Until the POC scheme was ended in July, 2012, 239 MOH staff had received POC payments financed by the project, almost meeting the target of 247 staff (ISR Seq. 5). 3.3. Support to  Support to improving governance and The program supported 190 MBPI positions, identified by MOH from September, 2005 until Merit Based performance in priority ministries by January, 2010, when this program was cancelled by the Government, and leading to the first Performance providing salary incentives to MOH restructuring of the project. Incentive Scheme officials responsible for implementing key Government strategies at the central and provincial levels, linked to performance, through the Merit Based Performance Incentive Scheme. COMPONENT 4. Strengthening Health System Stewardship Functions 4.1. Support to  Strengthen MOH policies and regulations in The policy on public service delivery, announced in 2006, called for increased autonomy of public policy development critical areas identified in the Health service providers, including in the health sector. HSSP2 supported these moves through the and implementation Strategic Plan, including: transition of contracting of NGOs under HSSP1 to MOH internal contracting of Special Operating o contracting and purchasing health Agency (SOA) for SDGs under HSSP2. services, including institutional arrangements for internal Additionally, through the scale up of the HEFs over the life of the program, HEFs became contracting by the MOH and Cambodia’s most significant social security scheme, also promoting remuneration reform with a PHDs, focus on front line clinical staff through both the salary incentive portions of the SDG and the o social health insurance, additional revenues gained for HFs from the HEFs. community-based health insurance and HEFs; The program also supported the development, implementation and regulation enforcement for o the autonomy of health care quality standards through the regular quality of care assessments, required under the Annual providers and strengthening health 43 care institution governance Service Delivery Management Contracts, and monitored by the SDG working group. The project arrangements in decentralization provided travel allowances for the MOH Quality Assessment team, led by the DHS. settings; o staff remuneration reform, These assessments were also used to determine eligibility of HEF, based on the guidelines in the focusing on front line clinical staff; HEF manual. Eligibility for HEF to health facilities relied upon scores from performance o detailed design of the assessments, led by a team from the DPHI with members from relevant MOH departments and decentralization reforms in the participation from PHDs and ODs for peer assessments. The program supported these activities health sector; towards an increased focus on quality of care, as well as capacity trainings on the tools, quality o development, implementation and linked with resource allocation, and management skills. regulation enforcement for quality standards and clinical guidelines; In 2006 and 2015, respectively, L1 and L2 quality assessments were implemented under the and support of the program for facilities receiving HEFs and SDGs, supporting government reforms o empowering new structures for toward the institutionalization of quality. increasing local accountability of health care providers to citizens In order to increase accountability of health providers to citizens, the program provided technical support to the National Center for Health Promotion. Areas of technical support included health promotion, nutrition, and behavior change surrounding food and hygiene for pregnant women and post-delivery. The program also made partial contributions toward the sub-national operational costs for outreach activities and priority behavior change communication. Finally, training of Health Facilities staff on the implementation of HEF, taking over HEFO, was conducted to strengthen institutional capacity at sub-national levels. 4.2. Strengthening  Support capacity strengthening to The program supported capacity strengthening to implement policy packages identified in the institutional implement policy packages identified in the Health Strategic Plan, sector-wide planning at all levels, and implementing financial management capacity Health Strategic Plan sector-wide planning and procurement strengthening plans in conjunction with the ongoing Public Financial at all levels, the Health Information Management Reform. Support was provided for trainings on financial management on cash flows Strategy, and implementing financial of national budget; costing activities for national programs within the DBF; monitoring management and procurement strengthening supervision to provincial departments, ODs, RHs, and SOAs after trainings; supervision for asset plans in conjunction with rolling out Public management for provinces, districts, HFs, and SOAs; and support to supervision of the web-based Financial Management Reform, guided by Health Information System (HIS). MOH’s Institutional Development Plan. The HSSP2 also integrated the processes for technical audits on health services and financial  Support the Government strategies on audits under a single firm (previously separated by function under the HSSP1). quality assurance cited in HSP2, including: At the HSSP2 Secretariat, 3 international consultants, 22 national consultant positions, and 21 o the development, implementation drivers, were supported by the program, as detailed in the HSSP2 Operational Manual. Despite and regulation enforcement across delays in integrating project management into the MOH structure, there was progress toward the health sector for quality standards; transfer of key consultant positions to DPHI, Personnel Department, and Human Resource Department. 44 o the development and implementation of routine facilities Supervision support was also provided to PHD regulation of drugs in private pharmacies through survey procedures to ensure that the DBF and technical support was provided to strengthen institutional capacity in M&E through working environments, facilities, the procurement of one international consultant. and equipment enable health workers to provide high quality Following the Government’s policies toward decentralization, decentralized procurement was care; initiated through the SDGs, allowing for small consumables, motorbikes, and civil works to be o the establishment of incentive completed by SOAs themselves, supported by hands-on trainings by the HSSP2 Secretariat. mechanisms; o strengthening demand side Support was provided through the SDG monthly incentives, based on individual and institutional feedback mechanisms for performance, which were subject to review and approval by the SDMG and subject to MOH monitoring client satisfaction in guidelines to ensure transparency and equity, as detailed in the SDG manual. 60% of user fees, public health service; and including additional revenue from HEFs, could also be used for staff incentives. o broaden institutional regulation by strengthening licensing in the HSSP2 was one of the major financiers for surveillance and response to emerging diseases. private sector, introducing the same Technical support was provided to the development of a National Dengue Strategic Plan for process in the public sector, and the 2013-2020, and two expert positions were supported for dengue and non-communicable development and implementation disease, based at WHO. Targets for reporting of dengue case fatality by public health facilities of accreditation system as a step-up surpassed their targets in December, 2013 (2014 PMR) and May, 2016 (2016 NAHC). after compliance to licensing Achievement was 0.33 (target 0.6) and 0.25 (target 0.5), respectively. requirements. 4.3. Strengthening  Support the development and enforcement Limited work was provided in the area of private sector licensing and accreditation, mainly private sector of regulations related to private sector through the contracting of eligible NGOs for the operating of the HEFs. An NGO, University regulation and providers; licensing and accreditation; Research Company, was also supported as HEF Implementer, by USAID through and MoU partnerships options for contracting accredited NGOs with MOH, and with support of World Bank and other partners. and private sector providers to provide public services; and engaging NGO and private sector providers in the AOP planning processes and the HCP. 4.4. Governance  Support to relatively under-resourced Technical and financial support was provided for procurement of small goods, services, trainings, and stewardship priority programs of reproductive, maternal, and workshops to the National centers including: Helminth & Dengue Fever (CNM), Maternal & functions of the neonatal and child health, including sub- Child Health, Health Promotion Centre (NCHP), Traditional Medicine Centre (NCTM), and the national programs programs addressing reproductive health, University of Health Sciences (UHS). and centers immunization, child health, newborn care, and nutrition; and non-communicable Support was provided to support the D&D process, as envisaged in the Government’s three-year diseases. implementation plan, including functional mapping at central, provincial, district, and commune levels and mapping functions to HSP2 and AOP categories to facilitate resource mapping. 45  Support for essential central level functions of National Programs and respective MOH The program initiated a move towards the integration of M&E functions from the central level departments and groups that will through the SDMG and its work on monitoring of SOA performance and developing tools for complement the drive to decentralization assessing eligibility for SDGs and HEFs and monitoring SDGs. The SDMG was presided over and local health system strengthening. by an under-secretary of state for health, and had a wide range of members from relevant MOH central departments (Department of Planning and Health Information, Department of Communicable Disease Control, General Department of Preventive Medicine, Department of International Cooperation, Central Medical Store, Department of Drugs and Food), one representative from one PHD, National Program Managers (Malaria, Dengue, Nutrition, EPI, MHC), and 7 HSSP2 partners. 4.5. Strengthening  Support toward increased community Outreach activities and community participation were supported through the NGOs operating the Community participation, multisectoral responses HEFs and to support Health Center Management Committees, with representation of Village Participation toward improving health, and empowering Health Support Groups (VHSG), using the SDGs. The program also supported outreach activities communities to hold health systems more in remote and difficult to access communities, including areas with indigenous persons, and accountable, based on the Strategic supported the allocation at every health facility a staff member who themselves were an Framework on Community Participation of indigenous person or who spoke an indigenous language. the MOH. The program supported the Annual Health Congress and JAPR development process, including attendance by selected commune members to attend the event.  Enhancing the governance role of Hospital and Health Center Management Support was also provided to the National Center for Health Promotion for health promotion, Committees. nutrition, and behavior change communications, as well as mass media plans to foster community awareness and preventative measures for CD and NCD. In order to increase  Prepare community leaders and political accountability of health providers to citizens, the program provided technical support to the representatives for increased health system National Center for Health Promotion on health promotion, nutrition, and behavior change management and oversight. surrounding food and hygiene for pregnant women and post-delivery, and made partial contributions toward the sub-national operational costs for outreach activities and priority behavior change communication. 46 Annex 2b. Indicators by PDO HIGH LEVEL HSP2 GOALS (IMPACT LEVEL) PDO 1: Improve health outcomes Original End of Project Infant mortality rate Target surpassed Baseline: 66 per 100,000 live births (2005-2008) 28 per 100,000 (CDHS 2014) Target: 50 per 100,000 (2015) Under 5 mortality rate Target surpassed Baseline: 83 per 1,000 live births (2005-2008) 35 per 1,000 (CDHS 2014) Target: 65 per 1,000 (2015) Stunting rate (WHO standards) Target achieved (87%) and trending positively (-5.1% per year on average between 2010 and 2014) Baseline: 43% (2005-2008) 32% (CDHS 2014) Target: 22% (2015) Maternal mortality Target potentially achieved and trending positively (-4.7% per year on average between 2010 and 2014) Baseline: 472 per 100,000 live births (2005-2008) 170 per 100,000 (CDHS 2014) Target: 140 per 100,000 (2015) HIV prevalence rate among 15-49 Target surpassed Baseline: 0.9% (2005-2008) 0.7% in 2013 (UNAIDS Cambodia Country Progress Report, 2015) Target: <0.9% (2015) TB death rate Target not achieved but trending positively (-5% per year on average between 2009 and 2015) Baseline: 75 per 100,000 (2005-2008) 55 per 100,000 in 2015 (WHO) Target: 32 per 100,000 (2015) Malaria CFR Data not available Baseline: 0.36 per 1,000 (2005-2008) Target: 0.1 per 1,000 (2015) Percentage of deaths due to road Data not available traffic accidents Baseline: 3.5% (2005-2008) Target: 2.8% (2015) OUTCOMES AND INTERMEDIATE OUTCOMES PDO 2: Strengthening institutional capacity Sub-objective 2a: Strengthening human resources Outcomes Original PR1 AF2 AF3 End of Project Ratio of MOH secondary midwives Continued Dropped - Target potentially achieved per 10,000 population per location Achievement by 12/31/2015 * Country ratio (“No target * Country ratio: 1.85 * Provincial average values and * Provincial average: 2.45 * Provincial median better indicator * Provincial median: 2.17 for secondary Baseline: midwives now Although the indicator was dropped, all coverage * Country ratio: 1.35 available”) ratios have increased at the end of the project. * Provincial average: 1.40 * Provincial median: 1.74 (Source: 2015 PMR) Target: * Country ratio: NA * Provincial average: NA * Provincial median: NA Percentage of staff covered by agreed Dropped - - NA and aligned incentive scheme ("Definitions Baseline: NA were unclear Target: NA and/or data collection systems have not been established") 47 Number of MOH staff receiving POC New Dropped - Target potentially achieved payments financed by Project 239 MOH staff received POC payments financed by ("No longer the Project by 06/30/2011 (ISR Seq. 5) before the Baseline: 0 (12/31/2009) relevant") POC scheme was ended in 07/01/2012. Target: 247 (12/31/2013) Health personnel receiving training New Continued Continued Target achieved through the Project (number) Although no target was explicitly established, this indicator is considered “achieved” since December Baseline: NA 2015 with 166,042 health personnel trained Target: NA (Source: ISR Seq.11, 06/20/2016) Outputs Percentage of health center having at - New Continued Target surpassed least one secondary midwife 100% of Health Centers with at least one secondary midwife Baseline: NA (Source: Latest HMIS data for Jan-June 2016) Target: 85% (12/31/2013) Number of HC with staffing level Dropped - - NA recommended by MPA Guidelines ("Definitions Baseline: NA were unclear Target: NA and/or data collection systems have not been established") Number of RH with staffing level Dropped - - NA recommended by CPA Guidelines ("Definitions Baseline: NA were unclear Target: NA and/or data collection systems have not been established") Number of HC with staffing level Dropped - - NA recommended by CPA Guidelines ("Definitions Baseline: NA were unclear Target: NA and/or data collection systems have not been established") Sub-objective 2b: Strengthening health system stewardship Outcomes Original PR1 AF2 AF3 End of Project Percentage of external funds for Revised Dropped - NA health included in AOPs ("Very process oriented and Baseline: 57% (12/31/2008) data not Target: 80% (12/31/2013) available") Percentage of RH, ODO and PHD Dropped - - NA offices with computerized HMIS ("Definitions Baseline: NA were unclear Target: NA and/or data collection systems have not been established") Percentage of functioning HCMCs Revised Dropped - NA ("Not within Baseline: NA control of the Target: NA project and data not available") Percentage of private entities Revised Dropped - NA licensed: ("Not supported - Polyclinics by the project") 48 - Consultation cabinets - Maternity clinics - Dental clinics - Pharmacies Baseline: NA Target: NA Percentage of licensed private Revised Dropped - NA Pharmacies and Depots ("Not supported by the project") Baseline: NA Target: NA Outputs Original PR1 AF2 AF3 End of Project Technical content and results-focus of Revised Dropped - Target potentially achieved AOP process improves based on Mid- The AOP process was recorded as “improved” by Term Review (MTR) and Final ("No specific 12/31/2013 at ISR Seq. 6. Evaluation way to measure") Baseline: NA Target: AOP process improved by 12/31/2013 Number and percentage of MOH Revised Dropped - Target potentially achieved central institutions and provinces The indicator value was 100% by 02/28/2014 (ISR submitting AOP and 3YRPs according ("Very process Seq. 7). to schedule and in MOH format oriented and levels already Baseline: 79% (12/31/2008) very high") Target: 95% (12/31/2013) Number of PHDs allocating budgets Dropped - - Target potentially achieved based on AOPs All provinces prepared AOPs in 2009 (ISR Seq. 2) ("Definitions Baseline: 0 (12/31/2008) were unclear Target: 23 provinces (12/31/2013) and/or data collection systems have not been established") Percentage of external funds for Dropped - - NA health sector included in 3YRPs and AOPs ("Definitions were unclear Baseline: 57% (12/31/2008) and/or data Target: 80%(12/31/2013) collection systems have not been established") AOP resource allocation of program Revised Dropped - Target potentially achieved budgets reflecting HSP2 and JAPR By 02/28/2014 (ISR Seq. 7) priorities ("No targets. MCH: 22% (1.MCH; 2.CDs; and 3.NCDs) Relevance not CDs: 48% clear") NCDs: 2% Baseline: (12/31/2008) MCH: 3.9% CDs: 20.2% NCDs: 0.5% Target: (12/31/2013) MCH: Increase CDs: Maintain NCDs: Increase Rate of Program execution for pooled Continued Dropped - Target potentially not achieved DP and for Government funds By 12/31/2013 (ISR Seq. 7) ("Monitored Baseline: (12/31/2008) during RGC: 93% RGC: 91% implementation DPs: 57% DPs: 85% support") 49 Target: (12/31/2013) RGC: 95% DPs: 95% Percentage of Government and AOP Dropped - - NA expenditure at provincial level ("Definitions Baseline: (12/31/2008) were unclear RGC: 85% and/or data AOP: 91% collection systems have Target: (12/31/2013) not been RGC: 37% established") AOP: 40% Share of operating cost budget Continued Dropped - Target potentially achieved reaching contracting ODs The indicator value was 100% by 12/31/2013 (ISR ("Difficult to Seq. 7). Baseline: NA measure, not Target: 100% (12/31/2013) entirely in control of the project, and adds relatively little value") Proportion of ODs implementing Continued Continued Continued Target achieved SDGs and internal contracting 100% of ODs implementing SDGs and internal meeting at least 80% of their contracting meeting at least 80% of their performance performance targets target by 03/30/2014 (ISR Seq. 8) and also by 06/30/2016 (ISR Seq. 11) Baseline: NA Target: 100% (12/31/2013) Financial Management Improvement Continued Dropped - Target potentially achieved Plan developed and implemented FMIP to be aligned with PFM reform and chart of ("Very process accounts, expected to be rolled out in mid 2015 (ISR Baseline: NA oriented and no Seq. 7). Target: FMIP implemented longer (12/31/2013) relevant") Increased number of ODs and PHDs Dropped - - NA using health indicators for prioritization in their AOPs ("Definitions were unclear Baseline: NA and/or data Target: AOPs better match health collection need priorities (12/31/2013) systems have not been established") Government health sector expenditure Dropped - - Target potentially achieved in line with NSDP and MTEF targets By 12/31/2014 ("Definitions Budgeted: 1.3% of GDP Baseline: 1% of GDP (12/31/2008) were unclear Executed: 1.1% of GDP Target: 1.2% of GDP (12/31/2013) and/or data (Source: 2014 Annual Health Financing Report) collection systems have not been established") Annual health planning summits Continued Dropped - NA (JAPR and JAOP) conducted with wide stakeholder participation ("Monitored during Baseline: (12/31/2008) implementation JAPR: Conducted annually support") JAOP: No Target: (12/31/2013) JAPR and JAOP: Conducted annually Percentage of HSP2 indicators that Revised Dropped - Target potentially not achieved have baselines and targets 50 ("Monitored 83% of indicators with baseline and target values by Baseline: 83% of indicators with during 12/31/2013 (ISR Seq. 7) baseline and 73% with targets implementation (12/31/2008) support") Target: 100% of indicators with baseline and targets (12/31/2013) Selected key HSP2 indicators Revised Dropped - NA disaggregated by location and sex ("Monitored Baseline: NA during Target: NA implementation support") Increased percentage of performance Dropped - - NA agreements between the MOH and PHDs meeting target performance ("Definitions indicators were unclear and/or data Baseline: 0% (12/31/2008) collection Target: 100% (12/31/2013) systems have not been established") PDO 3: Strengthening mechanisms to achieve more effective and efficient sector performance Sub-objective 3a: Strengthening health service delivery Outcomes Original PR1 AF2 AF3 End of Project Percentage of births delivery by Continued Continued Revised Target achieved (over 85% of target) trained personnel 84% by 12/31/2013 (Source: 2014 PMR) (Target 85.2% by 05/31/2016 (Source: 2016 NAHC) Baseline: 58% (12/31/2008) revised Target: 85% (12/31/2013) upward to 87% by 06/30/2016) Percentage of births delivery by Continued Continued Revised Target achieved (over 85% of target) trained personnel at health facility 80% by 12/31/2013 (Source: 2014 PMR) (Target 80.35% by 05/31/2016 (Source: 2016 NAHC) Baseline: 39% (12/31/2008) revised Target: 65% (12/31/2013) upward to 85% by 06/30/2016) Percentage of currently married Continued Dropped - Original target potentially not achieved women using a modern contraceptive 34.25% by 12/31/2013 (Source: 2014 PMR) method ("Data not reliable") Revised target potentially achieved Baseline: 26% (12/31/2008) (over 85% of target) Target: 49% (12/31/2013) 35% by 12/31/2014 (Source: 2014 PMR) Target lowered at AF1: 39% (12/31/2014) Percentage (and number) of children Revised Continued Continued Target achieved (over 85% of target) under one year immunized with DPT- 94.8% by 05/31/2016 (Source: 2016 NAHC) HepB3 Baseline: 84% (12/31/2008) Target: 95% (12/31/2013) Percentage of HIV+ pregnant women Continued Dropped - Target potentially surpassed receiving Antiretroviral drugs for 67% by 12/31/2013 (Source: 2014 PMR) PMTCT ("Project does not finance Baseline: 27% (12/31/2008) HIV/AIDS Target: 65% (12/31/2013) interventions. Covered by other donors") TB cure rate Continued Dropped - Target potentially surpassed 91% by 12/31/2013 (Source: 2014 PMR) Baseline: 90% (12/31/2008) ("Project does Target: >65% (12/31/2013) not finance TB 51 interventions. Covered by other donors") Number of malaria cases treated at Continued Dropped - Target potentially surpassed public health facilities per 1,000 1.7 cases by 12/31/2013 (Source: 2014 PMR) population ("Project does not finance Baseline: 4.1 (12/31/2008) Malaria Target: 3.7 (12/31/2013) interventions. Covered by other donors") Percentage (and number) of children New Continued Revised Original target surpassed (original definition): age 6-59 months who receives two 100% by 12/31/2013 (Source: 2014 PMR) doses of Vitamin A supplement every (Indicator 6 months (R1,R2) definition Revised target surpassed (AF3 definition): revised at 81.5% by 05/31/2016 (Source: 2016 NAHC) Baseline: 89% (12/31/2008) AF3 from Revised baseline at AF3: 77% “within the (12/31/2008) last 12 months” to Target: 96% (12/31/2013) “every 6 Revised target at AF3: months”) 80% (06/30/2016) thus bringing down the baseline value from 89% to 77%. The end target was revised accordingly from 96% to 80%) Percentage of children aged 12-59 New Dropped - Target potentially surpassed months who received mebendazole 100% by 12/31/2013 (Source: 2014 PMR) ("Similar to Baseline: 71% (12/31/2008) coverage of Vit. Target: 90% (12/31/2013) A") Percentage of pregnant women New Continued Revised Original and revised targets surpassed receiving Iron Folate supplementation 90.3% by 06/30/2016 (Source: HMIS) Baseline: 80% (12/31/2008) Target: 87% (12/31/2013) Revised target at AF3: 85% (06/30/2016) Percentage of population with access Dropped - - NA to full MPA ("Definitions Baseline: NA were unclear Target: NA and/or data collection systems have not been established") Percentage of population with access Dropped - - NA to at least CPA2 ("Definitions Baseline: NA were unclear Target: NA and/or data collection systems have not been established") People with access to a basic package - - New Target surpassed of health, nutrition, or reproductive 8,464,456 by 05/31/2016 (ISR Seq. 11) health services (number) 52 Baseline: 152,213 (12/31/2008) Target: 6,500,000 (06/30/2016) Percentage of pregnant women Continued Continued Revised Original target achieved by 12/31/2013 attending at least 2 antenatal care (over 85% of target) consultations (Target 81.5% (Source: 2014 PMR) aligned with Baseline: 81% (12/31/2008) NSDP 2014- Revised target surpassed by 05/31/2016 Target: 94% (12/31/2013) 2018 at AF3) 93% (Source: ISR Seq. 11) Revised target at AF3: 90% (06/30/2016) Number of pregnant women attending Continued Continued Revised Target surpassed at least 2 antenatal care consultations 2,239,784 (Source: 2014 PMR) (Target Baseline: 291,853 (12/31/2009) aligned with Target: 1,900,000 (06/30/2016) NSDP 2014- 2018 at AF3) Dengue case fatality rate reported by New Continued Revised Target surpassed by 12/31/2013 public health facilities 0.33 (Source: 2014 PMR) (Target Baseline: 0.7 (12/31/2008) aligned with Target surpassed by 05/31/2016 Target: 0.6 (12/31/2013) NSDP 2014- 0.25 (Source: 2016 NAHC) Revised target at AF3: 2018 at AF3) 0.5 (06/30/2016) Percentage of adults with diabetes Continued Dropped - NA treated at public health facilities ("Project does Baseline: 3.5 (12/31/2009) not cover Target: <0.55 (12/31/2013) treatment of diabetes at all public health facilities nor as part of HEF package") Outputs Original PR1 AF2 AF3 End of Project Consultations (new cases) per person Continued Dropped - Target potentially achieved per year (all consultations) 0.61 by 12/31/2013 (Source: 2014 PMR) ("Project not Baseline: 0.54 (12/31/2008) accountable for Target: 0.6 (12/31/2013) all consultation, just priority groups") Consultations (new cases) per person Continued Continued Continued Target achieved by 12/31/2013 per year (under 5) (over 85% of target) 1.43 (Source: 2014 PMR) Baseline: 1.1 (12/31/2008) Target: 1.5 (06/30/2016) Target surpassed by 05/31/2016 1.52 (Source: 2016 NAHC) Percentage of deliveries by C-section Continued Dropped - NA Baseline: 2.0 (12/31/2008) ("May Target: 3.2 (12/31/2013) incentivize unnecessary procedures") Case detection rate of smear (+) Continued Dropped - NA pulmonary TB (%) ("Project does Baseline: 69% (12/31/2008) not finance TB Target: >70% (12/31/2013) interventions. Covered by other donors") Percentage of families living in high Continued Dropped - Target potentially surpassed malaria endemic areas (<1km from 100% by 12/31/2013 (Source: 2014 PMR) forest) of 20 provinces have sufficient ("Project does (1 net / 2 persons) treated bed nets not finance (LLIT / ITN) Malaria interventions. 53 Baseline: 75.6% (12/31/2008) Covered by Target: 90% (12/31/2013) other donors") Percentage of children under 5 years Continued Dropped - Target potentially surpassed with pneumonia receiving correct 68.8% by 12/31/2014 (Source: 2014 PMR) antibiotic treatment at public facilities ("Only measured every Baseline: 48% (12/31/2008) 5 years. IMCI Target: 65% (12/31/2013) indicator to be revised to cover quality") Percentage of children under 5 years Continued Dropped - NA with diarrhea having received ORT and Zinc at public health facilities ("Only measured every Baseline: 58% (12/31/2008) 5 years. IMCI Target: 95% (12/31/2014) indicator to be revised to cover quality") Percentage of disease outbreak Dropped - - NA responses in timely manner ("Definitions Baseline: NA were unclear Target: NA and/or data collection systems have not been established") Percent of health centers New Continued Revised Target surpassed by 12/31/2013 implementing IMCI services 98% (Source: 2014 PMR) (Target Baseline: 69% (12/31/2008) aligned with Target surpassed by 05/31/2016 Target: 95% (12/31/2013) NSDP 2014- 100% (Source: 2016 NAHC) Revised target at AF3: 2018 at AF3) 90% (06/30/2016) Percentage of Essential Drugs (15 Continued Dropped - NA items listed) at HCs that faced stock- outs ("Not within control of the Baseline: NA project") Target: NA Health facilities constructed, New Continued Continued Target surpassed renovated, and/or equipped through 699 by 05/31/2016 (ISR, Seq. 11), including: the Project * 53 additional delivery rooms * 15 referral hospitals Baseline: 0 (12/31/2007) * 1 LINAC Target: 506 (12/31/2016) * 1 clean room * 103 solar lighting * 193 water improvement * 263 sanitation improvement Sub-objective 3b: Improving financial protection Outcomes Original PR1 AF2 AF3 End of Project Percent of poor population covered by New Revised Revised Target surpassed Health Equity Funds 100% by 05/31/2016 (Source: URC and 2016 NAHC) (Moved from (Target set at Baseline: 57% (12/31/2008) intermediary AF3) Target: 95% (06/30/2016) indicators to PDO level) Coverage of HEFs (by OD and Dropped - - NA beneficiaries) ("Definitions Baseline: NA were unclear Target: NA and/or data collection systems have not been established") 54 Number of cases receiving Health Continued Continued Revised Target surpassed Equity Fund assistance 8,464,456 by 05/31/2016 (Source: 2016 NAHC) (Target set at Baseline: 152,000 (12/31/2008) AF3) Target: 6,800,000 (06/30/2016) Number of OPD receiving Health Continued Continued Revised Target surpassed Equity Fund assistance 7,346,365 by 05/31/2016 (Source: 2016 NAHC) (Target set at Baseline: 312,713 (12/31/2009) AF3) Target: 5,500,000 (06/30/2016) Number of IPD receiving Health Continued Continued Revised Target surpassed Equity Fund assistance 869,743 by 05/31/2016 (Source: 2016 NAHC) (Target set at Baseline: 102,205 (12/31/2009) AF3) Target: 720,000 (06/30/2016) Number of deliveries receiving Health Continued Continued Revised Target surpassed Equity Fund assistance 230,348 by 05/31/2016 (Source: 2016 NAHC) (Target set at Baseline: 15,629 (12/31/2009) AF3) Target: 190,000 (06/30/2016) Number of individuals insured under Revised Dropped - NA CBHI schemes ("Project does Baseline: 79,873 (12/31/2008) not support Target: NA CBHI, just HEFs") Government health expenditure per Continued Dropped - USD 12.7 in 2014 capita ("Not within Baseline: USD 7.75 (12/31/2008) control of the Target: NA project") Outputs Original PR1 AF2 AF3 End of Project Percentage of Government health Continued Dropped - NA expenditure at provincial level and below ("Not within control of the Baseline: NA project") Target: NA Percentage of referral hospitals Continued Continued Revised Target surpassed implementing Health Equity Funds 100% by 06/30/2016 (Source: 2016 NAHC) (Target set at Baseline: 61% (12/31/2008) AF3) Target: 85% (06/30/2016) Percentage of Health Centers Continued Continued Revised Target surpassed implementing Health Equity Funds 91% by 06/30/2016 (Source: 2016 NAHC) (Target set at Baseline: 13% (12/31/2008) AF3) Target: 65% (06/30/2016) Number of cases receiving Health Continued Continued Revised Target surpassed Equity Fund assistance 8,464,456 by 05/31/2016 (Source: 2016 NAHC) (Target set at Baseline: 152,000 (12/31/2008) AF3) Target: 6,800,000 (06/30/2016) 55 Annex 3. Economic and Financial Analysis Cambodia is performing beyond projections based on time trend and on income per capita in terms of mortality and of life expectancy Total and public health expenditure are below projections based on time trend and on income per capita between 2008 and 2015 56 Value of Life Year parameters (Lancet) Changes in key health outcomes Life expectancy Under 5 mortality rate Maternal Mortality rate Predicted Actual Predicted Actual Predicted Actual 2009 62.8 65.8 67.5 361.5 2010 63.1 66.4 65.9 54.0 354.1 206 2011 63.3 66.9 64.3 346.8 2012 63.5 67.3 62.9 339.5 2013 63.7 67.8 61.4 332.3 2014 63.9 68.2 60.1 35.0 325.1 170 2015 . 58.8 318.0 57 Valuation of incremental life expectancy gains Value of Value of Income per increase in life increase in life Life Income per capita net of expectancy in expectancy in expectancy capita health million USD million USD increment (USD) expenditure (discount = (discount = (USD) 3%) 7%) 2009 3.0 750.09 702.43 655.7 268.3 2010 3.3 782.70 736.10 767.6 314.0 2011 3.6 824.84 778.31 899.6 368.0 2012 3.8 870.48 816.16 1012.0 414.0 2013 4.1 920.30 865.70 1177.4 481.7 2014 4.3 969.34 914.32 1325.8 542.4 PV 1110.3 361.4 Cost-benefit summary Total costs, in million USD 154.37 Total costs, in million USD (PV [3%]) 129.28 Total costs, in million USD (PV [7%]) 102.86 Benefits, in million USD (PV [3%]) 1110.3 Benefits, in million USD (PV [7%]) 361.4 NPV, in million USD (discount=3%) 981.1 NPV, in million USD (discount=7%) 258.5 CB ratio (discount=3%) 8.6 CB ratio (discount=7%) 3.5 58 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Simeth Beng Senior Operations Officer GED02 Edward Daoud Senior Finance Officer GSUOA Roch Levesque Senior Counsel LEGAM Magnus Lindelow Practice Manager GHN01 Nareth Ly Operations Officer GHN02 Donald Herrings Mphande Lead Financial Management Spec GGO31 Sirirat Sirijaratwong Procurement Specialist GGO08 Hope C. Phillips Volker Consultant GHNDR Supervision/ICR Chandra Chakravarthi Program Assistant GEDDR Ravan Chieap Program Assistant EACSF Seida Heng Consultant GHNDR Timothy A. Johnston Program Leader ECCU4 Pema Lhazom Senior Operations Officer GHNDR Da Lin Program Assistant EACSF Nareth Ly Operations Officer GHN02 Sirirat Sirijaratwong Procurement Specialist GGO08 Hope C. Phillips Volker Consultant GHNDR (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (all No. of staff weeks expenses charged to BB) Lending FY07 5.37 FY08 326.29 Total: 331.66 Supervision/ICR FY09 122.58 FY10 78.90 FY11 82.44 FY12 111.12 FY13 73.27 FY14 57.01 FY15 54.03 FY16 102.82 FY17 24.10 Total: 706.27 59 Annex 5. Beneficiary Survey Results (No beneficiary survey was conducted) Annex 6. Stakeholder Workshop Report and Results (No stakeholder workshop was conducted) 60 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Summary of Royal Government of Cambodia Completion Report (December 2016) The review of the implementation of Health Strategic Plan phase I for 2003-2007 has laid out the foundation for the Ministry of Health in its development of Health Strategic Plan phase II (HSP2) for 2008 to 2015. The process was led by the Department of Planning and Health Information with wide consultation with all key stakeholders including DPs, NGOs, sub-national level of health system, local authorities, and relevant line Ministries of the Royal Government of Cambodia. HSP2 has highlighted 4 top priorities--Reproductive Maternal Newborn and Child Health (RMNCH), Communicable Diseases (CD), Non- communicable Diseases (NCD), and Health System Strengthening. To achieve these goals of HSP2 and building on experience from HSSP1, Health Sector Support Program Phase II (known as HSSP2) was developed to support and implement the priorities set forth in HSP2. HSSP2 was financed jointly by the significant contribution from the Royal Government of Cambodia through loan from the WB, and grants from the WB, DFID, AFD, BTC, DFAT, UNICEF, and UNFPA. The Ministry of Health is the Executive Agency of the Program. In addition, KOICA and KFW joined the pooled fund from 20 August 2014 and 5 March 2015 respectively. The program builds on the positive experience of using joint monitoring arrangement from HSSP1 and HSSP Secretariat system. However, unlike HSSP1, the program proposes to support the transition of key accountability functions and systems to the respective Ministry of Health's Departments and moving away from reliance on the freestanding Project Implementation Unit. Most important aspect of HSSP2 was that the program designed with the joint contribution of the national budget to complement with other interventions/programs financially supported by additional external funding such as the GFATM. In improving health service delivery, HSSP2 put strong emphasis on nutrition for mothers and children, Reproductive Newborn and Child Health, some under-funded communicable diseases, non- communicable diseases, and Health System Stewardship functions. The indicators in over the past decade since prior to the design of HSSP1 and the continuation of HSSP2 have shown that the support from the WB, and other HSSP partners including ADB, AFD, DFID, DFAT, BTC UNFPA, UNICEF, KFW, and KOICA, has put on the right things and has been doing those right things right through building the national systems, and promoting the government leadership and ownership. This is one of the best examples, which could lead to effective development cooperation in Cambodia's Health Sector. Moving from NGO Contracting to internal contracting managed solely by the government is a major step toward strengthening the government leadership and ownership, leading to a strong health care system which will produce sustainable health outcomes as well as being able to effectively and efficiently respond to communicable diseases or any emerging infectious diseases. SOA/SDGs aim at financing and managing health service delivery at sub-national level--making the operational health system strong, adequate with supplies and function. Transition from the NGO-managed contracting to internal contracting, which has led to more sustainable development in strengthening health system and improving 61 health of the people under the ownership and leadership of the government, has faced considerable challenges for the health system to tackle including financial management, organizational capacity, technical capacity, the change in staff regulation and behavior. However, with all the support from experienced NGOs, HSSP2 DPs and high level leadership of the Ministry of Health, it has demonstrated good improvements—resulting in better access to improved quality of health care services at SDGs-implemented health facilities. PHDs are contracted by the central MOH through a Performance Agreement under which the PHD acts as a commissioner; the SOA districts represented by their directors are contracted by the PHD through a Service Delivery Agreement; within each SOA, health facilities (referral hospital and health centers) are contracted by the SOA with each party represented by the head of the institution; at facility level, performance contracts are made between the head of the facility and each staff member. The key stipulations in the contract between the PHD and the SOA are: responsibilities of the contracting parties, service provision, resource needs, performance achievement and sanctions, financing and legal representations. The most important commitments of the PHD are to provide financial resources, drugs and medical supplies to the SOA in a timely and transparent manner and to support the SOA in enforcing a performance management system, including reshuffling of non-performing staff. The SOA is required to comply with the three golden rules: no under-the-table payments, no pilfering of clients or conduct of private services in the public facilities, and no pilfering of drugs and medical supplies from the public facilities. Incentives are paid in full when targets are achieved and are reduced when the level of achievement falls short. Facility chiefs are responsible for achieving the contracted outputs. Funding for SOA districts comes from three major sources: the government budget, the SDGs and user fees. The government line item budget accounts for 50% to 70% of the SOA budget and is provided to the SOA as a quarterly advance through routine government channels (MEF, 2011). The SDG, a direct grant from HSSP2 pooled donor-government funds, is transferred through private banks directly to SOA accounts quarterly following reports. The implementation of SOA/SDGs has made the operational health system more accountable to the communities through engagement with local authorities (reporting to provincial and district councils), conducting clients’ satisfaction survey, and the implementation of community score card. All has led to improved quality of care and the availability of health services at health facilities. As of 31st December, 2015, proportion of Operational Districts implementing Service Delivery Grants (SDGs) and internal contracting meeting at least 80% of their performance targets has reached 100% in the entire health care system of Cambodia. Through this five years’ implementation of HSSP2, SOA has tremendously made changes in applying staff regulation in their facilities. This includes (1) they were more punctual, (2) they worked more hours at the facilities, (3) they were present at work even on public holidays (staff on duties), and (4) they paid more attention in service provision to clients. In other words, SOA has made 24 hours’ and 7-day-a-week’s availability of health services at the health facilities. Performance-based incentive with a set of target indicators determining the 62 achievements through SDGs’ contracts has also proven good improvement of health providers’ compliance with the national protocols, policies, and guidelines, demonstrating improved quality of care. As a result of such mechanism in place, maternal and child health has been of huge improvement, making Cambodia among a few countries in the developing world achieve MDGs 4 and 5. HSSP2 has made remarkable achievements of key outcome indicators for maternal and child health--Birth delivered by trained health personnel has reached 85.20 %; delivered at health facilities was 80.50%; Percentage of children under one year immunized with DPT-HepB3 was 94.38%; children aged 6-59 months who received two doses of Vitamin A supplement every 6 months reached 81.5%; and percentage of women receiving Iron Folate supplementation reached 82.17%. These improvements of outcome indicators have greatly impacted on MMR, IMR and Under-5 MR. According to CDHS, Maternal Mortality Ratio has declined sharply in the last decade--moving from 472 per 100,000 live births in 2005 to 206 in 2010, and then 170 in 2014. Likewise, the total fertility rate declined from 4.0 in 2000 to 3.0 in 2010, and to 2.7 in 2014. Both under 5 mortality Rate and the IMR showed remarkable declines over the period from 2000 to 2014. Under 5 mortality declined from 124 in 2000 to 83 in 2005 and 54 in 2010, and 35 in 2014, per the CDHS. IMR declined from 95 per 1,000 live births in 2000 to 66 in 2005 per the CDHS, then to 45 in 2010, and 28 in CDHS 2014. Both HSSP1, and in particular HSSP2, have strong focus on improving health of women, infants, and children. Since year 2000, significant decrease in the prevalence of stunting, evidently, from 2010 to 2014 stunting among the poorest Cambodians decreased by 7.4% points. Despite some progress made, nutrition remains the area of challenge and among the top priority to improve maternal newborn and child health. The 2014 Cambodia Demographic and Health Survey (CDHS) shows that in nutrition, Cambodia did not meet the 2010 Cambodia Millennium Development Goal (CMDG) targets. In Cambodia, 32.4% of children are stunted and 23.9% are underweight – in comparison to the targets of 24.5% and 19.2%, respectively. Stunting alone accounts for 45% of the projected economic losses. Overweight is now growing especially among the better-off population: overweight exceeded underweight (18% versus 14%, respectively). Another area of challenge ahead is that no significant improvement in complementary feeding for children aged 6-11.9 months, and also appropriate breastfeeding practice, especially among the wealthier population. Despite the challenges ahead, NNP did not get financial support from HSSP2 since early 2014. With all the positive impact on health service provision as well as the improved quality of care, most health staff complained that the incentive received through SDGs was too little (on average between 20-40 US dollars per month) in comparison with what they could earn through private practice in their moonlight jobs. The SDG incentive should be higher or bigger enough to drive quality changes and they should be done in a timely manner, with no delay or abrupt disruption. Most health staff and managers under SDGs contracts reported that they experienced that the procedures to get SDG payment were too strict, no flexibility, and too complicated. This may be part of the delay of the use of SDG fund. Unlike other projects, the longer they work on the more increasing payment they could get. 63 Most recently, especially early 2016, SDG payment reduced but more workload imposed- -causing big demotivation and dissatisfaction among health staff and managers. Some lessons learnt can be taken into consideration why Cambodia could achieve MDGs 4 and 5. Direction is set at the highest level by establishing clear development goals. The Sector Wide Management (SWiM) mechanism for health is used to align and direct the contribution and activities of the development partners in achieving MOH objectives. The Technical Working Group for Health and other sub-technical working groups and task forces have helped with coordination and development of technical content. The NGO support organization, MEDICAM, has helped facilitate collaboration between government activities and activities at the grassroots level. The MOH provides leadership and plays a central role as a technical advisor to the Provincial Health Departments (PHD) and the Operational Health District (OD) health offices. The ODs are the key actors for activities implemented at health facilities and community level – and are responsible for translating national policies into local actions. High level of commitment, support and follow-up from the Government and the Development Partners (Example include ‘skilled birth attendance’ area, where the government incentive for live births in health facility contributed to significant and sustained increases over the past 2 years; selection of SBA as a Joint Monitoring Indicator to be reviewed on quarterly basis through CDCF is another indicator of high level of commitment to this area). Some improvements in childhood nutritional status, particularly in severe stunting and underweight, are likely to have contributed to mortality declines; as well as improvements in rates of exclusive breastfeeding, early breastfeeding and coverage with vitamin A supplements. There have been significant increases in the proportion of women attending at least four antenatal care (ANC) visits (93%), making more of these visits early in pregnancy, delivering with a skilled birth attendant and delivering at health facilities. Improving availability of midwife at health facilities through (1) setting standards for at least one midwife and an additional secondary midwife at health center level, (2) midwifery incentive schemes, and (3) improved training/capacity building for midwife in both pre-service and in-service trainings all contributed to improving RMNCH. Another critical lesson is that HSSP2 funds were available for all 25 provinces to support the implementation of RMNCH priorities. Reducing newborn deaths will require increased attention on improving the quality of intrapartum, early essential newborn care and postnatal care for routine deliveries as well as for high risk newborns with prematurity and low birth weight, birth asphyxia and neonatal sepsis. Complementary efforts are needed to improve quality of care and, in particular, routine delivery and immediate postpartum and postnatal care, and EmONC services. Mechanisms are needed for improving quality, including regular supervision, self-assessment and improved training methods using clinical coaching. Ensuring quality and geographic coverage of EmONC is a must in improving maternal and newborns health, especially ensuring the functionality of health facilities with BEmONC and CEmNC. And this would include improving the quality and availability of ANC and PNC. The EmONC services should be 24 hours and 7 days a week at health facilities and must be accessible without financial barriers. 64 HSSP (both one and two) has not only assisted in supporting to strengthen national system but also ensured that the poor have access to quality health care services they need. Since early the 1990s, NGOs have pioneered the implementation of Health Equity Fund in order to break the financial barriers so that the poor can access to publicly provided health care services. Building on the experience, the Ministry of Health has adopted into the health care financing policy and the HEF implementation framework has been developed. Significant proportion of HSSP2 funding (pooled fund and the government's share) has been used to support Health Equity Fund implemented by NGOs--Health Equity Fund Operators and Health Equity Fund Implementer (URC). The HEF Operators including eligible local NGOs and CBOs worked closely with public health facilities and the poor through pre-identification and post-identification system determined by the Ministry of Planning. The HEF Implementer provides technical oversight of the HEF implementation and financial scrutiny ensuring that the poor will benefit the most, and the Health Facilities provide quality of care and make them available and accessible for the poor. Through HSSP2 support, 91.67% of Health Centers and 82% of Referral Hospitals have implemented Health Equity Fund. Remarkably, 100% of the poor have now been covered by HEF (Result Framework attached in Annex 3). Health Equity Fund appears to be the main reason that motivates people to come and use the public sector because they can get free health care services. With reference to the study on Utilization and Impact of Health Equity Fund conducted by the WB on June 20, 2016, it found that, among HEF beneficiaries, 25% of medical visits took place at public health facilities. HEF promotes health seeking towards Public Health Facilities--resulting in a marginally significant reduction in the use of informal sector. In addition, a World Bank study on Rural Health Markets (2013) concluded that the possession of a pre- (ID Poor) or post- (HEF) ID card increased health seeking behavior towards the public sector by 34%. An episode of hospitalization per household is as frequent as once a year, meaning that about one tenth of the annual income may be dedicated to health expenditures. Without HEF Mechanism, the poor usually faces catastrophic payments because seeking care at private sector would cost them 17USD for OPD consultation and treatment and 190 US dollars for hospitalization. Among households with some OOP payment, HEF have reduced the amount by 29%, on average. The effect is larger for households that are poorer, mainly use public health care and live closer to a district hospital. HEF are more effective in reducing OOP payments when they are operated by a NGO, rather than the government, and when they operate in conjunction with the contracting of public health services. However, during the implementation, HEFOs experienced funding interruptions which contributed to a negative environment in facilities and reduced staff morale, and can lead to shortages of drugs and equipment; all of which can erode beneficiary’s trust in providers. Moreover, there is an indication that reimbursement of transport to patients may be hindered as a consequence, leading to underutilization of the scheme. There is the need to revise the procedures and to work with the health facilities, HEFOs and MOH to improve the disbursement of funds. Gains in efficiency are likely to increase facility staff’s trust in the HEFs, creating a more positive environment for it beneficiaries within the public facilities. This may mean an examination of the entire reporting and disbursement process 65 – and re-trainings – if there are upstream errors that are causing the delays. Furthermore, HEF's underutilization is one of the significant issues that need to find out and understand the reasons. CDHS 2010 has suggested that only 4% of the poorest quintile reported having health service paid for by HEF, while the CSES 2011 finds that only 20% of the poor reported using HEF for free treatment. The most recent study of the WB June 2016 also finds that only 10% HEF beneficiaries use OPD, whilst 40% use IPD. The study also found that 44% of HEF beneficiaries claimed having little knowledge of their entitlement-- indicating the need for increasing knowledge about HEF's entitlement among beneficiaries. There seem to be problems with ID Poor targeting and with the villager’s perceptions of the fairness/transparency of the process. Improving these processes – improving equity and card distribution times – would increase satisfaction with selection and trust in the program. HSSP2 provided support for the review of curricula. However, this was done a couple of years ago and it is now the time to do it again. Thus, the curricula should be updated and responsive to the current needs, the context of health system development, and the epidemiological patterns. 17 public and private institutions are currently providing training for medical care, dentistry, pharmacy, nursing, midwifery, laboratory technician, and maintenance of medical equipment. Thousands of medical professionals come out of schools every year. They should have adequate skill and competency after their graduation. Cambodia, however, faces tremendous challenges in the pre-service training, and these include: (1) competency-based curricula for health profession training currently not in use; (2) all curricula have been reviewed several years ago with the support from HSSP2; (3) requirements for training hospitals are not standardized and often lack infrastructure and resources to perform as clinical placement sites; (4) students have limited exposure to clinical trainings and practice; (5) faculty members have very limited opportunities for capacity building or continued professional development; (6) quality of national entrance and exit needs to be further strengthened; (7) limited monitoring of the curricula implemented in health training institutions. Merit-based performance in deployment, retention, and promotion of medical professionals was not implemented because the government thinks that it could demoralize those who did not get it. Applying meritocratic system could lift up the main impediment in ensuring good distribution of health providers and retaining them in the system. All promotions and awards should be based on (1) experience, (2) morality, and (3) qualifications (doing the right thing in the right way and at the right time). Having at least one secondary midwife at one health center is key to improving reproductive maternal newborn and child health. The government midwifery incentive scheme of 60000 Riels per live delivery of one baby at health center level have evidently boosted facility birth deliveries, which is one of the main indicators driving the reduction of Maternal Mortality Ratio. The last component of HSSP2 was to strengthen Health System Stewardship Functions. This support area aligns with HSP2 Strategies to strengthen health system governance and health information system. The program put emphasis on the promotion of Harmonization and Alignment, Public Private Partnership, Policy Development and Implementation, Health Management Information System and Strengthening Community Engagement. 66 To promote Harmonization and Alignment and mutual accountability, HSSP2 supported the development of Annual Operation Plan and three-Year rolling plan. HSSP2 have contributed a great deal to promote harmonization and alignment. The fund from the program supported not only the implementation of HSP2, but also funded the development of Annual Operational Plan, conducting AOP appraisal, organizing pre-JAPR (Joint Annual Performance Review) and JAPR. AOP and JAPR were very crucial tools for all partners to align and harmonize their resources with the country's plan/ Pre-Joint Annual Performance Review (JAPR) and JAPR alongside with Health Congress were conducted every year in the promotion of mutual accountability because all key stakeholders including NGOs representatives could work jointly to understand the progress to date, successful factors, challenges ahead, recommendations and priority actions which will be addressed in the coming year's planning. So far 100% of Development Partners have aligned their resources with Health Strategic Plan. However, how their resources were put remains the challenges. HSSP1 and HSSP2 is a very good example to ensure sustainable development of health systems because the Development Partners' funding (both grants and loan) has gone through the government's systems. When Development partners become more interested in using the country's systems; they will then be improved. Private Sector engagement was through the establishment of sub TWGH for Private and Public Partnership. PPP strategic plan will be developed in due course and it will detail key strategic areas of this engagement. HSSP2 has supported the review of Health Management Information System to include data collected from the Private Sector. On the policy development and regulation, the draft Health Finance Policy is currently being reviewed by MEF before finalization and implementation and a private consultancy firm was engaged to prepare the Social Health Protection Framework which is likely to provide inputs toward the final Health Financing Policy. The final national Health Strategic Plan 3 (2016-20) was presented at the NHC during its meeting in March, 2016. The Health Information System has great improvement, moving from manual collection of data to computerized system, and the inclusion of private sector data into the HIS. HO2 has been completely computerized. However, only about 40% of HCs have been computerized. More computers are needed to fill the gap. The HIS has been much developed--computerization and updated to version 3 which includes ICD-10 (International Classification of Diseases) and data collection from private sector, but human capacity remains an uphill challenge to cope with the new development. Community Score Card initiated by the WB, implemented by several NGOs such as RHAC, CARE, and others has stimulated more discussion and engagement between community and local operational health provision facilities. Using the score card, community has a great opportunity to provide feedback and comments to health centers/referral hospitals--creating more productive dialogues. 67 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders Editorial comments were received from KOICA, DFAT and from MOH, and were directly included in the report. Summary of comments received from Cofinanciers and from MOH: Organization Comment Response MOH Para 2: please check the date of Date was corrected. Paris Peace Accord 1989? –> 23 October 1991 MOH Para 66: “...Except for Operational Clarification and more detailed district integrated supervision of included in para. 66. health centers, most training activities were assessed as low VFM.” [This paragraph is difficult to understand, please clarify?] Overall, HSSP2 Pooled Fund training and supervision expenditures were assessed as low VFM. [This view may reflect to the specific area, but not overall, please re-phase]. MOH Para 102: “It was estimated in Para. 102 was edited to include a 2012 that a full transition as mention to human resource originally planned would have constraints. been unlikely due to the resistance of MOH to follow WB/JPIG recommendations to transfer fiduciary staff to the Department of Budget and Finance (DBF).” [Please change the resistance to human resource constraint] KOICA Will Executive Summary be The ICR template does not inserted in the report? include an executive summary, but the datasheet provides a summary of the key information and of the ratings. KOICA I noticed that there are two Annex Annex table labels corrected 2c Indicators by PDO. Why these two Annexes have the same name? KOICA I feel that it is rather difficult to The structure in these two tables compare the indicators in the is purposely different. Section F Annex2c and the indicators under display indicators according to the Section F of Results PDO level and intermediary 68 Framework Analysis, because the level indicators, while Annex 2b structures are different. breaks down the indicators according to their type (impact, outcome, output), and breaking them down along the different PDOs. DFAT Outcome indicator 10 should refer The wording of the indicator to the rural poor and not to the should be the same as the whole poor population wording used in the results frameworks DFAT Thorough edit of acronyms would List of acronyms has been edited be useful and expanded DFAT A lesson learnt that should be Contractual arrangements have highlighted is the implementation indeed been simplified for H- arrangements of HEF and SDG of EQUIP, but we think that this HSSP2 were very complicated element is an implementation using six-monthly or annual detail which does not necessarily contracts with HEFOs and SOA constitute a broad lesson learned facilities. This bottleneck was from HSSP2. clearly identified during HSSP2 and has been solved in H-EQIP. DFAT Another lesson learnt that should This element has been reflected be documented as well is that in the section on “Efficiency” HSSP2 experienced few delays and funding shortfalls during transition /extension, which caused a serious problem for health service providers on the ground. Their root causes should be highlighted as lesson learnt or challenge that needs to be minimized with H-EQIP. DFAT HSSP2 learnt that transition for This point was mentioned in Secretariat to MOH systems faces para. 102. challenges. This was a lesson taken up with H-EQIP (no Secretariat from the beginning). DFAT The amount reported in the These differences are probably financing table (Annex 1b) to explained by the application of a reflect the contribution from fee contributing to the BETF and Australia differs from the DFAT Bank costs. accounting numbers. (Annex 2a) It would be Point added to Annex 2. worthwhile to highlight the training of Health Facilities staff on the implementation of HEF, 69 taking over HEFO, as institutional capacity strengthening at sub- national levels DFAT What does target “potentially Some indicators were dropped achieved” mean in Annex 2b from the RF, but for the purpose of the ICR, we still take them into account in our assessment if the indicators are still monitored at the end of the project. Because these indicators were dropped, we don’t mark them as “achieved” or “not achieved”, but as “potentially achieved/not achieved” DFAT Minor editorial comments (use of These comments were factored appropriate tense, typos) were in for the final version of the provided in track changes ICR report. 70 Annex 9. List of Supporting Documents Project documentation:  World Bank (2008) Project Appraisal Document for HSSP2  World Bank (2016) Project Appraisal Document for H-EQUIP  Financing Agreement (2008)  Grant Amendment (2010, 2012, 2013)  Additional Financing Project Papers (AF1, AF2, AF3)  Restructuring Papers (PR1, PR2, PR3)  Cambodia Health Strategic Plan (2008-2015)  Cambodia National Strategic Development Plan Update (2009-2014)  World Bank (2005) Country Assistance Strategy  World Bank (2016) Country Engagement Note  Martinez et al. (2011) Overall Assessment for Mid Term Review of Health Strategic Plan 2008-2015.  Aide Memoires and Back to Office Reports  Implementation Status and Results Reports  Integrated Financial and Technical Reports  HSSP2 Operational Manual  Financial Policies and Procedures Manual  SDG Manual  Procurement Plan  Environmental Assessment Report  Updated Environmental Management Plans  Framework for Land Acquisition Policy and Procedures  Indigenous Peoples Planning Framework  Social Assessment 71 Additional References:  Annear (2010) A comprehensive review of the literature on health equity funds in Cambodia 2001-2010 and annotated bibliography.  Annear et al. (2015) Cambodia Health System Review. Health in Transition.  Annear et al. (2016) National coverage and health service utilization by Health Equity Fund members, 2004-2015.  DFAT (2015) Sector wide approaches in the health sector: A desk-based review of donors’ experience in Asia and the Pacific  DFID (2014) HSSP2 Project Completion Review Report  Flores et al. (2013) Financial protection of patients through compensation of providers: The impact of health equity funds in Cambodia. Journal of Health Economics, 32 (pp. 1180-93).  IEG (2009) Do health sector-wide approaches achieve results? Emerging evidence and lessons from six countries.  Jacobs (2015) Enabling the rural poor access to health services through innovative health interventions in Cambodia (PhD thesis, Vrije Universiteit Brussel)  Jamison et al. (2013) Global Health 2035: a world converging within a generation. Lancet 382(9908), pp. 1898-1955.  Vaillancourt et al. (2011) Aid Effectiveness in Cambodia’s Health Sector: An Assessment of the Sector-Wide Management (SWiM) Approach and its Effect on Sector Performance and Outcomes 72 MAP 73