The World Bank DJ Improving Health Sector Performance (P131194) REPORT NO.: RES48206 DOCUMENT OF THE WORLD BANK RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF DJ IMPROVING HEALTH SECTOR PERFORMANCE APPROVED ON APRIL 2, 2013 TO REPUBLIC OF DJIBOUTI HEALTH, NUTRITION & POPULATION MIDDLE EAST AND NORTH AFRICA Regional Vice President: Ferid Belhaj Country Director: Marina Wes Regional Director: Keiko Miwa Practice Manager/Manager: Rekha Menon Task Team Leader(s): Fatima El Kadiri El Yamani The World Bank DJ Improving Health Sector Performance (P131194) I. BASIC DATA Product Information Project ID Financing Instrument P131194 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 02-Apr-2013 30-Sep-2021 Organizations Borrower Responsible Agency Republic of Djibouti Ministry of Health Project Development Objective (PDO) Original PDO The project development objective is to improve the utilization of quality health care services for maternal and child healthandcommunicable disease control programs (HIV/AIDS, tuberculosis and malaria). Current PDO The project development objective is to improve the utilization of quality maternal and child health services. Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-64080 03-May-2019 03-Jul-2019 31-Dec-2019 30-Sep-2021 1.00 .80 .35 IDA-D4590 03-May-2019 03-Jul-2019 31-Dec-2019 30-Sep-2021 5.00 3.88 1.21 IDA-52160 02-Apr-2013 21-Apr-2013 11-Jul-2013 31-Dec-2020 7.00 6.55 0 TF-19258 13-May-2015 13-May-2015 27-Jul-2015 31-Dec-2020 7.00 7.00 0 The World Bank DJ Improving Health Sector Performance (P131194) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No II. SUMMARY OF PROJECT STATUS AND PROPOSED CHANGES This restructuring paper seeks the Country Director’s approval for a proposed Level 2 restructuring of the Djibouti Improving Health Sector Performance Project (Projet d’Amélioration de la Performance du Secteur de la Santé, PAPSS; P131194). This proposed restructuring is in response to a government request dated September 15, 2021 and received by the Bank on September 20, 2021 and proposes to extend the closing date of the project and related open project financing - IDA grant (IDA-D4590) and IDA credit (IDA-64080) - by two months from September 30, 2021 to November 30, 2021. This extension would allow for project funds to be fully utilized and finalize the procurement of needed medical equipment and materials (Formation sanitaire-FOSA). The parent project is a results-based financing (RBF) project funded by a US$7 million IDA credit (IDA-52160), approved by the World Bank’s Board of Directors on April 2, 2013 and became effective on July 11, 2013 with an original closing date of December 31, 2018. The first restructuring, completed in April 2015, was processed to revise the PDO to exclude malaria. The project had its first additional financing (AF) (TF-19258) approved on May 13, 2015 through a grant of US$7 million from the Health Results and Innovation Trust Fund (HRITF) with the same original closing date. The second restructuring, completed in December 2018, extended the project closing date from December 31, 2018 to April 30, 2019. The second AF (IDA-D4590 for US$5 million and IDA-64080 for US$1 million) was approved on May 3, 2019 and became effective almost 8 months later, on December 31, 2019with original closing date of December 31, 2020. The third restructuring extended the project closing date from December 31, 2020 to September 30, 2021. This would be the fourth stand-alone and final restructuring (note that the previous AF also embedded a restructuring) of the project and none of the credits or grants associated with this project have a cumulative extension over two years. The original Project Development Objective (PDO) of the project was to improve the utilization of quality health care services for maternal and child health and communicable disease control programs (HIV/AIDS, tuberculosis and malaria). The PDO was modified as part of the first restructuring in April 2015 to drop the reference to malaria as it was deemed no longer relevant in Djibouti. It was then further revised as part of the second AF in May 2019 when the PDO became to improve the utilization of quality maternal and child health services. The project is on track to achieve its Development Objective. The pace of implementation, disbursement, and achievement of results is moderately satisfactory. The original credit and HRITF grant linked to the first AF were fully disbursed while the remaining balance under IDA-D4590 is US$1.21 million and under IDA-64080 is US$350,000. The PAPSS Project Implementation Unit (PIU) has put great efforts to document project activities and results in the run up to project closing. To date, the project has supported over 111,980 pregnant women with completing 2 or more antenatal visits, and 62 percent of children under age 1 are fully immunized. In addition, 85 percent of pregnant women are now receiving at least two doses of tetanus toxoid. Through the second AF, health facilities in three refugee camps have been incorporated in the RBF scheme to be supported by the project. Over 46,900 displaced persons (refugees, asylum seekers and migrants) have received health care services at these health facilities. The World Bank DJ Improving Health Sector Performance (P131194) The project was impacted by delays due to COVID-19 which had a knock-on effect on the timing and execution of certain activities. In particular, the procurement of additional medical equipment and materials for selected health facilities (FOSA) to address challenges related to the provision of quality care and combat the impacts of COVID-19. The procurement of additional medical equipment and materials for selected FOSA would entail funds reallocation within the same disbursement category (category 1) or within the authorized 15% category overdraws. Preparations are already underway/completed through the joint efforts of the PIU/MoH, the Central pharmaceutical procurement agency (Centrale d'achats de matériels et médicaments essentiels- CAMME) and the World Bank. Also, given the PIU’s many responsibilities, there was a delayed start on work for the government’s project assessment report, which is integral to the ICR exercise. With this in mind, the Government requested the Bank for two additional months from the current date of September 30, 2021 to November 30, 2021 to carry out the intended activities and fully achieve the objectives set by the project. III. DETAILED CHANGES LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications 30-Apr-2019, 31-Oct- IDA-52160 Closed 31-Dec-2018 2019, 31-Dec-2020 IDA-64080 Effective 31-Dec-2020 30-Sep-2021 30-Nov-2021 30-Mar-2022 IDA-D4590 Effective 31-Dec-2020 30-Sep-2021 30-Nov-2021 30-Mar-2022 30-Apr-2019, 31-Oct- TF-19258 Closed 31-Dec-2018 2019, 31-Dec-2020