Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD3799 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT PAPER ON A PROPOSED ADDITIONAL CREDIT IN THE AMOUNT OF US$121.0 MILLION AND A PROPOSED ADDITIONAL GRANT IN THE AMOUNT OF SDR 57.9 MILLION (US$79.0 MILLION EQUIVALENT) TO THE DEMOCRATIC REPUBLIC OF THE CONGO FOR A FOURTH ADDITIONAL FINANCING FOR THE HEALTH SYSTEM STRENGTHENING FOR BETTER MATERNAL AND CHILD HEALTH RESULTS PROJECT May 29, 2020 Health, Nutrition and Population Global Practice Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective April 30, 2020) Special Drawing Currency Unit = Rights (SDR) SDR 0.73 = US$1 FISCAL YEAR January 1 - December 31 Regional Vice President: Hafez M. H. Ghanem Country Director: Jean-Christophe Carret Regional Director: Amit Dar Practice Manager: Magnus Lindelow Task Team Leaders: Hadia Nazem Samaha, Avril Dawn Kaplan ABBREVIATIONS AND ACRONYMS AF Additional Financing CERC Contingent Emergency Response Component CERIP Contingent Emergency Response Implementation Plan CGPMP Cellule des Projets et Marchés Publics COVID-19 Coronavirus Disease 2019 CRW Crisis Response Window DHIS District Health Information System DRC Democratic Republic of the Congo EVD Ebola Virus Disease GBV Gender-based violence GDP Gross domestic product GFF Global Financing Facility GRS Grievance Redress Service HNP Health Nutrition and Population HRITF Health Results Innovation Trust Fund IDA International Development Association IPPF Indigenous Peoples Plan Framework MOPH Ministry of Public Health NGO Non-governmental organizations NPF New Procurement Framework PBF Performance-based financing PDO Project Development Objective Projet du Développement du System de Santé (Health System Strengthening for Better PDSS Maternal Child Health Results Project) PEF Pandemic Emergency Facility PHEIC Public Health Emergency of International Concern PIU Project Implementation Unit PNDS Plan National de Développement Sanitaire (National Health Development Plan) REDISSE Regional Disease Surveillance Systems Enhancement SEA Sexual Exploitation and Abuse SH Sexual harassment SRP Strategic Response Plan UHC Universal Health Coverage UNICEF United Nations International Children’s Emergency Fund USAID United States Agency for International Development WHO World Health Organization TABLE OF CONTENTS I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ........................................ 7 II. DESCRIPTION OF ADDITIONAL FINANCING .................................................................... 20 III. KEY RISKS ..................................................................................................................... 21 IV. APPRAISAL SUMMARY .................................................................................................. 22 V. WORLD BANK GRIEVANCE REDRESS .............................................................................. 27 VI SUMMARY TABLE OF CHANGES ..................................................................................... 28 VII DETAILED CHANGE(S) .................................................................................................... 28 VIII. RESULTS FRAMEWORK AND MONITORING ................................................................... 32 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) BASIC INFORMATION – PARENT (Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) - P147555) Country Product Line Team Leader(s) Congo, Democratic IBRD/IDA Hadia Nazem Samaha Republic of Project ID Financing Instrument Resp CC Req CC Practice Area (Lead) P147555 Investment Project HAFH2 (9322) AFCC2 (6546) Health, Nutrition & Financing Population Implementing Agency: Ministry of Health, Ministry of Finance ADD_FIN_TBL1 Is this a regionally tagged project? No Bank/IFC Collaboration No Expected Original Environmental Approval Date Closing Date Guarantee Current EA Category Assessment Category Expiration Date 18-Dec-2014 31-Dec-2021 Partial Assessment (B) Partial Assessment (B) Financing & Implementation Modalities Parent [ ] Multiphase Programmatic Approach [MPA] [ ] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [ ] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) May 29, 2020 Page 1 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Development Objective(s) To improve utilization and quality of maternal and child health services in targeted areas within the Recipient's Territory and, to provide an immediate and effective response to an eligible crisis or emergency Ratings (from Parent ISR) RATING_DRAFT_ NO Implementation Latest ISR 27-Jun-2018 30-Jan-2019 29-Oct-2019 03-Jan-2020 31-Mar-2020 12-May-2020 Progress towards achievement of S S MS MS MS MS PDO Overall Implementation S MS MS MU MS MS Progress (IP) Overall Safeguards MS MS MU MU MS MS Rating Overall Risk S S S S S S BASIC INFORMATION – ADDITIONAL FINANCING (Fourth Additional Financing for Health System Strengthening for Better Maternal and Child Health Results Project - P173415) ADDFIN_TABLE Urgent Need or Capacity Project ID Project Name Additional Financing Type Constraints P173415 Fourth Additional Cost Overrun Yes Financing for Health System Strengthening for Better Maternal and Child Health Results Project Financing instrument Product line Approval Date Investment Project IBRD/IDA 11-Jun-2020 Financing Projected Date of Full Bank/IFC Collaboration May 29, 2020 Page 2 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Disbursement 30-Jun-2022 No Is this a regionally tagged project? No Financing & Implementation Modalities Child [ ] Series of Projects (SOP) [✓] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [✓] Conflict [ ] Deferred Drawdown [ ] Responding to Natural or Man-made disaster [ ] Alternate Procurement Arrangements (APA) [✓] Contingent Emergency Response Component (CERC) Disbursement Summary (from Parent ISR) Net Source of Funds Total Disbursed Remaining Balance Disbursed Commitments IBRD % IDA 460.00 397.54 50.03 89 % Grants 54.50 37.71 16.79 69 % PROJECT FINANCING DATA – ADDITIONAL FINANCING (Fourth Additional Financing for Health System Strengthening for Better Maternal and Child Health Results Project - P173415) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFi n1 SUMMARY (Total Financing) Proposed Additional Total Proposed Current Financing Financing Financing Total Project Cost 514.53 200.00 714.53 May 29, 2020 Page 3 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Total Financing 514.53 200.00 714.53 of which IBRD/IDA 460.00 200.00 660.00 Financing Gap 0.00 0.00 0.00 DETAILS - Additional Financing NewFinEnh1 World Bank Group Financing International Development Association (IDA) 200.00 IDA Credit 121.00 IDA Grant 79.00 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount Congo, Democratic Republic 121.00 79.00 0.00 200.00 of National PBA 42.00 0.00 0.00 42.00 Crisis Response Window 79.00 79.00 0.00 158.00 (CRW) Total 121.00 79.00 0.00 200.00 COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [ ✔ ] No Does the project require any other Policy waiver(s)? [ ] Yes [ ✔ ] No INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population May 29, 2020 Page 4 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Contributing Practice Areas Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks PROJECT TEAM Bank Staff Name Role Specialization Unit Team Leader (ADM Hadia Nazem Samaha Health systems HAFH2 Responsible) Avril Dawn Kaplan Team Leader Health Systems HAFH2 Clement Tukeba Lessa Procurement Specialist (ADM EA2RU Kimpuni Responsible) Jean-Claude Azonfack Procurement Specialist EA2RU Lanssina Traore Procurement Specialist EA2RU Financial Management Francis Tasha Venayen EA2G2 Specialist (ADM Responsible) Environmental Specialist (ADM Joelle Nkombela Mukungu SAFE3 Responsible) Social Specialist (ADM Richard Everett SAFS3 Responsible) Amba Denise Sangara Team Member HAFH2 Amy Champion Team Member HAFH2 Elena Segura Labadia Counsel LEGAM Faly Diallo Team Member WFACS Gil Shapira Team Member Economist DECHD Gyorgy Bela Fritsche Team Member Performance Based Financing HAFH2 Julie Luvisa Bazolana Team Member AFCC2 Karamath Djivede Sybille Team Member Private Sector HHNGE Adamon Lombe Kasonde Team Member Pharma HAFH2 Lucie Lufiauluisu Bobola Procurement Team AFCC2 May 29, 2020 Page 5 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Marion Jane Cros Team Member Health financing HHNGF Michel Muvudi Lushimba Team Member Performance Based Financing HAFH2 Supriya Madhavan Team Member Family planning HAFH2 Extended Team Name Title Organization Location May 29, 2020 Page 6 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING Project Background 1. Parent project: The Executive Directors approved the Health System Strengthening for Better Maternal and Child Health Results Project (PDSS, P147555) on December 18, 2014 for US$226.5 million equivalent (US$130 million International Development Association (IDA) Credit 55720; US$90 million IDA Grant D0210; and US$6.5 million Health Results Innovation Trust Fund (HRITF) Grant TF018675). The project became effective on May 30, 2016. The initial project development objective (PDO) was to improve utilization and quality of maternal and child health services in targeted areas within the Recipient's Territory. 2. First Additional Financing (AF1): AF1 was approved on May 31, 2017 for US$163.5 million equivalent (US$120 million IDA Credit 59980; US$40 million Global Financing Facility (GFF) Grant TF0A4579; and US$3.5 million United States Agency for International Development (USAID) Grant TF0A5096). AF1 aimed to strengthen the parent project’s long-term objectives of reducing maternal and child mortality and chronic undernutrition by scaling up activities. AF1 included restructuring of the parent project as follows: (i) inclusion of a Contingent Emergency Response Component (CERC), where the original Part 3(a)(iv) “preparation and implementation of the Recipient’s Ebola preparedness plan” was absorbed under the new Part 4(a) “CERC”; (ii) restructuring of the Original Part 3(c) Project Management to be under Part 3(a) as Part 3(a)(iv); (iii) inclusion of a new Part 3(c) to support retirement benefits of the Ministry of Public Health (MOPH) and the organizational reform of MOHP; (iv) revision of the results framework; and (v) extension of the closing date from December 30, 2019 to December 30, 2021. The GFF grant became effective on August 18, 2017, the USAID grant became effective on November 22, 2017, and the IDA Credit became effective on February 13, 2018. 3. Second Additional Financing (AF2): AF2 was approved on January 24, 2018 for US$10 million from the Global Fund (Grant TF0A6945). It aimed at increasing the delivery of the existing integrated package of essential health services to the targeted population. This grant funded Performance Based Financing (PBF) under Components 1 and 2 of the parent project. The Global Fund grant became effective on August 14, 2018 and closed on August 30, 2018. By the end of the disbursement grace period, December 31, 2018, the balance of US$5.47 million was cancelled. 4. First triggering of the CERC: On May 8, 2018, the CERC was triggered at the request of Democratic Republic of the Congo (DRC) after the official declaration of the ninth Ebola Virus Disease (EVD9) outbreak in the province of Equateur. At this time, 30 Ebola cases were confirmed, and 27 deaths were recorded. The World Bank approved the request to activate the CERC on May 25, 2018. The Pandemic Emergency Facility (PEF) was also triggered at the request of DRC (May 25, 2018), and an additional US$11.4 million grant was mobilized under the PEF Cash Window. The PEF funding went directly to the implementing partners of the World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) while the CERC funding was disbursed through the project and Ministry of Health. 5. The EVD 9 outbreak was declared controlled on July 24, 2018. However, on August 1, 2018, DRC declared the 10th Ebola Virus Disease (EVD10) outbreak in the North Kivu province. Since not all CERC financing for EVD9 had been exhausted, and due to the similar nature and urgency of the emergency activities, DRC’s approved Contingent Emergency Response Implementation Plan (CERIP) was amended to include support for EVD10. The CERC reallocation was approved on November 29, 2018. May 29, 2020 Page 7 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) 6. Third Additional Financing (AF3): AF3 was approved on February 27, 2019 for US$120 million. Of this amount, US$80 million was allocated from national IDA to replenish PDSS core activities that had been reprogrammed to support the EVD response under the government’s Strategic Response Plan (SRP) 1 and 2 when the first CERC was triggered. The remaining US$40 million in AF3 was used to continue EVD support as part of SRP 3. To be agile, the US$40 million in AF3 was directly included in the CERC rather than being allocated to the project then reallocated to CERC. AF3 also included a restructuring to revise the PDO to reflect the activation of the CERC, update the results framework to reflect CERC results (with no changes to core project indicators) and changes in procurement arrangements to reflect the World Bank’s New Procurement Framework. AF3 did not become effective until August 28, 2019. While the project was waiting to become effective, EVD10 was not contained. The virus expanded to new health zones and was identified in other countries (Uganda in June 2019) and in major cities within DRC (Goma in July 2019). 7. Second triggering of the CERC: The Recipient requested a second activation of the CERC in the amount of US$50 million before AF3 became effective to finance the Fourth Ebola Strategic Response Plan (SRP 4). The goal of SRP 4 was to stop the chain of EVD transmission and address the potential spread of Ebola within the country and across borders to neighboring countries. The second activation reallocated US$25 million from Category 1 of CR-55720 and US$25 million from Category 1 of Gr-D0210 under the Parent Project to the CERC. 8. Third triggering of the CERC: The Recipient requested the third activation of the CERC before AF3 was effective. Again, the funds were used to finance SRP-4 and to respond to the ongoing EVD10 outbreak, which was still not contained. The third triggering reallocated US$30 million from Category 1 of GFF TF0A4579 to the CERC. By 2020, the project was running out of funds for core PDSS activities. Therefore, the restructuring approved in February 2020 reallocated US$12 million from CERC-3 back to Component 1 of the project. 9. The progression of the project, which includes three AFs and three CERC activations, is summarized in Table 1. The total cost of the project is currently US$514.5 million. Of this total amount, US$188 million has been allocated to the EVD9 and EVD10 responses (US$80 million CERC1, US$40 million AF3, US$50 million CERC2, and US$18 million CERC3). Table 1: PDSS AF and CERC activations Approval Effective Total (US$, Cr/Gr/TF Amount (US$, Objective million) million) Parent Nov-14 May-16 226.5 Cr-55720 130 Improve utilization Gr-D0210 90 and quality of TF-18375 6.5 maternal and child health services in targeted health zones AF1 Mar-17 Feb-18 163.5 Cr-59980 120 Expand geographic TF-A4579 40 coverage and TF-A5096 3.5 emphasize family planning, nutrition, health financing reforms, and May 29, 2020 Page 8 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) retirement of health workers. These were key priority areas identified in the Global Financing Facility (GFF) investment case which resulted in funding from GFF and USAID AF2 Mar-18 Aug-18 10 TF-A6945 4.53 The Global Fund – a (5.47 GFF partner – was cancelled) included to support the core objectives of the PDSS CERC1 Nov-18 Nov-18 80 Cr-59980 45 C1 → C4.2 CERC Respond to EVD9, reallocation 15 C2 → C4.2 CERC and later to EVD10 from 20 C3 → C4.2 CERC Categories 1-3 to CERC AF3 Feb-19 Aug-19 120M Gr-D4390 80 C1-C3 Reconstitute 80M 40 C4.2 CERC allocated to CERC1 to components 1-3, add an additional 40M to CERC for EVD10 response CERC2 May-19 Aug-19 50M Cr-55720 25 C1 → C4.2 CERC Respond to EVD10 Gr-D0210 25 C1 → C4.2 CERC CERC3 Aug-19 Aug-19 30M TF-A4579 30 C1 → C4.2 CERC Respond to EVD10 L2 Feb-20 Mar-20 TF-A4579 12 C4.2 CERC → C1 Ensure sufficient restructuring Cr-59980 8.14 C4.1 → C1 funding for C1 of the project C1: Improve Utilization and Quality of Health Services at Health Facilities through PBF C2: Improve Governance, Purchasing and Coaching and Strengthen Health Administration Directorates and Services through PBF C3: Strengthen Health Sector Performance – Financing and Health Policy C4.1: Disease Surveillance Strengthening and Response C4.2: CERC 10. The project has four components: (1) Improve Utilization and Quality of Health Services at Health Facilities through Performance Based Financing (PBF); (2) Improve Governance, Purchasing and Coaching and Strengthen Health Administration Directorates and Services through PBF; (3) Strengthen Health Sector Performance – Financing and Health Policy; and (4) Disease Surveillance Strengthening and Response, which includes the CERC. The project covers 169 districts in 11 of the country’s 26 provinces, which is close to a third of the population. Its intervention uses PBF, the largest of its kind globally, to strengthen service delivery and ensure quality and good governance. The contracting approach involves public and private health facilities, public health administration, central ministry of health departments and the provincial public purchasing bodies. Beyond PBF, the project is the main vehicle in DRC May 29, 2020 Page 9 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) to increase policy dialogue and donor engagement around human resources for health, pharmaceuticals, governance, and health financing. The project has supported capacity development and provided technical assistance for the development and implementation of key health sector policies. 11. As of May 2020, approximately 89 percent of IDA funding has been disbursed overall and the project will close on December 31, 2021. This includes 89 percent of the parent project, 93 percent of AF1, 100 percent of AF2 and 65 percent of AF3. Approximately US$67 million remains. Disbursement has increased in support of the results achieved to date and the project’s burn rate is about US$80 million per year. Hence, the project will not have enough funds to operate through its current closing date of December 31, 2021. Table 2: PDSS disbursement as of May 2020 AF No. Total (US$ ) Disbursed (US$ ) Undisbursed (US$ ) % Disbursed IDA-55720 130.00 113.80 8.41 88% IDA-D0210 90.00 82.93 1.49 92% Parent TF-18375 6.50 4.43 2.07 68% Total 226.50 201.16 11.97 89% IDA-59980 120.00 122.88 0.15 102% TF-A4579 40.00 25.28 14.72 63% AF1 TF-A5096 3.47 3.47 0.00 100% Total 163.47 151.63 14.87 93% AF2 TF-A6945 4.53 4.53 0.00 100% AF3 IDA-D4390 120.00 77.93 39.97 65% Total 514.50 435.25 66.81 85% Project Results for Core Project Activities 12. Progress towards the PDO is currently rated Moderately Satisfactory. At the end of 2019, three PDO indicators under the parent project have been met and the remaining three are on track to be met. In 2019 alone, 8,822,459 people received essential health, nutrition and population services (target 7,819,376 people). Figure 1 presents progress made on service delivery PDO indicators. From 2016 to 2019, the proportion of pregnant women who received at least four antenatal care visits increased from 36 to 50 percent (target 55 percent); proportion of people who had a new curative consultations increased from 38 to 45 percent (target 50 percent); and fully vaccinated children increased from 62 to 81 percent (target 70 percent). May 29, 2020 Page 10 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Figure 1: Progress towards health service utilization PDO indicators, 2016-19 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pregnant women who received at least New curative consultations per person Completely vaccinated children (%) 4 prenatal visits (%) per year (%) 2016 2017 2018 2019 Source: Ministry of Public Health, District Health Information System (DHIS2) 13. The project goes beyond increasing utilization of essential health services: it focuses on improving service quality. The project uses a quarterly checklist to assess different aspects of health care quality.1 The checklist aims to assess structural quality against national norms, and adherence to clinical and therapeutic protocols as defined by national policy. The quality checklist and scores differ depending on level of care and are used to adjust payment. As Figure 2a and 2b present, between 2016 and 2019, the average quality score increased from 23 to 55 percent at health centers, and from 33 to 67 percent at hospitals (target 60 percent). 1 For health centers, the quality checklist assesses general organization of the facility, the facility’s management plan, finances, committee for identifying vulnerable people, hygiene and sterilization, external consultations, family planning, laboratory, observation of services, medicine and consumables, tracer medications, maternal services, vaccinations, prenatal care and HIV/Tuberculosis. For hospitals, the checklist is the same, except vaccinations is removed and surgery is added. May 29, 2020 Page 11 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Figure 2A: Evolution of the composite Figure 2B: Evolution of the composite quality score Health Centers, 2016-19 quality score for Hospitals 2016-19 Source: DRC National PBF Database 14. In addition to routine monitoring and evaluation of results using the country’s National Health Management Information System and PBF database, the project includes a rigorous impact evaluation of PBF. The midline survey of project supported PBF conducted in three out of the 11 provinces was completed in October 2018 to measure short-term impacts at the facility level and shows promising results. The preliminary data indicate improvements in multiple structural quality indicators in project-supported health zones. For example, the proportion of facilities that have water and soap in consultation rooms increased from 46 percent at baseline to 69 percent at midline. Furthermore, facilities are more likely to have antiseptic gel, functioning toilets, proper fencing, and basic functioning equipment for provision of maternal and child health. Facilities have also increased the number of days per week in which they provide antenatal care and the data suggest a significant increase in availability of family planning products such as birth control pills, injectables and implants. The end line survey is planned to be done by the fourth quarter of 2020, which would allow further understanding of the outcomes and impacts of the project. These results will be used to inform future investments in health systems strengthening in DRC. 15. DRC has adopted PBF as a national policy and institutionalized the approach. This is most evident by the government approving a National Policy on Strategic Purchasing validated by the Council of Ministers in November 2018. This policy will ensure that all parties implementing PBF will be aligned to the national policy, thereby reducing fragmentation that has hampered the health system for the past 10 years. The policy was developed after review and consultation with all the stakeholders (Government, donors, non-governmental organizations (NGOs), civil society) who have been involved in implementing PBF in DRC. 16. PDSS plays a role in improving health system governance. The project is well anchored in the Five-Year Health System Development Strategy (Plan National de Développement Sanitaire 2019-2022 – PNDS) validated by the Government in November 2019 and is seen by the Government as the embryo to achieving Universal Health May 29, 2020 Page 12 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Coverage (UHC) by 2030. The PNDS was accompanied by the development of the program-based budgeting reform in the health sector, which reflects priorities of the PNDS in the budget template. Before, priorities of the PNDS were not reflected in the budget: the budget was input-based and included mostly salary and non-salary budget lines with limited disaggregation by health priority area and province. Now, budgets of PNDS priorities are set based on the PNDS result framework, thereby allowing domestic and donor commitments and expenditures to be tracked on a yearly basis to improve governance and transparency. The PDSS is supporting the implementation of program- based budgeting at the central and provincial levels, which will permit the Ministry of Health to monitor implementation of the PNDS and institutionalize resource mapping and expenditure tracking. Additionally, the PDSS has supported several health financing analytic pieces related to public financial management and domestic resource mobilization in the health sector, leading to interventions to improve health budget execution and to better align donors. 17. The project does not have sufficient funding to continue core activities through its closing date of December 31, 2021. Replenishing the project’s financing gap through Additional Financing 4 (AF4) will allow the project to continue making progress on its PDO indicators, and to meet its original objectives. PDSS response to the 10th Ebola outbreak 18. As of May 24, 2020, there have been 3,463 EVD cases, including 3,317 confirmed and 146 probable cases, of which 2,280 cases have died (overall case fatality ratio 66 percent).2 Of the total confirmed and probable cases, 57 percent (n=1970) were female, 29 percent (n=1002) were children aged less than 18 years, and 5 percent (n=171) were healthcare workers. As of May 24, 2020, 1,171 cases have recovered from EVD. The outbreak reached 19 health zones in North Kivu, nine health zones in Ituri and one health zone in South Kivu. EVD10 in DRC is the second largest Ebola outbreak after the 2013-16 outbreak in West Africa, and the largest in DRC history. WHO declared EVD10 a Public Health Emergency of International Concern (PHEIC) on July 17, 2019 according to International Health Regulations and plans to maintain this status through at least May 2020. The PHEIC is still effective to date as new Ebola cases were confirmed in April 2020. 19. DRC has responded to the crisis through four SRPs. The fourth plan was approved on July 12, 2019 to cover the period between July to December 2019. SRP 4.1, an extension of the fourth response plan, was approved on January 24, 2020 to cover response activities and preliminary transition activities at the provincial level through June 2020. It has now been extended to cover through September 2020. Between February 24 and April 10, 2020, there were no new cases of EVD. Two days before the outbreak was to be declared over, a new case was confirmed in the city of Beni on April 10, 2020. Since this date, seven new cases have been confirmed, with the last confirmed case being on April 27, 2020.3 For the outbreak to be declared over, no new cases can emerge for 42 days – double the incubation period for infection. However, based on the West African Ebola outbreak from 2013-16, it will be critical to continue intense surveillance for 90 days once the outbreak is declared over to avoid resurgence of infection. 2 World Health Organization. May 26, 2020. Ebola Virus Disease Democratic Republic of the Congo. External Situation Report 94. Accessed May 28, 2020 from: https://www.who.int/publications-detail/ebola-virus-disease-democratic- republic-of-congo-external-situation-report-94-2019 3 Ministry of Health. May 26, 2020. Epidemiological Situation. Accessed May 28, 2020 from: https://www.riposte- epidemie-rdc.info/situations.php May 29, 2020 Page 13 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) 20. The World Bank’s Health Nutrition and Population (HNP) response to the EVD10 outbreak has focused on three key pillars: funding, technical support and pandemic preparedness. Additional World Bank support through the DRC Eastern Recovery Project (P145196 – STEP Project), has financed community-based interventions. These include high-intensive labor works that have led to improving the livelihood of about 10,000 people in Ebola affected health zones. • Funding: PDSS has provided funding for the EVD9 and 10 responses through the MOPH and UN agencies. Funding has been used to deliver free health services and medicines in zones affected by the outbreak, provide hazard pay to frontline health responders, conduct surveillance activities including active cases finding, prompt case investigation and community-based surveillance, leading to earlier detection and isolation of cases. In addition, there is critical support for multi-disciplinary interventions around a confirmed case, including vaccination of primary and secondary contacts, support for prevention and control measures at health facilities and in the community, support for case management at Ebola Treatment Units and transit centers, safe and dignified burials and strengthened laboratories in areas that are vulnerable to transmission. These interventions are coupled with increased risk communication and community engagement efforts to ensure integral community appropriation of the response, improved health seeking behaviors so that new cases are immediately reported, isolated and treated. • Technical support: The World Bank has been on the ground providing technical support to DRC throughout the outbreak. The World Bank has provided technical contribution to each SRP and to the development of the Center of Excellence for Ebola. The Center of Excellence for Ebola is expected to serve as the foundation for building a national public health institution for DRC, which will also play a regional role in the context of Ebola outbreaks. It has also provided technical support to establish a tool to track resource mobilization as well as expenditures per pillars and cost categories to achieve greater transparency and accountability from all implementing agencies involved in the response. • Pandemic preparedness: The World Bank has been working with DRC to develop an initial one-year basic preparedness plan that targets the country’s 26 provinces and has financing in place for the nine countries that border DRC. These efforts will tie into the Regional Disease Surveillance Systems Enhancement IV (REDISSE IV - P167817) project, approved in April 2019 but not yet effective. These plans are currently being used to prepare for the spread of Coronavirus Disease 2019 (COVID-19) outside of Kinshasa. 21. The project has surpassed its PDO indicator related to the EVD response. As of May 27, 2020, 303,905 people were vaccinated for the virus, surpassing the PDO target of 120,000.4 Contact tracing has been a challenge throughout the response, but several initiatives have been taken to decrease loss to follow up. These include establishing a Monitoring Unit, distributing food to contacts, engaging community leaders, and conducting active case finding and door-to-door activities. This is coupled with community watch interventions to track the movement of new arrivals, deaths and illnesses within the community. During the week of May 4 to 10, 2020 there were no contacts lost to follow up.5 To improve case management and testing, decentralized transit centers are being used to rapidly test and isolate cases in a setting close to the community. During the same week, 95 percent of suspected 4 Ministry of Health. May 27, 2020. Situation Epi 26-05-2020. Accessed May 28, 2020 from: https://www.riposte-epidemie- rdc.info/document.php?doc=tds1590567164 5 Ministry of Health, WHO, United Nation’s Children’s Fund and Partners. May 14, 2020. Dashboard on the State of the EVD Response: May 4-10, 2020. Accessed May 28, 2020 from: https://www.riposte-epidemie- rdc.info/document.php?doc=tds1589698636 May 29, 2020 Page 14 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) EVD cases had a safe and dignified burial.6 Community engagement has been critical throughout the response to ensure that people are vaccinated, seek care when ill, and follow procedures for safe and dignified burials. The response adopted a community-centered approach with feedback mechanisms to address rumors. At the same time, anthropologists and social scientist were engaged to provide feedback on all response pillars. Gaining trust from local religious, traditional and community leaders has been critical to mitigate community resistance and is facilitated by using community structures and community health workers who speak the local language. 22. Halting the transmission of Ebola in Eastern Congo has been challenging due to a range of factors. The region has experienced decades of violence and instability, which have fueled widespread poverty, gender-based violence (GBV), malnutrition and weak public sector service delivery. A key factor in the failure to stop the epidemic has been increasing mistrust from communities towards the Ebola response, including community perceptions of Ebola as business, politicization of Ebola or even a “weapon of war.” The response has had the benefit of novel therapies and a new vaccine to assist in efforts to break chains of transmission. Yet, EVD10 has been challenging to control and is now in its 21st month. Lack of trust between communities and EVD response teams has been a major impediment to ending the outbreak. A combined approach of financing Ebola response in tandem with core PDSS activities in Ebola affected provinces aims to increase communities’ trust in health structures and thereby their health-seeking behavior. 23. The financing from AF4 is necessary to continue financing the EVD10 response. It will strengthen linkages with communities and primary health care systems to rapidly detect and respond to Ebola by reinforcing critical outbreak measures such as surveillance, infection prevention and control, and existing community structures. Only through the combination of these direct response measures can this complex outbreak be effectively contained. Relevance of PDSS to COVID-19 pandemic 24. Continued investment in core PDSS activities is critical, particularly in light of the COVID-19 pandemic. COVID-19 was confirmed in DRC on March 10, 2020. As of May 26, 2020, there were 2,546 cases (2,545 confirmed cases and one probable case) and 68 deaths (67 confirmed deaths and one probable death).7 COVID-19 has now spread to seven Provinces8, while Kinshasa remains the epicenter with 2,293 cases. If COVID-19 is not contained in DRC, it will create a surge in the demand for health services as is currently happening in countries throughout the world. 25. The DRC COVID-19 Strategic Preparedness and Response Project (P173825, US$47.2 million, approved on April 2, 2020 ) and the REDISSE IV Project (P167817, US$150 million DRC allocation, approved on April 26, 2019 for US$150 million) are the main projects financing the COVID-19 response. Neither project is effective as of May 27, 2020. The COVID-19 Strategic Preparedness and Response Project is taking the lead to contain and respond to COVID-19. It focuses on the emergency response, communication with communities and behavior change. REDISSE IV is complimentary. It will work primarily at the national level. It aims to strengthen laboratory capacity and improve community-based surveillance as well as improve human resource capacity. The two projects will exchange information to minimize the chances of duplication and maximize synergies as they respond to the pandemic. The 6 Ibid 7 Multisectoral Response Committee for the CoVID-19 Pandemic in DRC. Epidemiological situation May 26, 2020. Accessed May 28, 2020 from https://mailchi.mp/3ecf3158ce25/covid-19-bulletin-n-64-du-mardi-26-mai- 3943213?e=e7794651e3 8 Kinshasa (2,293 cases), Kongo Central (176 cases), North Kivu (35 cases), Haut-Katanga (21 cases), South Kivu (16 cases), Ituri (2 cases), Kwilu (2 cases). May 29, 2020 Page 15 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) geographic coverage of these projects will be the same. They will target provinces with active COVID-19 cases and adapt their geographic coverage as needed as the pandemic progresses. 26. The Multisectoral Nutrition and Health Project (P168756, US$502 million, approved on May 28, 2019) aims to increase utilization of quality nutrition-specific and nutrition-sensitive interventions targeting children and pregnant and lactating women. It operates in four provinces: Kwilu, Kasai Central, Kasai and South Kivu. The project overlaps with PDSS in two of the four provinces it supports. The project strengthens a vast network of community health workers to deliver basic nutrition, family planning and health services to families. It finances the expansion of the same PBF approach used under PDSS to new health zones, including those in Kasai Central, Kasai and South Kivu. Community health workers, community mobilization, and a communication strategy supported through this project will be essential to engage and educate communities about COVID-19 and to refer people for health and nutrition services. Both the community- and facility-based nutrition services strengthened through this program will be critical during COVID-19. The disruptions to food supply and livelihoods, sharp price changes, and reduced income associated with the pandemic response will restrict the availability of and people’s access to sufficient, diverse and nutritious sources of food. 27. The health system in DRC needs to be prepared to respond to the increased demand related to COVID-19. Funding from any standalone project will not be sufficient to handle the complex nature of pandemic: PDSS plays a key role if the pandemic spreads widely outside of Kinshasa where it is currently concentrated. PDSS is the vehicle to deliver essential health services and drugs to approximately one third of the country. New mathematical models predict that service disruption associated with COVID-19 could leave 1,616,00 children without oral antibiotics for pneumonia, 3,307,900 children without the DPT vaccine, lead to 699,800 fewer deliveries in health facilities and 964,200 fewer women benefiting from family planning services. COVID-19 could increase infant mortality by 16 percent and maternal mortality by 8 percent during the next 12 months.9 Continuing service delivery through PBF will help maintain advancements made in reproductive, maternal and child health outcomes while the pandemic is ongoing. Furthermore, the PDSS PBF quality checklist includes infection prevention control procedures that are critical to protect frontline health workers during the pandemic and reduce the spread of the new virus within a clinical setting. PBF also finances curative consultations among other primary health care services, which will be necessary to provide treatment to patients who present at health facilities with symptoms of COVID-19, as well as other conditions.10 Households will likely have a harder time financing care due to the socioeconomic consequences of the pandemic, making PDSS subsidies for services even more critical during this time. Finally, given that testing for COVID-19 will likely be limited throughout the country, it may be difficult for providers to distinguish the new virus from other common conditions. PDSS will be essential to ensuring that COVID-19 patients are properly triaged. PDSS Implementation Progress 28. Project Implementation Progress is rated Moderately Satisfactory. Implementation of most project activities, such as contracting of health facilities to support health and population services, is well underway. The contracting approach involves public and private health facilities, subnational public health administration, central ministry of 9 Global Financing Facility. 2020. Préserver les services de sante essentiels pendant la pandémie : République Démocratique du Congo. (Preserve Essential Health Services during the COVID-19 Pandemic Democratic Republic of Congo). 10 Symptoms range from mild to severe, and can include fever, cough and shortness of breath. Other symptoms, including headache, sore throat, abdominal pain, and diarrhea, have been reported, but are less common. These symptoms are similar to existing conditions, notably malaria, lower respiratory infections and other common bacterial or viral infections. May 29, 2020 Page 16 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) health departments and the provincial public purchasing bodies. Contracts have been put in place with 2,545 Health Centers, 166 Hospitals, 165 Health District Teams, 11 Provincial Health Teams, 11 Public Purchasing Agencies – including provincial satellites and the Central Strategic Purchasing Support Cell. Under the Ebola emergency response, the project was able to swiftly sign contract with UN agencies such as WHO, UNICEF, IOM and others to support implementation of activities outlined in multiple Ebola strategic plans developed between August 2018 and January 2020. Yet, due to the EVD9 and EVD10 outbreaks, the implementation of other activities has faced delays. For example, contracts to determine the number of civil servants eligible for retirement have been developed, and firms have been hired to calculate the pension amount and manage grievances. However, the actual launching of these activities has not started. Due to the rapid scaleup in activities due to Ebola as well as the multiple sources of funding coming through the PDSS, Implementation Progress was downgraded to Moderately Unsatisfactory for one Implementation Status Report in January 2020. Multiple actions were taken to bring the rating back to Moderately Satisfactory by March 2020. These actions included restructuring the project and scaling up the fiduciary team within PDSS – it now has three financial management specialists (up from one), two internal auditors (up from one), three procurement specialists (up from one) and six accountants (up from two). 29. Procurement is currently rated Moderately Satisfactory. The project previously faced difficulties with procurement, with the rating falling to Moderately Unsatisfactory between October 2019 and March 2020. However, multiple changes were made within the project to improve procurement, which led to an upgrade in rating to Moderately Satisfactory. For example, the project was restructured in February 2020 to move procurement from the Ministry’s procurement unit (Cellule des Projets et Marchés Publics – CGPMP), to the PDSS. The World Bank has provided technical assistance to PDSS to ensure all procurements are updated and available in STEP and has conducted a rigorous examination of PDSS contracts to assess their implementation status, particularly for the Ebola contracts, which are a priority and are monitored on a daily basis. 30. Financial Management is rated Moderately Unsatisfactory. The project has eight Designated Accounts, which has created confusion for the project's financial management team during the EVD response when the CERC was triggered three times, and funding was shifting between categories of multiple accounts. The rating for Financial Management remains Moderately Unsatisfactory, largely due to the Project Implementation Unit’s continued difficulty to adequately monitor the effects of disbursements (both planned and actual) and commitments (both current and future) on available funds (both from the loan account, and the Designated Account), both at value date and in projections. This limitation led to an excessive commitment of project funds to the CERC component of the project and created a shortfall in the funds available for other project activities scheduled for the project’s remaining duration. Since the project’s Mid-Term Review in July 2019, improvements have been made. For example, there was a mismatch between the Designated Account balances in the commercial banks and the balances reported in Client Connection due to errors in processing, which has now been corrected. All audit reports (latest calendar year 2018) and Interim Financial Reports (latest for the fourth quarter of 2019) were submitted on time. The calendar year 2018 audit report produced an unqualified opinion, whereas the calendar year 2017 audit report had a qualification point on Financial statements of designated account B. 31. Environmental and Social Safeguards are rated Moderately Satisfactory. The project is now implementing the Indigenous Peoples Plans approved under AF3. The project supports the most vulnerable groups in DRC, including indigenous people, through the equity fund that provides primary health services free of charge. On the environmental side, the project experienced challenges with operationalizing the Healthcare Waste Management Plan and improving sanitation and hygiene at health facilities. The project responded by establishing a minimal score for the Hygiene and Sterilization section of the Quality Checklists of Health Centers and Hospitals as a precondition May 29, 2020 Page 17 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) to receive any PDSS financing, this will begin implementation shortly. The project also recently hired a new environmental specialist to further support monitoring of safeguards compliance. Project Risks 32. The project’s overall risk rating remains Substantial. The rating is due to the challenging operating environment in DRC, the fiduciary risks, as well as the weak capacity of the implementing institutions. In addition, the country’s political instability, frequent security crises, and the macro-economic situation has led to additional risks for project implementation. The Ebola outbreaks further add to the project’s risk, as does the COVID-19 pandemic. New projections from the London School of Hygiene and Tropical Medicine form April 30, 2020 predict that after one year of an unmitigated epidemic, the total number of symptomatic cases will be between 23 and 28 million people (95 percent confidence interval 14-40 million), with an estimated 180,000 to 240,000 deaths (95 percent confidence interval 92,000-270,000 deaths).11 If this scenario is realized, there will be major economic implications and the health system will be overwhelmed. Another project risk is related to the sustainability of the PBF model. The government has invested resources into PBF in Kinshasa, but not outside the capital. The project is working through Component 3 to expand fiscal space and increase resources for essential health services as DRC works towards UHC. Rationale for AF4 33. Financing gap for core activities: The reallocation of funds to the CERC created a financing gap for core PDSS activities (Components 1, 2 and 3). Core project activities covered by the financing gap include: the provision of a package of priority health services targeting children, adolescents, pregnant women and mothers through PBF; strengthening capacity of health administration directorates within the Ministry of Public Health, health verification teams and civil society organizations to administer PBF; and providing support to the health reform process, particularly as it relates to health financing and UHC. Without AF4, the project will not be able to run through its closing date and will likely not achieve its intended objectives. AF4 is particularly important to ensure that gains made in reproductive, maternal, neonatal and child health are maintained during COVID-19. As of April 2020, a total of US$188 million has been allocated to the EVD9 and 10 responses through the CERC component of PDSS, as shown below: CERC 1 - US$80M + CERC 2 - US$50M + CERC 3 - US$18M + CERC funding as part of AF3 - $40M Total of US$188M financing gap - US$80M replenished in AF3 Total of US$108M financing gap AF3 initially replenished US$80 million to the project. However, AF3 only replenished funds that reallocated to the Ebola response when the first CERC was triggered. It did not account for the remaining funds that were put into the CERC during AF3, nor the reallocated funds when the second and third CERC were triggered. The PDSS therefore has a financing gap of US$108 million (US$188 million allocated to the CERC, of which US$80 million was replenished during AF3). 11 LSHTM CMMID COVID19 Working Group. April 30, 2020. Modelling projections for COVID19 epidemic in Dem. Republic of the Congo. Accessed May 28, 2020 from https://cmmid.github.io/topics/covid19/LMIC-projection-reports.html May 29, 2020 Page 18 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) 34. Cost-overrun for core activities: AF4 will add US$42 million to support core activities in Components 1-3 of the project. This funding will cover a cost-overrun resulting from the socio-economic impact of COVID-19 on households. As a result of the pandemic, households will have greater difficulty accessing and financing primary health care. Health facilities will have greater difficulties procuring drugs and vaccines. The US$42 million will be allocated to i) increase subsidies to the 2,800 health centers contracted by the PDSS in the Provinces already covered by the project so that financial access does not deter care seeking; ii) purchase essential drug and vaccines to ensure that facilities do not encounter massive stock outs; iii) improve the infection prevention control and water and sanitation aspects of the health facilities to reinforce quality of care; and iv) finance GBV interventions as per the GBV action plan developed under the safeguard documents, which to had not been fully costed to take into account the greater risk of GBV due to the COVID-19 response. 35. Cost-overrun for EVD10 response: AF4 will add US$50 million to support the ongoing EVD10 response. While PDSS was deeply involved in the costing of the EVD10 response, it was not foreseen that the outbreak would last for more than 21 months and have a geographic spread across three provinces in a fragile and conflict-affected settings. As part of the international scale-up strategy, efforts to expand coverage of treatment centers, reinforce point of entry controls and strengthen community surveillance led to a cost overrun for the Ebola response as compared to the estimations completed in early 2019 to inform AF3. Without AF4, PDSS will not have sufficient resources to support SRP4.1, which covers through September 2020. 36. Overall project amount: AF4 is for US$200 million. This includes US$108 million to cover the financing gap after triggering the CERC a second and third time, and US$50 million to cover the EVD10 response cost overrun, both of which will be financed with Crisis Response Window funds. It also includes US$42 million to cover a cost overrun resulting from lower socioeconomic status of households due to COVID-19, which will be financed through IDA resources. 37. Relationship to Crisis Response Window (CRW) eligibility note: The CRW eligibility note requested a financing amount of US$280 million, with US$180 million being allocated to PDSS through AF4. Out of the US$180 million, US$50 million would go directly to continue Ebola response activities, whereas US$130 million would go to replenish the funds that were taken from core PDSS activities to finance the emergency response to Ebola. However, in the meantime AF3 had already reallocated US$80 million to replenish some funding from national IDA and was then subsequently not re-directed to Ebola emergency response as foreseen at the time of finalization of the CRW eligibility note. This discrepancy between the CRW eligibility note (requesting US$180 million replenishment) and the PDSS AF4 Project Paper (requesting US$158 million replenishment with CRW funds) is due to responding to a fast-moving landscape of Ebola Crisis funding while in parallel trying to safeguard funding to keep essential PDSS project activities running. The need to continue ensuring funding for core PDSS activities is especially important given that the Project is aiming to address the underlying health system weaknesses that make it so difficult to effectively respond to outbreaks when they occur. May 29, 2020 Page 19 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) II. DESCRIPTION OF ADDITIONAL FINANCING 38. This AF will cover the PDSS financing gap and cost overrun related to the COVID-19 pandemic and ongoing EVD support. It will allocate US$150 million to core project activities (US$108 million financing gap and US$42 million cost overrun) and US$50 million to the CERC for the EVD10 response (cost overrun). The proposed changes in project allocation by components are summarized in Table 3. As the table illustrates, AF4 will add US$80 million to component 1, US$40 million to Component 2, US$30 million to Component 3; and US$50 million to the CERC (Component 4.2). This funding will fill the financing gap after using PDSS as the main vehicle to finance the Ebola response and will finance core activities through the project’s closing date. It will also cover the cost overrun resulting from COVID-19 and that is required to end the EVD10 outbreak and provide ongoing surveillance in the Ebola-affected provinces as recommended by WHO. Table 3: Project Allocation by Component (US$ million) CERC1 AF3 CERC2/3 L2 Proposed Components Parent AF1 AF2 Rest. AF4 1. Improve Utilization and Quality of 120 174 176.5 131.5 176.5 126.5 146.6 226.6 Health Services at Health Facilities (+54) (+2.5) (-45) (+45) (-50) (+20.1) (+80) through PBF 2. Improve Governance, Purchasing and Coaching and Strengthen Health 65.2 90.7 92.7 77.7 92.7 62.7 62.7 102.7 Administration Directorates and (+25.5) (2) (-15) (+15) (-30) (+40) Services through PBF 3. Strengthen Health System 41.3 110.3 110.3 90.3 110.3 110.3 110.3 140.3 Performance – Financing/Health Policy (+69) (-20) (+20) (+30) 4.1 Disease Surveillance 0 15 15 15 15 15 6.9 6.9 Strengthening and Response (+15) (-8.1) 0 0 0 80 120 200 188 238 4.2 CERC (+80) (+40) (+80) (-12) (+50) TOTAL 226.5 390 394.5 394.5 514.5 514.5 514.5 714.5 39. The project’s results framework is being updated to add the methodology for data collection for each indicator. The results framework was revised during the last project restructuring approved in February 2020. The indicator baselines, targets, definitions and data sources remain the same. Climate Change Co-Benefits 40. The project has been screened for climate and disaster risks and the risk is Moderate to Low. Changes in the epidemiology of infectious diseases associated with climate variability in Africa over the last 40 years have been reviewed and documented, and there is growing evidence of the impact of climate change on infectious disease transmission patterns, nutritional status, reproduction and geographic range. Ebola outbreaks are projected to become more frequent with global warming due to its intermittent connection to wildlife and climate. Some researchers are connecting deforestation to the disease, noting that the change in landscape is bringing wildlife in May 29, 2020 Page 20 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) closer contact with humans. As the virus is typically found in wildlife, and transmission from animals to humans occurs through contact with infected bodily fluids, causing a spillover in species. In addition, the impact of climate change on nutrition outcomes is expected to increase with rising temperatures, which can reduce protein and certain micronutrients in crops. Also, climate change undermines efforts to address undernutrition, hitting women and children the hardest. Poor health and undernutrition in turn further undermine people’s resilience to climatic shocks and their ability to adapt. 41. The project intends to address the above vulnerabilities by strengthening community engagement and outreach, thereby improving community knowledge and thus empowering households. AF4 will continue to ensure access to safe water sources and essential WASH services to reduce the potential for illness and spread of infection. III. KEY RISKS 42. The Overall risk for the proposed AF is rated Substantial. The Political and Governance risk is rated High mainly due to the continued unstable political environment, while recent elections resulted in the election of a new President, volatile security situation in North Kivu and other Provinces where recurrent attacks have taken place throughout the EVD10 response. These attacks have been against health workers and have resulted in the destruction of health facilities treating Ebola patients. The project has supported community engagement throughout the EVD10 response to try to gain trust of communities and mitigate violence targeted at health workers and facilities. The Macroeconomic risk is rated Substantial due to the fall of commodity prices and the global COVID- 19 pandemic, which present additional risks that were not envisaged during the preparation of the parent project. DRC has extensive exposure to heavily affected COVID-19 economies (specifically China, Europe and the United States). A slowdown in global growth and reduced demand for mining product (which account for more than 90 percent of total exports), with adverse consequences on commodity prices, will weigh on the DRC’s economic prospects through reduced net exports and foreign direct investment. The project aims to increase subsidies for households who will be hard hit by the economic slowdown to mitigate households from incurring out of pocket expenditures, which could push them further into poverty, when seeking essential health services. Technical Design risks remain Substantial due to the challenges of implementing PBF in remote regions of the country that are difficult to access. This risk is mitigated through the provision of technical assistance to review and revise the PBF approach as needed and to build capacity in country to analyze data and trends in service delivery to track achievements and inform changes to the project design. Institutional capacity risks are High given the complexity of addressing the Ebola response. The Project Implementation Unit has been scaled up to expand capacity to implement project activities. Fiduciary risk is High. Fiduciary mitigating measures include the hiring of additional technical assistance (account and financial management specialists) as well as continuing to use the manual the project developed for Hazard Pay procedures. Furthermore, looking at the geographical scope, the associated issues of access, and the complexities of working closely with development partners to achieve results continues to present a risk for which mitigating measures have been put in place. These measures include joint operational plans with development partners to capitalize on the value added of each to achieve greater efficiency. 43. Social risk rating remains Moderate. The project’s risk for sexual exploitation and abuse (SEA) and sexual harassment (SH) was rated Moderate during the recently completed DRC portfolio review assessing risk for GBV, including SEA/H. The project developed a risk mitigation plan outlining associated mitigation measures that the project intends to implement, including an accountability and response framework, which would incorporate codes of conduct for health care personnel, a grievance redress mechanism set up to handle SEA/H-related complaints ethically and confidentially, as well as a response protocol for ensuring access to integrated services for survivors. May 29, 2020 Page 21 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Planned mitigation measures also include awareness-raising around SEA/H and community consultations with women in addition to training activities related to SEA/H prevention and response for project and health care personnel as well as clinical care for sexual assault survivors for health care providers. To support implementation of all these measures, the project is in the process of hiring two safeguards specialists and will hire a GBV specialist to oversee all related SEA/H mitigation and response activities. Furthermore, the existing SEA/H risk mitigation plan will be updated within 60 days of effectiveness. IV. APPRAISAL SUMMARY A. Economic and Financial Analysis Parent Project Activities 44. The economic and financial analysis of the parent project activities remains valid. AF4 will continue to generate economic benefits through a greater emphasis on addressing Reproductive, Maternal, Neonatal, Child and Adolescent Health. Investment in essential health services is even more relevant in the context of COVIVD-19, as demand for services at health facilities will likely increase rapidly and substantially, while households have less ability to pay for services. A Cost-Benefit Analysis of PDSS was conducted in 2015 to measure the project’s economic performance and assess its returns against alternatives. The cost benefit analysis showed a rate of return of 16 percent. The project is expected to continue with the same or higher rate of return given that AF4 replenishes funding for core activities. 45. Disease outbreaks affect economic activity by decreasing demand (in response to reduced consumer and business confidence, which can substantially and abruptly reduce spending; exports may fall due to disruptions in logistics) and reducing supply (labor absenteeism and disruptions of supply chains will reduce production in agriculture and other sectors; some businesses will close altogether). The impacts of EVD10 and COVID-19 will be to reduce productivity of both labor and capital, which are the major components of growth. PDSS has directly supported the EVD9 and 10 responses, which have reduced the number of cases, deaths and duration of the illness, all of which have implications on the economic toll of the outbreak. While PDSS is not financing the COVID-19 response directly, the services delivered through the project will also be a critical to reduce deaths associated with the virus. 46. The 2014-16 Ebola outbreak in West Africa demonstrates the potential loss associated with a major Ebola outbreak. The outbreak resulted in an estimated 28,616 cases and 11,310 deaths in Guinea, Liberia and Sierra Leone.12 Ebola in West Africa quickly reversed much of the recent economic growth in the region due to a sharp decrease in private sector investment and cross border trade. For example, a recent study of economic activity in Liberia before and after the Ebola outbreak, 12 percent of firms had closed, more than double the annual firm closure rate of 5 percent per year in Africa.13 Multiple studies have estimated the economic loss associated with the crisis, as summarized by Huber, Finelli and Stevens and presented in Table 4.14 In a 2018 analysis of the 12 Centers for Disease Control, 2016. Available at: https://www.cdc.gov/vhf/ebola/history/2014-2016- outbreak/index.html 13 Bowles, J., Hjort, J., Melvin, T., Werker, E. Ebola, jobs and economic activity in Liberia. J Epidemiol Community Health. 2016;70:271–277. 14 Huber, C., Finelli, L., Stevens, W. The Economic and Social Burden of the Ebola Outbreak in West Africa. The Journal of Infectious Diseases. 2018; Suppl 5. May 29, 2020 Page 22 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) economic and social burden of the Ebola outbreak in West Africa, the authors argue that most of these estimates do not consider the broader social costs of the outbreak. They estimated that the combined economic and social burden of the outbreak was much higher, at US$53.19 billion. As compared to the macroeconomic and social approach used in other estimates, Bartsch, Gorham and Lee examined the cost of a case of Ebola from a different perspective.15 They considered the costs of supportive care, personal protective equipment, personnel wages and productivity losses for mortality and absenteeism, and estimated that the cost per case of Ebola ranged from US$480 to US$912 when a patient fully recovered, and from US$5,929 to US$18,929 when a patient died, varying by age and country. Their estimate of the total cost in West Africa ranged from US$82 to US$356 million. Table 4: Summary of estimates of economic cost of 2014-15 Ebola outbreak Estimate Direct cost of controlling Impact on economic Impact on economic outbreak output growth World Bank 2014 US$18 million preparation 0.1%-3.3% reduction in US$3.8-US$32.6 billion lost costs in Senegal and Nigeria investment (2015) GDP (affected countries, 2%-3.4% reduction in 2014-15) exports (2014) World Bank 2015 US$6.8 billion lost GDP (affected countries, 2014- 15) US$550 million lost GDP (non-affected sub-Saharan African countries 2015) World Bank 2016 40% decrease in US$2.8 billion lost GDP working Liberians (2014- (2014-16) for Guinea, 16) Liberia and Sierra Leone UN Economic US$290.6 million for Sierra US$335.3 million US$716 million lost PPP Commission on Africa Leone, Guinea, Liberia (2014- reduction in Sierra (2014) for Guinea, Liberia 2015 15) Leone exports (2014) and Sierra Leone US$5.4 million preparation costs in Central African Republic, DRC, Sao Tome and Principe (2014) UN Food and 12% reduction in crop Agriculture Organization volume (2014) (2015) UN Development Loss of exports (2014): Programme (2014) 30% in Guinea 14% in Liberia 10% in Sierra Leone UN Development US$4.7 billion lost GDP Programme (2015) (2017) for Guinea, Liberia and Sierra Leone Office of the UN Special US$5.9-US$8.9 billion global 15 Bartsch, S.M., Gorham, K., Lee, B.Y. The cost of an Ebola case. Pathogens and Global Health. 2015; 109(1). May 29, 2020 Page 23 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Envoy for Ebola (2015) support (2015) African Development US$1.4 billion lost PPP Bank (2015) (2014) for Guinea, Liberia and Sierra Leone Source: Huber, Finelli and Stevens, 2018 47. In September 2019, the World Bank produced initial estimates of the economic impact of EVD10.16 The report models four scenarios, the least severe assumes that EVD-10 does not spread to additional provinces or outside of the country and is contained by February 2020, whereas the most severe assumes that EVD10 spreads to three additional provinces and regionally to Burundi, Rwanda and Uganda resulting in border closures. In the best-case scenario, the short-term economic impact is mild: Gross Domestic Product (GDP) would be 0.2 percent lower than baseline without the outbreak resulting in foregone nominal GDP of US$230 million in 2020. However, in the worst-case scenario, the short-term economic impact is more severe: GDP would be 1.4 percent lower than baseline, resulting in US$1.7 billion in foregone nominal GDP in 2020. The long-term estimates through 2025 are more pronounced, with GDP losses of 0.4 and 1.8 percent for the best- and worst-case scenarios respectively. 48. The true economic impacts of EVD10 are difficult to assess given the uncertainty of the disease’s epidemiological path, the complex environment where the outbreak is playing out, and the emergence of the COVID-19 pandemic. Continued investment in health system strengthening and in the EVD10 response with strong community involvement will support a secure environment for trade, travel, and commerce links as the region emerges from both EVD10 and COVID-19. Based on expected social and economic benefits, the implementation of the continued health system strengthening and EVD10 activities is fully justified. Substantial resources have been invested into the response since August 2018, and now that the disease is close to being contained, it is critical to continue investing in the response and surveillance until the outbreak is declared over. B. Technical 49. The technical justification for the parent project activities and for emergency Ebola activities funded under the CERC remains valid. PDSS core activities are now even more critical during the COVID-19 pandemic to be able to provide optimal medical care, maintain essential health services close to the community and minimize risks for patients and health personnel. The World Bank is one of the largest funders of the EVD10 response. The approach employed through SRP 4.1 uses proven public health measures (surveillance, contact tracing, laboratory confirmation/testing, infection prevention and control, engaging communities) as well as new tools at hand (vaccine and therapeutics), to contain the outbreak and to bring it to an end. C. Institutional Arrangements 50. The project’s institutional arrangements remain the same. The institutional arrangements were revised after the parent project’s Mid Term Review in July 2019 and restructuring that was approved in February 2020. The restructuring aimed to improve the fiduciary oversight of the project. The Project Implementation Unit is at the Secretary General level, which is placed under the MOPH. The Secretary General ensures that health policy documents, national directives and health standards are applied in the sector according to the country's policies. The Secretary General monitors all projects anchored in the General Secretariat and ensures the smooth running 16 World Bank Group. September 2019. The Economic Impact of the 2018 Ebola Epidemic in the Democratic Republic of Congo: Estimates for DRC and Neighboring Countries: preliminary draft. May 29, 2020 Page 24 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) of all the reforms affecting health system administration on behalf of the Minister of Health. The Secretary General chairs the Technical Coordination Committee of the National Steering Committee, which is responsible for validating sectoral documents that are submitted by commissions, departments or specialized programs. Fiduciary responsibilities for project implementation are integrated into the Project Implementation Unit’s mandate. The Project Implementation Manual will be updated within 60 days of project effectiveness. 51. The PDSS Project Implementation Unit is now managing four HNP projects. Beyond PDSS, this includes the COVID- 19 Strategic Preparedness and Response Project, the REDISSE IV Project and the Multisectoral Health and Nutrition Project. The rationale for using the same Project Implementation Unit for these projects is to increase efficiency and coordination among health sector activities supported with World Bank finances. Currently, efforts are being made to ensure that fiduciary, safeguards and GBV retrofitting are addressed in a complementary manner and across the portfolio rather than project by project. D. Financial Management 52. All financial arrangements remain the same, which were confirmed at the time of the CERC triggering. The Financial Management rating to the parent project from latest archived PRIMA Assessment, filed in January 8, 2020 was Moderately Unsatisfactory. The Financial Management performance rating has been Moderately Unsatisfactory since July 2017 and there are substantial and long outstanding performance issues under this operation that need to be addressed. An action plan has been put in place to address financial management shortcomings, including improved budget and funds flow management, reinforcement of the internal control environment and addressing the inherent shortcomings of the current institutional arrangements of the project that have been made evident during implementation. These actions are aimed at improving overall financial management. 53. For disbursement purposes, a Designated Account will be opened in a financial institution acceptable to IDA and managed by the Project Implementation Unit. This account will be held in US dollars. The Designated Account will receive cash advances to pay for project expenses eligible for IDA financing. Any interest earned on funds deposited in the Designated Account shall be deposited into the project account. Payments will be made in accordance with the provisions of the manual of procedures (i.e., joint signatures by the Project Implementation Unit Coordinator and Chief Financial Officer). 54. Disbursement Arrangements. The transaction-based disbursement method will be applied for the Designated Account, which will receive an initial advance of equivalent to six months expenditure forecast. Replenishments will be based on six months forecast. Other disbursement methods - reimbursements, special commitments and direct payments will apply as well and the minimum value of applications for these methods is established at 20 percent of the Designated Account ceiling. Documentation of the Designated Account will be carried out on a monthly basis. As the country is currently under remedies due to lapsed loans, the Designated Account will open once the lapsed loans issue is resolved. Until then, the advance disbursement method is not permitted for this project except for Emergency Expenditures for the CERC. 55. Mandatory Direct Payment pilot. Since this project is prepared under Situations of Urgent Need of Assistance or Capacity Constraints, PDSS will be required to use the Direct Payment disbursement method for disbursement under contracts for goods, works, non-consulting services and consulting services procured/selected through international open or limited competition or Direct Selection, unless the Special Commitment disbursement May 29, 2020 Page 25 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) method is used. E. Procurement 56. Procurement under AF4 will be carried out in accordance with the following: World Bank Procurement Regulations for Investment Project Financing for Borrowers (dated July 2016, revised November 2017 and August 2018) under the New Procurement Framework (NPF) and the World Bank’s Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by International Bank for Reconstruction and Development (IBRD) Loans and IDA Credits and Grants (dated July 2016) as well as the provisions stipulated in the Financing Agreement. All contracts envisaged under this AF will require the project team to further develop the simplified Project Procurement Strategy for Development (PPSD), prepared for negotiations, and a procurement plan to be validated by the World Bank. Taking into account that (i) this AF4 will also finance activities under CERC relevant for the emergency response; and (ii) it has not been possible for the Borrower to complete a PPSD and procurement plan for the entire project during project preparation, referring to documents covered under the World Bank Policies, particularly World Bank Guidance, Procurement in Situations of Urgent need of Assistance or Capacity Constraints that includes inter alia a Guidance on the use of streamlined Procurement Arrangements for Projects prepared in accordance with IPF Policy, Paragraph 12 of Section III: Projects in Situations of Urgent Need of Assistance or Capacity Constraints under Section “III,” part “A” point 3 and Part F of the same Section III, it is acceptable that the Borrower has prepared a short and simplified PPSD and an initial Procurement Plan supported for this PPSD for the negotiations of this AF. The AF4 will provide the required resources to continue with signing of contracts and initiation of activities. The performance rating from the latest archived P-RAMS Assessment, filed March 7, 2020, was Moderately Satisfactory. Given (i) the country context and associated risk, (ii) the authority’s interference in procurement activities; and (iii) that this project will be implemented in DRC under the World Bank’s NPF, the procurement risk is rated High. F. Safeguards 57. Since the proposed AF4 is only addressing the financing gap and cost overrun due to COVID-19 and the ongoing Ebola response, the scope and nature of the parent project activities remain the same and thus there is no change in the Safeguard Policies triggered. The parent project has been assigned Environmental Category B. While the safeguard policies have not changed, the project paper notes that the Safeguard Policies Triggered have changed (Table VI: Summary of Table Changes) to reflect that the relevant safeguard documents, as described below, were updated and res-disclosed due to AF4. 58. The originally approved Indigenous People’s Plan Framework (IPPF) remains valid, as no changes in the location of the current project activities are envisioned. This was also confirmed when the CERCs were triggered. In particular, OP 4.10 (Indigenous Peoples) was triggered under the parent project and will remain triggered under the proposed operation. The IPPF was prepared and disclosed under the parent project. Nine Indigenous Peoples Plans were updated and disclosed in February 2019 as part of AF3. They are being implemented as per World Bank guidelines. The IPPF was updated and have been publicly disclosed in-country and on the World Bank’s external website on May 22, 2020 for AF4. Overall, the project social safeguards performance is Moderately Satisfactory. 59. The parent project triggered the OP 4.01 (Environmental Assessment), which will remain triggered under the proposed operation. The Environmental and Social Management Framework and Health Care Waste Management Plan were disclosed in country in October 2016 and updated and disclosed as per World Bank guidelines in May 29, 2020 Page 26 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) December 2017 and subsequently re-disclosed in February 2019. These documents were updated and have been publicly disclosed in-country and on the World Bank’s external website on May 22, 2020 for AF4. Overall, the project environment safeguards performance is Moderately Satisfactory. V. WORLD BANK GRIEVANCE REDRESS 60. Communities and individuals who believe that they are adversely affected by a World Bank-supported project may submit complaints to existing project-level grievance redress mechanisms or the World Bank’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org May 29, 2020 Page 27 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) VI SUMMARY TABLE OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Safeguard Policies Triggered ✔ Implementing Agency ✔ Project's Development Objectives ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ VII DETAILED CHANGE(S) COMPONENTS Current Component Name Current Cost Action Proposed Component Proposed Cost (US$, (US$, millions) Name millions) Improve Utilization and 146.70 Revised Improve Utilization and 226.67 Quality of Health Services at Quality of Health Health Facilities through PBF Services at Health Facilities through May 29, 2020 Page 28 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Performance-Based Financing Improve Governance, 62.70 Revised Improve Governance, 102.70 Purchasing and Coaching Purchasing and and Strengthen Health Coaching and Administration Directorates Strengthen Health and Services through PBF Administration Directorates and Services through Performance-Based Financing Strengthen Health Sector 110.30 Revised Strengthen Health 140.30 Performance – Financing System Performance - and Health Policy Capacities Financing, and Health Policy Disease Surveillance System 194.90 Revised Disease Surveillance 244.86 Strengthening and Response Strengthening and Response TOTAL 514.60 714.53 Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative 2015 0.00 0.00 2016 10,075,930.03 10,075,930.03 2017 47,858,471.77 57,934,401.80 2018 62,263,533.15 120,197,934.95 2019 110,000,000.00 230,197,934.95 2020 80,000,000.00 310,197,934.95 2021 90,000,000.00 400,197,934.95 2022 119,802,065.20 520,000,000.15 2023 0.00 520,000,000.15 2024 0.00 520,000,000.15 2025 0.00 520,000,000.15 2026 0.00 520,000,000.15 May 29, 2020 Page 29 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) 2027 0.00 520,000,000.15 SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Latest ISR Rating Current Rating Political and Governance ⚫ High ⚫ High Macroeconomic ⚫ Substantial ⚫ Substantial Sector Strategies and Policies ⚫ Moderate ⚫ Moderate Technical Design of Project or Program ⚫ Substantial ⚫ Substantial Institutional Capacity for Implementation and ⚫ High ⚫ High Sustainability Fiduciary ⚫ High ⚫ High Environment and Social ⚫ Moderate ⚫ Moderate Stakeholders ⚫ Moderate ⚫ Moderate Other Overall ⚫ Substantial ⚫ Substantial Safguard_Table COMPLIANCE Change in Safeguard Policies Triggered Yes Safeguard Policies Triggered Current Proposed Environmental Assessment OP/BP Yes Yes 4.01 Performance Standards for Private No No Sector Activities OP/BP 4.03 Natural Habitats OP/BP 4.04 No No Forests OP/BP 4.36 No No Pest Management OP 4.09 No No Physical Cultural Resources OP/BP No No 4.11 May 29, 2020 Page 30 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Indigenous Peoples OP/BP 4.10 Yes Yes Involuntary Resettlement OP/BP 4.12 No No Safety of Dams OP/BP 4.37 No No Projects on International Waterways No No OP/BP 7.50 Projects in Disputed Areas OP/BP 7.60 No No LEGAL COVENANTS2 LEGAL COVENANTS – Fourth Additional Financing for Health System Strengthening for Better Maternal and Child Health Results Project (P173415) Sections and Description SCHEDULE 2. Section I.E. (i) No later than sixty (60) days after the Effective Date, or such later date as agreed by the Association, update the Project Implementation Manual; and (ii) immediately thereafter, shall carried out the Project in accordance with the provisions of the Project Implementation Manual; SCHEDULE 2. Section I.E. (i) No later than sixty (60) days after the Effective Date, or such later date as agreed by the Association, update and publish a SEA/H Plan; and (ii) immediately thereafter, shall carried out the Project in accordance with the SEA/H Plan; Conditions Type Description Disbursement SCHEDULE 2. Section III. B. 1. b. (CERC Disbursement Conditions) May 29, 2020 Page 31 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) VIII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Congo, Democratic Republic of RESULT_NO_PDO Fourth Additional Financing for Health System Strengthening for Better Maternal and Child Health Results Project Project Development Objective(s) To improve utilization and quality of maternal and child health services in targeted areas within the Recipient's Territory and, to provide an immediate and effective response to an eligible crisis or emergency Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target Improve the utilization and quality of maternal and child health services in targeted areas. Women having at least 4 antenatal care visits before delivery (%) (Percentage) 36.00 55.00 Action: This indicator has been Revised People who have received essential health, nutrition, and 5,208,170.00 7,819,376.00 population (HNP) services (CRI, Number) Action: This indicator has been Revised Number of children immunized (CRI, Number) 434,750.00 1,063,706.00 Number of women and children who have received basic nutrition services (CRI, Number) 4,352,206.00 5,505,670.00 May 29, 2020 Page 32 of 49 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline End Target Action: This indicator has been Revised Number of deliveries attended by skilled health personnel 421,214.00 1,250,000.00 (CRI, Number) Average score of the quality checklist at the health centers (%) (Percentage) 21.00 60.00 Action: This indicator has been Revised Children Fully Immunized (%) (Percentage) 62.00 70.00 Action: This indicator has been Revised New curative consultations per capita per year (Text) 0.38 0.50 Action: This indicator has been Revised Provide an immediate and effective response to an eligible crisis or emergency Eligible individuals vaccinated during EVD (# - cumulative) (Number) 0.00 120,000.00 Action: This indicator has been Revised PDO Table SPACE May 29, 2020 Page 33 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Intermediate Results Indicators by Components RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Improve Utilization and Quality of Health Services at Health Facilities through PBF New acceptors of modern contraceptives (%) (Percentage) 5.00 15.00 Action: This indicator has been Revised First time adolescent girls acceptant of modern contraceptives 0.00 3.00 (%) (Percentage) Action: This indicator has been Revised Pregnant women counseled and tested for HIV (%) (Percentage) 15.00 25.00 Action: This indicator has been Revised Existing users of modern contraceptives (%) (Percentage) 2.00 15.00 Action: This indicator has been Revised Contraceptive prevalence (new and existing female users %) (Percentage) 6.00 15.00 Action: This indicator has been Revised Births attended by skilled professional (%) (Percentage) 52.00 85.00 Action: This indicator has been Revised Health service delivered to target population through PDSS 0.00 20,000,000.00 support (# – annual) (Number) May 29, 2020 Page 34 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Action: This indicator has been Revised Improve Governance, Purchasing and Coaching and Strengthen Health Administration Directorates and Services through PBF Health personnel receiving training (# - cumulative) (Number) 0.00 10,000.00 Action: This indicator has been Revised Average availability of tracer medicines at hospitals/health centers (%) (Percentage) 69.00 70.00 Action: This indicator has been Revised Single contract signed at province level (# – annual) (Number) 2.00 11.00 Action: This indicator has been Revised Average performance score of Provincial Health Directorates under Single Contract (%) (Percentage) 72.00 77.00 Action: This indicator has been Revised Strengthen Health Sector Performance – Financing and Health Policy Capacities Civil servants eligible for retirement in the Ministry of Health that have received their retirement indemnities/packages (# - 0.00 4,000.00 cumulative) (Number) Action: This indicator has been Revised Poor people benefiting from fee exemption mechanisms (%) 0.00 20.00 (Percentage) May 29, 2020 Page 35 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline End Target Action: This indicator has been Revised Disease Surveillance Strengthening and Response (Action: This Component has been Revised) Contacts of suspected or confirmed EVD cases lost to follow up 0.00 0.00 (%) (Percentage) Action: This indicator has been Revised Suspected EVD samples received that have been tested (%) 0.00 100.00 (Percentage) Action: This indicator has been Revised Suspected and confirmed EVD cases for whom safe and dignified 0.00 100.00 burials have been carried out (%) (Percentage) Action: This indicator has been Revised IO Table SPACE Monitoring & Evaluation Plan: PDO Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Numerator: Pregnant Health All monthly data woman who received 4th Management reported by health Ministry of Health antenatal care visit or more Information facilities into the HMIS (MoH)/Project Women having at least 4 antenatal care Quarterly during the quarter System (HMIS) at completion of each Implementation Unit visits before delivery (%) Denominator: Number of (Système quarter. Data entry is (PIU) pregnant women in the National due one month after the population (4%). d'Information quarter is complete. May 29, 2020 Page 36 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Data for Kinshasa added in Sanitaire - However, due to Q4 2018. Baseline set by DHIS-2) internet connectivity taking average between Q1 issues, data entry often and Q2 2016. takes longer than one month. Hence, the Project team download data for each targeted province (or health zone in provinces that are not completely covered) 3-6 months after the end of each quarter to ensure data is complete. The team will track trends in each indicator on a quarterly and annual basis. Major fluctuations in the indicator will be examined in greater detail. Quarterly. Note: Sum of first growth targets are monitoring visits for for annual People who have received essential children aged 6m-23m, sum. HMIS MoH/PIU health, nutrition, and population (HNP) children fully immunized Reporting is services and women who had cumulative skilled delivery. over the year. May 29, 2020 Page 37 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Annual sum of fully vaccinated children. Ba seline takes HMIS sum of Q1 Number of children immunized 2016 and Q2 2016 and multiples by 2. Annual sum of first growth monitoring visits for children aged 6m- HMIS Purchasing agencies Number of women and children who 23m. database (public utilities; EUPs) have received basic nutrition services Nutrition advice and feeding supplement s are part of the package delivered. Annual sum HMIS Number of deliveries attended by of women skilled health personnel who had delivery May 29, 2020 Page 38 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) attended by skilled professional . Baseline calculated by taking sum of Q1 and Q2 2016 and multiplying by two. Numerator: Sum of the quarterly quality score (%) of all PBF health centers. Denominator: Number of health centers contracted through PBF. Take average of verified Criterion-based clinical quality scores for all Average score of the quality checklist at measures and vignettes Quarterly PBF Database MOHP/HMIS health facilities covered the health centers (%) will also be included in the by project financed PBF. quality checklist. The quality check list will be applied at two levels: at the health center and at the first level referral hospital level. Numerator: Number of Download data 3-6 HMIS fully immunized children Quarterly months after the end of MoH/PIU Children Fully Immunized (%) Database under one year of age. quarter for targeted Denominator: Number of provinces or targeted May 29, 2020 Page 39 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) children less than one year health zones (when old (3.49%). entire province not A child is considered fully covered). Track trends immunized when she/he for quarterly and annual has received immunization estimates, explore major for BCG, polio, DTC3, and fluctuations as needed. measles. In the last few years the DTP vaccine has been replaced by Penta, which includes apart from DTP, Hemophilus Influenza and Hepatitis The project will also measure fully immunized children under 1 which is a more sensitive and complete measure of correct and timely application of all obligatory immunizations done prior to 11 months of age. This measure is also a proxy of the quality of the EPI program (follow-up on defaulters; quality and effectiveness of outreach and community based programs). May 29, 2020 Page 40 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Download data 3-6 months after the end of Numerator: Number of quarter for targeted new curative consultations provinces or targeted in target health zones HMIS health zones (when New curative consultations per capita per Quarterly MOH/PIU during year Database entire province not year Denominator: Total covered). Track trends population in target health for quarterly and annual zones during year estimates, explore major fluctuations as needed. Sum of eligible individuals who were vaccinated Periodic Extract data from Ebola Implementing Eligible individuals vaccinated during EVD during the past month. Monthly vaccination monthly reports. Agencies/MoH/PIU (# - cumulative) Eligible individuals are reports those defined by national protocol. ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Numerator: Number of Download data 3-6 new acceptors of modern months after the end of contraceptive methods. quarter for targeted Modern methods such as HMIS provinces or targeted New acceptors of modern contraceptives Quarterly MOH/PIU injections, pills, implants database health zones (when (%) and IUDs, excluding entire province not condoms. These methods covered). Track trends are purchased in health for quarterly and annual centers / communities and estimates, explore major May 29, 2020 Page 41 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) first level referral hospitals. fluctuations as needed. Denominator: Women of reproductive age (estimated at 21% of the total population) Numerator: Number of Download data 3-6 new adolescent acceptors months after the end of of modern contraceptive quarter for targeted methods. Modern methods provinces or targeted such as injections, pills, HMIS health zones (when First time adolescent girls acceptant of Quarterly MOH/PIU implants and IUDs, database entire province not modern contraceptives (%) excluding condoms. covered). Track trends Denominator: Number of for quarterly and annual adolescent girls (estimated estimates, explore major at 32 percent of the fluctuations as needed. population) Numerator: percentage of Download data 3-6 pregnant women who months after the end of were counseled and tested quarter for targeted for in target health zones provinces or targeted during the quarter HMIS health zones (when Pregnant women counseled and tested Quarterly MOH/PIU Denominator: number of database entire province not for HIV (%) pregnant women in target covered). Track trends health zones during the for quarterly and annual quarter (estimated at 4% of estimates, explore major the population) fluctuations as needed. Numerator: Number of Download data 3-6 existing users of modern HMIS months after the end of Existing users of modern contraceptives Quarterly MOH/PIU contraceptive methods. database quarter for targeted (%) Modern methods such as provinces or targeted injections, pills, implants health zones (when May 29, 2020 Page 42 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) and IUDs, excluding entire province not condoms. These methods covered). Track trends are purchased in health for quarterly and annual centers / communities and estimates, explore major first level referral hospitals. fluctuations as needed. Denominator: Number of women of reproductive age (estimated at 21% of total population) Download data 3-6 months after the end of Numerator: sum of new quarter for targeted and existing users of provinces or targeted modern contraceptives HMIS health zones (when Contraceptive prevalence (new and Quarterly MOPH Denominator: number of database entire province not existing female users %) women of reproductive age covered). Track trends (estimated at 21% of the for quarterly and annual total population) estimates, explore major fluctuations as needed. Download data 3-6 months after the end of quarter for targeted Numerator: number of provinces or targeted births attended by a skilled HMIS health zones (when professional Quarterly MOPH Births attended by skilled professional (%) database entire province not Denominator: number of covered). Track trends births (estimated at 4 for quarterly and annual percent of the population) estimates, explore major fluctuations as needed. May 29, 2020 Page 43 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Download data 3-6 months after the end of quarter for targeted provinces or targeted Annual sum of verified Health service delivered to target health zones (when services of the PMA Quarterly PBF database MOPH population through PDSS support (# – entire province not package and the PCA annual) covered). Track trends package for quarterly and annual estimates, explore major fluctuations as needed. Number of health Extract from project personnel who received records the number of training through project individuals trained each support quarter. Training can be Project Health personnel receiving training (# - This indicator measures the Quarterly technical (related to MOH/PIU records cumulative) cumulative number of service quality or clinical health personnel receiving protocols), managerial, training through a Bank- or related to PBF financed project. implementation. Numerator: sum of the quality score on the availability of Essential Extract verified data Medicines (%) of all health from PBF database three centers contracted via PBF Average availability of tracer medicines at Quarterly PBF database months after quarter MOH/PIU Denominator: Number of hospitals/health centers (%) ends to ensure data health centers contracted completeness. through PBF. Hospitals not included Note: data was available as of Q4 2017. May 29, 2020 Page 44 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) Annual number of Single Contracts signed at the provincial level. The single contract sets up a performance framework Document province for all donors. It is a name when contract is Project Single contract signed at province level (# budgeted business plan in Quarterly formally signed in MOH/PIU records – annual) the provincial health project results tracking administration, funded sheet. with available national and external funds. Note: this is the signed contracts. After it is signed, it remains active for the whole year. Numerator: sum of DPS performance score under Document performance single contract (%) score for each province Average performance score of Provincial Project Denominator: Number of Quarterly when it is finalized. MOH/PIU Health Directorates under Single Contract Records DPS who signed the single Maintain records in (%) contract centralized location. Baseline available as of Q3 2017 Cumulative sum of civil Extract from project servants eligible for Civil servants eligible for retirement in the records the number of retirement in the Ministry Project Ministry of Health that have received Quarterly civil servants who MOH/PIU of Health that have Records their retirement indemnities/packages (# received retirement received their retirement - cumulative) indemnities/packages. indemnities/packages Numerator: Number of Extract verified data Poor people benefiting from fee Quarterly PBF database MOH/PIU poor people benefiting from PBF database three exemption mechanisms (%) from fee exemption months after quarter May 29, 2020 Page 45 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) mechanisms. ends to ensure data Denominator: Number of completeness. people eligible for fee exemption mechanisms (estimated at 5% of the total population) The project would support mechanisms to exempt poorer people of fee payments, or to lower their level of fee payment at the health facility. These data are directly accessible through the PBF system. At the health center level up to 5% of all consultations can be exempted, and at the hospital level, up to 10% of referred patients can be exempted, and up to 10% of admissions can be exempted. The exemptions are reimbursed through the PBF mechanism. Numerator: Number of people who encountered Reports from Extract data from suspected/confirmed Ebola Ebola Implementing Contacts of suspected or confirmed EVD Monthly implementing reports of implementing case that could not be Agencies/MoH/PIU cases lost to follow up (%) agencies agencies. contacted during the past month Denominator: Number of May 29, 2020 Page 46 of 47 The World Bank AFIV DRC Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P173415) people who encountered suspected/confirmed Ebola case during the past month The end target is to have no contacts lost to follow up (0%). Numerator: number of EVD samples tested during the Implementing Extract data from past month Ebola Implementing Suspected EVD samples received that Monthly agency implementing agency Denominator: number of Agencies/MoH/PIU have been tested (%) reports reports EVD samples received during the past month Numerator: Number of safe and dignified burials conducted for suspected/confirmed Ebola deaths during the past month Implementing Extract data from Suspected and confirmed EVD cases for Denominator: Number of Ebola Implementing Monthly agency implementing agency whom safe and dignified burials have deceased who were Agencies/MoH/PIU reports reports. been carried out (%) suspected or confirmed Ebola cases during the past month Safe and dignified burial is defined as per national protocol. ME IO Table SPACE May 29, 2020 Page 47 of 47