The World Bank Improving Maternal and Child Health through Integrated Social Services (P123706) REPORT NO.: RES38853 DOCUMENT OF THE WORLD BANK RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF IMPROVING MATERNAL AND CHILD HEALTH THROUGH INTEGRATED SOCIAL SERVICES APPROVED ON MAY 21, 2013 TO REPUBLIC OF HAITI HEALTH, NUTRITION & POPULATION LATIN AMERICA AND CARIBBEAN Regional Vice President: J. Humberto Lopez Country Director: Anabela Abreu Regional Director: Luis Benveniste Practice Manager/Manager: Michele Gragnolati Task Team Leader(s): Andrew Sunil Rajkumar, Snjezana Plevko The World Bank Improving Maternal and Child Health through Integrated Social Services (P123706) I. BASIC DATA Product Information Project ID Financing Instrument P123706 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 21-May-2013 31-Dec-2019 Organizations Borrower Responsible Agency Fonds d'Assistance Economique et Sociale Republic of Haiti (FAES),Ministry of Public Health and Population (MSPP),Institut Haïtien de Statistique et d’Informatique Project Development Objective (PDO) Original PDO The objective of the proposed Project is to increase the access and use of maternal and child health, nutrition and other social services in the Recipient’s territory. The Project will support services in at least three Departments with a total catchment population of around 1.8 million people, targeting pregnant women,children under five and vulnerable families.Progress on the objectives of the Project will be measured by the following:(i) percent of children under five immunized; (ii) percent of institutional deliveries; (iii) contraceptive prevalence rate; and (iv) decrease in percentage of families categorized as extremely vulnerable. Current PDO To increase the access and use of maternal and child health services, strengthen cholera control, and improve targeting of social services in the Recipient s territory, with a particular focus on areas affected by Hurricane Matthew. Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-D2030 14-Jun-2017 29-Jun-2017 24-Jan-2018 31-Dec-2019 25.00 25.25 .18 The World Bank Improving Maternal and Child Health through Integrated Social Services (P123706) IDA-H8640 21-May-2013 14-Jun-2013 12-Sep-2013 31-Dec-2019 70.00 58.98 6.36 TF-14474 14-Jun-2013 14-Jun-2013 15-Sep-2014 31-Dec-2019 20.00 12.00 8.00 TF-13431 20-Apr-2013 20-Apr-2013 20-Apr-2013 30-Jun-2014 .82 .82 0 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. SUMMARY OF PROJECT STATUS AND PROPOSED CHANGES 1. The project has 3 components: Component 1 – “Providing Maternal and Child Health, Nutrition and Social Services” – finances: (i) Results-Based Financing (RBF) activities focusing on maternal and child health, (ii) cholera control activities, and (iii) Post-Hurricane Matthew response activities and rehabilitation of health infrastructure. Component 2 – “Strengthening the Stewardship and Management Capacity of Government” – supports the setup of a social registry for the identification and tracking of beneficiaries and social assistance programs, and general stewardship and management of the main implementing agencies, the Ministry of Public Health and Population (MSPP) and the Fund for Economic and Social Assistance (FAES). Component 3 – “Piloting Vulnerability Indicators for More Targeted Social Service Delivery” – finances activities aimed at piloting the calculation of vulnerability indicators (mainly in support of the Fifth Demographic and Housing Census), a key step in targeting the vulnerable in the delivery of social services. At the time of Board approval, the total cost of the project was US$ 90 million equivalent which included an IDA Grant of SDR 46.7 million (US$70 million equivalent, IDA-H8640) and a Grant from the Health Results and Innovation Trust Fund (HRITF) of US$20 million (TF-14474). In June 2017, an Additional Financing grant of US$25 million from the Crisis Response Window was approved by the Board to respond to the impact of Hurricane Matthew (October 2016). 2. The last ISR rating for the PDO is Satisfactory. End targets for 4 out of 5 PDO indicators have been achieved – all except immunization for children under 5. (There is a high possibility that the end target for this indicator will not be achieved by the end of the Project, in which case the PDO rating would be downgraded to Moderately Satisfactory.) The immunization program has been adversely affected by systemic issues that have been beyond the scope of the present Project to address, including deficiencies in outreach at the community level as well as supply chain, planning and management deficiencies. Implementation Progress is rated Moderately Satisfactory due to: (i) implementation delays related to the increasing challenges with the country context (political, security, inflation and fuel issues); and (ii) fiduciary performance issues with FAES. (The latter have since improved following FAES’s compliance with strengthened fiduciary capacities, finalization of annual implementation plans and reimbursement of the ineligible expenditures to the Bank.) There is no overdue audit under this project or implementing agencies. The last audit reports from MSSP and FAES were received on time with unqualified opinion (clean) on the audit statements by the auditors. There are no outstanding IFRs for MSPP. Due to operational difficulties, the FAES PIU was not able to provide the June and September 2019 IFRs within the deadlines stated in the Project legal document; however, the Bank team is working with FAES to help them resolve this issue. The World Bank Improving Maternal and Child Health through Integrated Social Services (P123706) 3. A new Health Project was approved by the Board on 16 May 2019 and will continue to finance and strengthen key health activities financed under the current Project (PASMISSI) but will not yet be fully operational by the current closing date of PASMISSI. Progress under Component 1: 4. RBF stream: The activities under this stream started with a pilot in 7 facilities in 2014; the stream now includes 124 health facilities. The Project's RBF stream is a part of a national RBF program that also has parallel financing from USAID and Canada, with each financier providing RBF financing for a different group of health facilities. 5. The RBF program faced initial implementation challenges due to lack of experience in RBF in the country, as well as a slow harmonization process across other financiers of the program (USAID and Canada). Thanks to strong stewardship of the MSPP and coordination efforts among donors, all health facilities under the program (regardless of who the financier is) have the same RBF tariffs, verification system and method for determining quality payments. There has been significant progress with the indicators (services) covered by the program. However, the program has experienced significant challenges more recently due to the country context issues mentioned below, especially with: (i) its verification activities which have been delayed (leading to delays in RBF payments), and (ii) the activities of the RBF Impact Evaluation endline survey (see below for more on this). For the Project’s RBF stream, the extension is required to conclude during Q1 2020 the analysis of the data collected under the endline Impact Evaluation survey. 6. Cholera stream: Project performance focusing on the cholera response has been particularly outstanding as no cholera cases have been report ed since January 2019. The laboratory transport network for the collection of patient samples has been strengthened in coordination with partners to enable fast laboratory confirmation of suspected cases of cholera. Joint MSPP-NGO teams are still active in order to maintain a response capacity. This is partly supported by a PASMISSI-financed contract with UNICEF. Under this stream, activitiessupported by UNICEF need to be finalized over the next 6 months through a contract extension that would be co-financed by the new Bank Health Project. (The extended contract would finance prevention and response capacity support activities and an environmental study to confirm the absence of epidemic cholera strains in the environment, among others.) All other activities have been concluded. 7. Post-Hurricane Matthew response activities and rehabilitation of health infrastructure: The main activities here include civil works for health facilities and warehouses, re-instating of the vaccine cold-chain and general immunization support (through UNICEF), as well as provision of equipment at rehabilitated health facilities (through UNOPS). Despite mitigating measures, all of these activities have been severely affected by the deteriorating context (see below). Depending on the evolution of the country context, out of 90 unfinished rehabilitations, an estimated 90% would be concluded by the proposed closing date (31 March 2020); the remaining 10% would be concluded under the new Bank Health Project. In terms of the vaccine cold chain activities and provision of equipment, the contracts with UNICEF and UNOPS would be extended for 9 months and would be co-financed by the new Project after PASMISSI closes. Progress under Component 2: 8. The implementation progress under this Component, which is implemented by the FAES, was for many months hindered by fiduciary issues, including undocumented expenses as well as ineligible expenditures for a total of US$386,266. After joint Bank and FAES efforts were deployed through strengthening of the PIU fiduciary team with procurement and FM specialists reassigned by FAES and an accounting consultant hired by the Project, as well as The World Bank Improving Maternal and Child Health through Integrated Social Services (P123706) support from the Bank team, a total amount of US$117,266 was reconciled and US$65,000 that was deemed ineligible was reimbursed to the Bank. The Bank team continues to work with the FAES PIU to document the remaining balance. Once these fiduciary issues were settled, implementation progress picked up. The first draft of the National SP Strategy – including consultations with different stakeholders and support for designing one of the pillars – has been finalized with the support of this Component, and this draft has been circulated for comments to different stakeholders. It is expected to be presented to the Cabinet for endorsement in January 2020. The Project has also contributed to strengthening the SIMAST by: (i) helping to reinforce its technological infrastructure and to improve system functionality; and (ii) helping to extend its use by other entities under the Ministry of Social Affairs. The latter include the Bureau of State Secretary for the Integration of Disabled Individuals and the Institute for Social Wellbeing and Research. Progress under Component 3: 9. Activities have been fully completed. Component 3 focused on “Piloting Vulnerability Indicators for More Targeted Social Service Delivery”; its activities were planned to also be used as an input in the preparation of the 5th population census. The pilot census was implemented in September 2018. Moreover, the data captured by the pilot allowed the Institut Haïtien de Statistique et d’Informatique (IHSI) to become familiar with the methodology to calculate and produce estimates on vulnerability clusters for the four departments included in the pilot census. Outputs related to these activities have been finalized. More generally, the 5th census project has encountered delays due to the ongoing challenging context and the field work has been postponed. However, financing for completion of the census has been mobilized through other sources. No further activities are required under Component 3. Scope of Changes: 10. The proposed changes are: 1) extension of the closing date to March 31, 2020 (a 3-month extension); and 2) reallocation between disbursement categories (under the Project's original IDA grant) for MSPP-implemented activities, to ensure availability of financing to conclude civil wor ks and activities implemented by UN agencies. Rationale/Justification: 11. The extension is needed to contribute to orderly closure of the Project activities and maximize its impact, including: (i)“transferring” the health-related contracts to the new Health Project (P167512), (ii) finalizing the National SP Strategy and developing an initial roadmap for its implementation, and (iii) supporting the extension and strengthening of the SIMAST . Without the extension, an estimated 30% of civil works, as well as the delivery of equipment to rehabilitated facilities and immunization-activities, the finalization and initial roadmap for the National SP Strategy, and expansion of the SIMAST will not be concluded and cannot be transferred to the new Health Project without interruption in implementation. Social protection activities cannot be transferred to the new Health Project. Extending and transferring the health-related contracts to the new Health Project will provide an ample timeframe to ensure the completion of all civil works, equipment delivery and immunization activities with adequate quality. 12. Delays in Project activities – and thus the need for an extension – stem from the challenges with the country context. The mitigation measures undertaken over the last 18 months – not only under the current Project (PASMISSI), but also those managed by other international development partners (including the UN agencies) – are no longer sufficient to counter the impact of the country's political, economic and security crisis. The World Bank Improving Maternal and Child Health through Integrated Social Services (P123706) 13. Insecurity and growing fuel shortages over the last year have considerably hindered Project activities due to restricted access to project sites (due to roadblocks, attacks, civil unrest) adversely affecting: (i) civil works; (ii) RBF verification and Impact Evaluation survey activities; (iii) the delivery/installation of medical and vaccine cold chain equipment by UNOPS and UNICEF (contracted by the Project); and (iv) PIU and Bank supervision activities. On the SP side, security issues have substantially slowed down the finalization of the National SP Strategy and the consultative process for this Strategy, as well as the launching of the procurement process for the expansion of the SIMAST. The security situation has stabilized to some extent since late November, but risks remain. Finally, rapidly increasing inflation and depreciation of the Gourde adversely affects contr acts denominated in Gourdes (in particular civil works contracts) – especially the timely provision of materials and salary payments of construction workers. To partly address this issue, contract amendments have been made through heavy and time-consuming administrative processes, causing further delays. 14. To address these delays and mitigate these risks through this restructuring for the activities managed by the MSSP: (1) UN contracts (three contracts) would be extended by 9 months and would be co-financed by the new health Project (P167512) to allow for appropriate conclusion of activities; (2) Civil works contracts (eight contracts) would be amended and co-financed under the new Project to provide enough time for their conclusion; (3) Field- based engineers and supervisors have been deployed and are based close to the civil works sites; and (4) Intensive follow-up would take place with the PIU, to ensure speedy resolution of fiduciary bottlenecks. For the activities managed by the FAES, the risks would be mitigated by contracting the World Food Program – which has been supporting the Ministry of Social Affairs and Labor on the population of the SIMAST and the preparation of the national SP Strategy – to fast- track the remaining activities, which are solely technical assistance ones and can be realistically completed within the next three months. The scope of the expansion of the SIMAST activities has also been scaled down (reduced geographical coverage and target population) to match the limited additional three months implementation period. A local survey firm, that has completed the recent expansion of the registry, will be contracted on a single source basis to ensure that this activity is completed within the newly sought closing date. More frequent and enhanced support will also be provided by the Bank team. 15. The reallocation between disbursement categories would allocate additional funds to civil works activities and to UN agency activities under Category 7B of the original IDA Financing Agreement – recognizing in particular the increased importance that the Project gave, over time, to third-party implementation by UN agencies. (Among others, the latter was critical for the Project's successful efforts to control cholera.) Category 7B covers all MSPP-implemented activities except those related to RBF and Emergency Response activities. Most of the reallocated funds for Category 7B would come from Category 2 (activities supporting the RBF program), given that there is substantial funding for RBF activities from the HRITF grant under this Project. II. DETAILED CHANGES LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications The World Bank Improving Maternal and Child Health through Integrated Social Services (P123706) IDA-D2030 Effective 31-Dec-2019 31-Mar-2020 31-Jul-2020 IDA-H8640 Effective 31-Dec-2018 31-Dec-2019 31-Mar-2020 31-Jul-2020 30-Jun-2014, 12-Dec- TF-13431 Closed 31-Dec-2013 2014 TF-14474 Effective 31-Dec-2018 31-Dec-2019 31-Mar-2020 31-Jul-2020 REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Current Current Actuals + Proposed Disbursement % Ln/Cr/TF Expenditure Allocation Committed Allocation (Type Total) Category Current Proposed IDA-H8640- GO,CW,NCS,CS,T 001 R,OP Pt 9,405,809.33 9,405,809.33 9,405,809.33 100.00 100.00 Currency: A.1(a)(b), B1 XDR Results-Based Payments Part 13,343,000.00 486,090.28 4,500,000.00 100.00 100.00 A.1(c) GO,CW,NCS,CS,T R,OP Pt A.2(a-f), 2,543,483.00 2,496,348.56 2,543,483.00 100.00 100.00 B2 Conditional Cash 0.00 0.00 0.00 100.00 100.00 Grants Pt A.2(g) GO,CW,NCS,CS,T 3,680,096.00 3,734,342.44 3,734,342.44 100.00 100.00 R,OP Pt C Emergency Exp 0.00 0.00 0.00 100.00 100.00 Pt A3 GO,CW,NCS,CS,T 750,000.00 0.00 200,000.00 100.00 100.00 R,OP Pt A1b&d GO,CW,NCS,CS,T 14,315,458.67 13,458,655.76 23,654,212.23 100.00 100.00 R,OP A1a A1 B1 GO,CW,NCS,CS,T 2,662,153.00 449,167.18 2,662,153.00 100.00 100.00 R,OP Pt B2ab Total 46,700,000.00 30,030,413.55 46,700,000.00 The World Bank Improving Maternal and Child Health through Integrated Social Services (P123706)