FOR OFFICIAL USE ONLY Report No: PCBASIC0275941 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT PROGRAM APPRAISAL DOCUMENT FOR A PROPOSED LOAN IN THE AMOUNT OF US$300 MILLION WITH THE SUPPORT OF A GRANT UNDER THE SOCIAL SUSTAINABILITY INITIATIVE FOR ALL UMBRELLA MULTI-DONOR TRUST FUND IN THE AMOUNT OF US$4.5 MILLION TO THE REPUBLIC OF COLOMBIA FOR A PROGRAM FOR IMPROVED ACCESS TO EFFECTIVE HEALTH SERVICES FOR THE VULNERABLE AND ENHANCED HEALTH SYSTEM RESILIENCE January 18, 2024 Health, Nutrition & Population Global Practice Latin America and Caribbean 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 December 15, 2023 Currency Unit = Colombian Pesos US$1 = COP 3,970 US$0.00025 = 1 COP FISCAL YEAR January 1 - December 31 Regional Vice President: Carlos Felipe Jaramillo Regional Director: Jaime Saavedra Country Director: Mark Roland Thomas Practice Manager: Tania Dmytraczenko Task Team Leader(s): Jeremy Henri Maurice Veillard, Vanina Camporeale The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) ABBREVIATIONS AND ACRONYMS ADRES Administrator of the Resources of the General System of Social Security in Health (Administradora de los Recursos del Sistema General de Seguridad Social en Salud) AM Accountability Mechanism BDUA Unique Affiliate Database (Base de Datos Única de Afiliados) CAC High-Cost Account (Cuenta de Alto Costo) CBA Cost-Benefit Analysis CGR General Comptroller of the Republic (Contraloría General de la República) COP Colombian Pesos CPF Country Partnership Framework DALYs Disability Adjusted Life Years DLI Disbursement Linked Indicator DLRs Disbursement Linked Results DNP National Planning Department (Departamento Nacional de Planeación) EEE Electrical and Electronic Equipment ESSA Environmental and Social Systems Assessment EPS Health Insurance Companies (Entidades Promotoras de Salud) FSA Fiduciary Systems Assessment FTLC Therapeutic Formula Ready for Consumption (Formula Terapéutica Lista para el Consumo) GBV Gender-Based Violence GFATM The Global Fund to Fight AIDS, Tuberculosis and Malaria GDP Gross Domestic Product GHG Greenhouse Gas GoC Government of Colombia GRS Grievance Redress Service HCW Healthcare Waste ICBF Colombian Institute of Family Welfare (Instituto Colombiano de Bienestar Familiar) IDB Inter-American Development Bank INS National Health Institute (Instituto Nacional de Salud) IPSS Healthcare Providers (Instituciones Prestadoras de Servicios de Salud) IRI Intermediate Results Indicator The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) IRR Internal Rate of Return ISP Implementation Support Plan LAC Latin America and the Caribbean MHCP Ministry of Finance and Public Credit (Ministerio de Hacienda y Crédito Público) MoC Memorandum of Collaboration MSPS Ministry of Health and Social Protection (Ministerio de Salud y Protección Social) NAP National Adaptation Plan NCDs Non-communicable Diseases NDCs National Determined Contributions NPV Net Present Value OECD Organization of Economic Cooperation and Development PAP Program Action Plan PARE Acceleration Plan for the Reduction of maternal mortality (Plan de Aceleración para la platform Reducción de la mortalidad materna) PC Program Coordinator PDI Program Development Indicator PDO Program Development Objective PEF Program Expenditure Framework PforR Program-for-Results PHC Primary Health Care PIGCCS Comprehensive Climate Change Management Plan for the Sector (Plan Integral de Gestión del Cambio Climático Sectorial) PND National Development Plan (Plan Nacional de Desarrollo) POM Program Operational Manual PPT Temporary Protection Permits (Permiso de Protección Temporal) PQRSD Petitions, Complaints, Claims, and Suggestions (Petición, Queja, Reclamo, Sugerencia o Denuncia) RA Results Area REPS Special Registry of Health Service Providers (Registro Especial de Prestadores de Salud) RISS Integrated Healthcare Networks (Redes Integradas de Servicios de Salud) RIPS Registry at Individual Level (Registro Individual de Prestación de Servicios) SDG Sustainable Development Goals SGSSS General System of Social Security in Health (Sistema General de Seguridad Social en Salud) The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) SISCO Information System for Community and Collective Activities in Sexual and SSR Reproductive Health (Sistema de Información de Actividades Comunitarias y Colectivas en Salud Sexual y Reproductiva) SISPRO Social Protection Integrated Information System (Sistema Integrado de Información de la Protección Social) SIVIGILA Public Health Surveillance Information System (Sistema de Información para la Vigilancia en Salud Pública) SOE State-owned Enterprise UHC Universal Health Coverage UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UPC Government-fixed per Capita Price (Unidad de Pago por Capitación) WB World Bank WHO World Health Organization WEEE Waste Electrical and Electronic Equipment The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) TABLE OF CONTENTS DATASHEET .......................................................................................................................................2 I. STRATEGIC CONTEXT .................................................................................................................. 9 A. Country Context .............................................................................................................................. 9 B. Sectoral and Institutional Context ............................................................................................... 10 C. Relationship to the CPS/CPF and Rationale for Use of Instrument ............................................ 14 II. PROGRAM DESCRIPTION .......................................................................................................... 15 A. Government Program ................................................................................................................... 15 B. Theory of Change .......................................................................................................................... 17 C. PforR Program Scope .................................................................................................................... 19 D. Program Development Objective (PDO) and PDO Level Results Indicators ............................... 21 E. DLIs and Verification Protocols .................................................................................................... 22 III. PROGRAM IMPLEMENTATION .................................................................................................. 25 A. Institutional and Implementation Arrangements ....................................................................... 25 B. Results Monitoring and Evaluation .............................................................................................. 26 C. Disbursement Arrangements ....................................................................................................... 26 D. Capacity Building........................................................................................................................... 27 IV. ASSESSMENT SUMMARY .......................................................................................................... 27 A. Paris Alignment ............................................................................................................................. 27 B. Technical Strategic Relevance and Technical Soundness of the Program .................................. 28 C. Fiduciary Aspect ............................................................................................................................ 30 D. Environmental and Social Assessment......................................................................................... 31 V. RISK ......................................................................................................................................... 33 ANNEX 1. RESULTS FRAMEWORK MATRIX ........................................................................................ 34 ANNEX 2. TECHNICAL ASSESSMENT SUMMARY ................................................................................ 53 ANNEX 3. FIDUCIARY SYSTEMS ASSESSMENT SUMMARY .................................................................. 67 ANNEX 4. ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT SUMMARY.................................... 71 ANNEX 5. PROGRAM ACTION PLAN.................................................................................................. 74 ANNEX 6. IMPLEMENTATION SUPPORT PLAN ................................................................................... 78 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) @#&OPS~Doctype~OPS^dynamics@padpfrbasicinformation#doctemplate DATASHEET BASIC INFORMATION Project Beneficiary(ies) Operation Name Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Colombia Health System Resilience Does this operation have an IPF Operation ID Financing Instrument component? Program-for-Results P180534 No Financing (PforR) @#&OPS~Doctype~OPS^dynamics@padpfrprocessing#doctemplate Financing & Implementation Modalities [ ] Multiphase Programmatic Approach (MPA) [ ] Fragile State(s) [ ] Contingent Emergency Response Component (CERC) [ ] Fragile within a non-fragile Country [ ] Small State(s) [ ] Conflict [ ] Alternative Procurement Arrangements (APA) [ ] Responding to Natural or Man-made Disaster [ ] Hands-on Expanded Implementation Support (HEIS) Expected Approval Date Expected Closing Date 08-Feb-2024 30-Jun-2026 Bank/IFC Collaboration No Proposed Program Development Objective(s) To improve access to effective health services for the vulnerable population and enhance the resilience of the health system to climate change and public health threats. @#&OPS~Doctype~OPS^dynamics@padborrower#doctemplate Page 2 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Organizations Borrower: Republic of Colombia Implementing Agency: Ministry of Health and Social Protection Contact: Guillermo Jaramillo Title: Minister of Health Telephone No: 6013305043 Email: gjaramillo@minsalud.gov.co @#&OPS~Doctype~OPS^dynamics@padfinancingsummary#doctemplate COST & FINANCING (US$, Millions) Maximizing Finance for Development Is this an MFD-Enabling Project (MFD-EP)? No Is this project Private Capital Enabling (PCE)? No SUMMARY Government program Cost 24,893.00 Total Operation Cost 1,647.00 Total Program Cost 1,646.25 Other Costs 0.75 Total Financing 1,647.00 Financing Gap 0.00 Financing (US$, Millions) World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 300.00 Non-World Bank Group Financing Page 3 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Counterpart Funding 1,342.50 Borrower/Recipient 1,342.50 Trust Funds 4.50 Global HIV/AIDS 4.50 @#&OPS~Doctype~OPS^dynamics@paddisbursementprojection#doctemplate Expected Disbursements (US$, Millions) WB Fiscal Year 2024 2025 2026 2027 Annual 24.39 113.48 111.53 55.10 Cumulative 24.39 137.87 249.40 304.50 @#&OPS~Doctype~OPS^dynamics@padclimatechange#doctemplate PRACTICE AREA(S) Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population CLIMATE Climate Change and Disaster Screening Yes, it has been screened and the results are discussed in the Operation Document @#&OPS~Doctype~OPS^dynamics@padrisk#doctemplate SYSTEMATIC OPERATIONS RISK- RATING TOOL (SORT) Risk Category Rating 1. Political and Governance  Substantial 2. Macroeconomic  Low 3. Sector Strategies and Policies  Substantial Page 4 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 4. Technical Design of Project or Program  Moderate 5. Institutional Capacity for Implementation and Sustainability  Moderate 6. Fiduciary  Moderate 7. Environment and Social  Moderate 8. Stakeholders  Low 9. Other  10. Overall  Substantial @#&OPS~Doctype~OPS^dynamics@padpfrcompliance#doctemplate POLICY COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✓] No Does the project require any waivers of Bank policies? [ ] Yes [✓] No @#&OPS~Doctype~OPS^dynamics@padlegalcovenants#doctemplate LEGAL Legal Covenants Sections and Description ARTICLE IV — REMEDIES OF THE BANK 4.01. The Additional Events of Suspension consists of, namely, that the Health Legislation shall have been amended, suspended, abrogated, repealed, or waived, so as to affect materially and adversely, in the opinion of the World Bank (WB), the ability of the Borrower to comply with its Program related obligations set forth in this Agreement, including the responsibilities applicable to the SGSSS Entities. SCHEDULE 2. Program Execution. Section I. Implementation Arrangements. A. Program Institutions. 1. The Borrower, through the MSPS shall maintain throughout Program implementation a Program Coordination Team (composed of a Program Coordinator and key staff from relevant MSPS vice-ministries, divisions, sub-divisions and other Departments; from ADRES, and other SGSSS Entities) with structure, functions, and responsibilities as set forth in the Program Page 5 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Operational Manual, including the responsibility for collecting the information required to ensure DLI compliance and submitting it to the Verification Agency, as well as for submitting progress reports to the WB. 2. ADRES shall maintain its responsibility throughout Program implementation for the administration of the SGSSS resources received from MSPS and UPC payments, according to the information provided by BDUA’s consolidated database and managed by the MSPS. 3. The CGR shall be responsible for: (a) supporting in the application of the Anti- Corruption Guidelines to the Program, and (b) conducting annual financial audits of the MSPS and ADRES reflecting the Program Expenditures; all as per the Memorandum of Collaboration to be signed between the CGR and the WB. SCHEDULE 2. Program Execution. Section I. Implementation Arrangements. C. Verification Arrangements and Verification Protocols. 1. The Borrower, through MSPS, shall engage and maintain, throughout Program implementation, a Verification Agency for the Program acceptable to the WB, in accordance with the terms of reference acceptable to the WB. 2. The Borrower, through MSPS, shall ensure that the Verification Agency referred to in the preceding paragraph shall: (a) verify the data and other evidence supporting the achievement(s) of one or more DLRs and recommend corresponding payments to be made in accordance with the verification protocol, and (b) submit to MSPS the corresponding verification reports in a timely manner and in form and substance satisfactory to the WB. SCHEDULE 2. Program Execution. Section I. Implementation Arrangements. D. Program Action Plan (PAP). The Borrower, through MSPS, shall carry out the PAP and cause the PAP to be carried out: (a) in accordance with the schedule set out in said plan, and in a manner satisfactory to the WB; (b) except as the WB and the Borrower, through MSPS, shall otherwise agree in writing not to assign, amend, abrogate, or waive, or permit to be assigned, amended, abrogated, or waived, the PAP, or any provision thereof, and (c) maintain policies and procedures adequate to enable it to monitor and evaluate, in accordance with guidelines acceptable to the WB, the implementation of the PAP. SCHEDULE 2. Program Execution. Section II. Excluded Activities. The Borrower shall ensure that the Program excludes any activities which: A. in the opinion of the WB, are likely to have significant adverse impacts that are sensitive, diverse, or unprecedented on the environment and/or affected people; or B. involve procurement. @#&OPS~Doctype~OPS^dynamics@padconditions#doctemplate Conditions Type Citation Description Financing Source 5.01. The Additional Conditions of Effectiveness consist of the following: (a) that the Grant Agreement under the Social ARTICLE V — Sustainability Initiative for Effectiveness EFFECTIVENESS; Trust Funds All Umbrella Multi-Donor TERMINATION Trust Fund, has been executed and delivered and all conditions precedent to its effectiveness or to the right of the Borrower to Page 6 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) make withdrawals under it (other than the effectiveness of this Agreement) have been fulfilled. 5.01. The Additional Conditions of Effectiveness consist of the following: (b) ARTICLE V — that the Program Effectiveness EFFECTIVENESS; IBRD/IDA Operational Manual has TERMINATION been adopted in a manner and with contents acceptable to the WB. 5.01.The Additional Conditions of Effectiveness consist of the following: (c) ARTICLE V — that the Memorandum of Effectiveness EFFECTIVENESS; IBRD/IDA Collaboration between the TERMINATION WB and the Borrower’s Office of the Comptroller General has been signed. 1. No withdrawal shall be made: (a) on the basis of DLRs, associated to its respective DLI, achieved prior to the Signature Date, except that, withdrawals up to an aggregate amount not to exceed twenty-four Disbursement SCHEDULE 2. SECTION IV. B IBRD/IDA million thirty-five thousand eighty-eight Dollars (USD 24,035,088) from the Loan, may be made on the basis of DLRs 2.1 and 6.1, as per Schedule 4, achieved prior to this date but on or after March 15th, 2023. 1. No withdrawal shall be Disbursement SCHEDULE 2. SECTION IV. B made: (b) for any DLR, IBRD/IDA associated to its respective Page 7 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) DLI, under Category (1) to (6) until and unless the Borrower has furnished evidence satisfactory to the WB that said DLR has been achieved. 2. Notwithstanding the previous provision, if any of the DLRs under Categories (1) to (6) has not been achieved by the date by which the said DLR is set to be achieved (or such later date as the WB has established by notice to the Borrower, through MSPS, the WB may, by notice to the Borrower: (a) except for not scalable DLRs, authorize the withdrawal of such lesser amount of the unwithdrawn proceeds of SCHEDULE 2. SECTION IV. B. the Loan then allocated to Disbursement IBRD/IDA 2 said Category which, in the opinion of the WB, corresponds to the extent of achievement of said DLR, said lesser amount to be calculated in accordance with the formula set out in Schedule 4 of this Agreement; (b) only for non-scalable DLRs, withhold the allocated amount for the unmet DLR(s) and, at its sole discretion, may authorize, at a later date, the full release of the amounts so withheld, if and when the Page 8 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) WB is satisfied that the respective DLR(s) has/have been achieved; (c) reallocate all or a portion of the proceeds of the Financing then allocated to said DLR to any other DLR, and/or (d) cancel all or a portion of the proceeds of the Loan then allocated to said DLR. I. STRATEGIC CONTEXT A. Country Context 1. Colombia is one of the most inequitable countries in the world. Income inequality in Colombia is the highest among Organization of Economic Cooperation and Development (OECD) countries and the second highest among eighteen Latin America and Caribbean (LAC) countries. 1 Although the COVID-19 shock further increased inequality, subsequent economic recovery reverted income inequality to its previous level. Nevertheless, the Gini coefficient remained high, at 0.523 in 2022. Such inequalities translate into large disparities in key development outcomes, including health outcomes. Colombia ranks poorly among OECD countries for key population health indicators such as maternal mortality, child mortality, survival from breast cancer, and chronic disease management. In addition, access barriers to effective health services have a disproportionate, negative impact on the vulnerable population. The rapid population aging and the epidemiological transition result in a high Non-communicable Diseases (NCDs) burden. 2. Colombia has strong macroeconomic policy institutions and a strong track record of solid fundamentals based on inflation targeting, a flexible exchange rate, and rules-based fiscal policy. The Government of Colombia (GoC) implemented measures to mitigate risks arising from economic imbalances and safeguard the macroeconomic framework, including a responsive monetary policy response to address rising inflation. Fiscal reforms in 2021 and 2022, as well as the strengthening of the fiscal rule and fiscal council, provide a solid framework for reducing the deficit and debt to Gross Domestic Product (GDP) ratios and rebuilding fiscal reserves. Foreign direct investment remains robust and is expected to finance almost all the current account deficit. Colombia has ample foreign exchange reserves. The central Government’s debt features a long average maturity (9.9 years) and duration (6.2 years), which helps cushion the impact of shocks to debt and debt service payments. A proactive regulatory framework, coupled with adequate capital and liquidity buffers, positions the financial system to absorb potential shocks from financial stress abroad and an increase in risky credit portfolios. The GoC remains committed to macroeconomic stability: it secured additional resources through the 2022 tax reform to expand social protection and anticipates a reduction in the overall deficit in compliance with the fiscal rule. 1 World Bank. (2021). Building an Equitable Society in Colombia. Available here Page 9 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 3. Colombia is highly vulnerable to climate change and geophysical hazards, mostly due to its geographically diverse characteristics and socioeconomic context. Most of the population resides in a mountainous region along the Andes prone to landslides and flooding, which account for 65 percent of natural hazards. Many departments are expected to experience a significant increase in days with a heat index exceeding >35°C, 2 driven by elevated atmospheric humidity, heightening the risk of cardiovascular and respiratory diseases. The El Niño southern oscillation also affects the country, leading to abnormal climatic conditions like intense droughts and extreme rainfall patterns. Communities along the Caribbean and the Pacific coasts are at risk of sea-level rise, storm surges, and extreme temperatures. These climate risks pose long-term challenges to Colombia’s development by increasing the risk of damages to physical capital, disruption of electricity generation, reduced labor productivity, human capital erosion, and agricultural losses. 3 B. Sectoral and Institutional Context 4. The Colombian General System of Social Security in Health (Sistema General de Seguridad Social en Salud, SGSSS) provides nearly universal health insurance coverage and high financial protection to its beneficiaries. In 2022, more than 98 percent of Colombia’s population was insured, and out-of-pocket spending was low at about 15 percent of current health expenditures. 4 Life expectancy rose to 76.8 years at birth in 2021, outperforming the regional average of 75.1 years, while all-cause mortality declined by more than 30 percent between 2000 and 2019, surpassing the LAC average reduction of 14 percent. 5 Colombia allocated 7.7 percent of its GDP to health in 2022, placing it among the top health spenders in the region. 5. The SGSSS functions through a managed competition strategy to promote efficiency and quality. At the first tier, Health Insurance Companies (Entidades Promotoras de Salud, EPSs) compete for consumers based on service quality, with citizens free to choose health plans. Price competition is absent, as EPSs derive revenues from the Government-Fixed per Capita Price (Unidad de Pago por Capitación, UPC) multiplied by the number of persons it insures. The value of the UPC considers age, sex, and place of residence of the population and is defined annually. At the second tier, Healthcare Providers (Instituciones Prestadoras de Servicios de Salud, IPSs) compete to be contracted by EPSs based on a price-quality combination. The Ministry of Health and Social Protection (Ministerio de Salud y Protección Social, MSPS) is the steward of the health sector, including public health functions. 6 The SGSSS has two main insurance regimes: (i) the contributive regime for salaried, pensioned, and independent workers, and (ii) the subsidized scheme for low-income, vulnerable, displaced, and incarcerated populations. In the case of the subsidized scheme, Law 100 decentralizes the planning function for health services to 37 departments and districts. 6. The SGSSS faces important challenges requiring urgent attention. These include: (i) disparities in access to effective health services, especially Primary Healthcare (PHC); (ii) an aging population with increased demand for integrated health services and a high burden of NCDs; (iii) major gaps in mental healthcare provision with limited ability to address needs derived from six decades of internal conflict and from COVID-19; (iv) additional pressures on the sector due to a massive influx of Venezuelan migrants to Colombia; (v) inadequate availability and distribution of healthcare 2 https://climateknowledgeportal.worldbank.org/ 3 https://openknowledge.worldbank.org/entities/publication/9b706816-2618-48d0-87d4-e7e99b7ad779 4 World Bank (2019). External Assessment of Quality of Care in the Health Sector in Colombia. Available here 5 OECD. Health At a Glance: Latin America and the Caribbean 2023. Available here 6 The roles and functions of the MSPS include the formulation and evaluation of policies, plans, programs and projects related to patient protection, promotion and prevention, health insurance and professional risks, provision of services and PHC, financing and information systems, including surveillance and pandemic preparedness, and climate change adaptation and mitigation strategies, the formulation, adoption and evaluation of policies related to pharmaceuticals, medical devices and biomedical technology. Page 10 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) professionals; (vi) cost-focused performance management; (vii) gaps in health surveillance and risk communication, and (viii) limited efforts to mitigate and address the effects of climate change in a context of high vulnerability. 7. Important gaps persist in access to effective health services, especially in remote and rural areas. Barriers to access care persist due to: (i) poor quality of care; (ii) limited physical access; and (iii) financial constraints. In 2022, one in two respondents to the national survey on quality of life reported experiencing access barriers due to poor quality of care. Furthermore, the high volume of accepted tutelas 7 (legal remedies) filed over the last decade, ninety percent of which were related to access to care, indicates a lack of integration and service continuity that is particularly detrimental to the vulnerable population. 8. Access to health promotion, preventive care, and screening for health conditions at the PHC level does not meet current or evolving population health needs. Forty-five percent of PHC facilities are licensed to provide a set of essential maternal and child health services, while only twenty-six percent provide a set of essential services for infectious disease care and even fewer (nineteen percent) are licensed to provide a set of essential services for NCDs care. As documented in the World Bank (WB) 2021 study on PHC system performance, 8 addressing this requires (i) a new care model rooted in PHC that offers a comprehensive package of services centered on population health needs; (ii) investments that enhance the availability and distribution of healthcare professionals trained to work in multidisciplinary care teams, and (iii) health promotion and disease prevention strategies that target the vulnerable. 9. Maternal and child mortality from malnutrition are not on track to reach the Sustainable Development Goals (SDG) by 2030. Colombia lags among OECD countries, with high maternal mortality affecting rural, Afro-Colombian, indigenous, low-income, and low-education populations. In 2020, the percentage of pregnant women with four or more prenatal visits decreased by 9.2 percentage points, which contributed to 544 avoidable deaths 9 (a seven-percentage points increase in Colombia’s maternal mortality ratio from 80 per live birth in 2019 to 87 per live birth in 2020). 10 Maternal mortality among indigenous peoples in Colombia is nearly five times higher than the national average, and the under-five years of age child mortality rate shows important regional disparities. 10. NCDs remain the leading cause of death in Colombia, imposing high and unsustainable costs on the health system. The most prevalent NCDs (cancer, cardiovascular diseases, chronic obstructive pulmonary disease, hypertension, diabetes, and depression) are responsible for seven of the ten leading causes of morbidity and mortality, constituting 78 percent of deaths in 2021. The costs associated with the high burden of NCDs are among the top three in the region, and they are expected to increase with the aging of the population and the prevalence of multimorbidity among people with NCDs. 11. Breast cancer is the leading cause of mortality for women in Colombia and the most prevalent type of cancer among women.11 Between 2010-2017, all cancer mortality rates in Colombia rose. The most significant increase occurred in breast cancer mortality. 12 The World Health Organization (WHO) projects a 49.1 percent increase in breast cancer 7 Tutelas are a mechanism through which constitutional judges can force health insurance companies to provide services to patients within a reasonable timeframe. 8 World Bank Group. 2020. Primary Healthcare Vital Signs Profile Assessment for Colombia. Available here 9 Castañeda-Orjuela C, Hilarion Gaitan L, Diaz-Jimenez D, Cotes-Cantillo K, Garfield R. Maternal mortality in Colombia during the COVID-19 pandemic: time series and social inequities. BMJ Open. 2023. Available here 10 Departamento Administrativo Nacional de Estadística. Mortalidad Materna en Colombia en la última década y el efecto del Covid-19. 2021. Available here 11 WHO Global Cancer Observatory. 2020. Available here 12 Observatorio Nacional de Cáncer. Ministerio de Salud y Protección Social. Cáncer: Tendencia de la mortalidad cruda, desagregada por sexo, grupo etario y departamento, 2005 - 2018. Available here Page 11 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) incidence and a 66.6 percent increase in mortality by 2040 without effective intervention. Disparities in breast cancer screening, early detection, and timeliness of diagnosis and treatment for women exist based on which health regime Colombians are affiliated with, with worse outcomes for vulnerable women in the subsidized regime. 12. The Venezuelan migration has strained Colombia’s healthcare sector due to an unforeseen surge in demand for health services and its related financial implications. By 2023, nearly 2.9 million Venezuelan migrants resided in Colombia, with more than 1.7 million holding Temporary Protection Permits (Permiso de Protección Temporal, PPT), allowing social services access. Moreover, over 1.9 million pendular migrants regularly enter Colombia to access social services. As of May 2023, 1,291,800 migrants were affiliated to the SGSSS, with 78.4 percent in the subsidiary regime. The WB has provided technical assistance and financial support through a prior health Program-for-Results (PforR) operation (P169866) that aimed to affiliate 225,250 migrants. Migrants often arrive in Colombia with nutritional deficiencies, incomplete vaccination schemes, and generally weak immune systems. 13. Although 76 percent of documented migrants with PPT are affiliated to the SGSSS, they still encounter ongoing challenges in accessing effective healthcare stemming from financial, geographical, and administrative barriers. Consequently, the migrant population experiences poor health outcomes, including a high prevalence of maternal mortality and acute child malnutrition, inadequate management of chronic conditions, poor access to antiretroviral treatment for migrants with HIV, and limited access to essential preventive and health promotion services. Among the estimated 22,000 migrants with HIV living in Colombia in 2021, only 2,364 were affiliated to the SGSSS and receiving care consistent with national clinical practice guidelines. Migrants without PPT status face additional obstacles in accessing effective healthcare due to additional financial and administrative barriers. 14. Enhancing the resilience of health systems is a priority post-pandemic. Resilient health systems are integrated systems that are: (i) alert to threats and risk factors; (ii) responsive to changing population health needs; (iii) absorptive to contain health shocks; and (iv) adaptable to minimize disruptions. A recent WB report emphasized the importance of investing in effective Universal Health Coverage (UHC), bolstering pandemic preparedness and response, and improving mitigation and adaptation to climate change’s health impacts to enhance the health system's resilience.13 Importantly, the consequences of climate change on health could heighten the risk of future pandemics in highly biodiverse countries like Colombia, for example, through the risk of transmission of new viruses from animals to humans. Integrating a One Health approach into public health surveillance and risk communication systems – recognizing the interdependence of human health, animal health and the environment – is an important strategy for strengthening pandemic preparedness, response, and overall sector resilience to public health threats. 15. Climate change is driving a surge in respiratory, cardiovascular, and infectious diseases, with extreme temperatures increasing cardiovascular and respiratory illnesses. Projections pinpoint a more than 440 percent rise in heat-related emergency room visits between 2020-2039 for a total of 380,565 visits. 14 Extreme heat can also lead to mortality due to the worsening of pre-existing conditions, such as NCDs. In Colombia, between 1998 and 2013, 267,730 deaths were attributable to heatwaves. Estimated cumulative economic losses due to premature mortality associated with non-optimal temperatures range from 1 to 4.8 percent of 2019 GDP. Rising temperatures and shifting rainfall patterns also heighten the transmission potential of vector-borne diseases like dengue and malaria. 13 Building Resilient Health Systems in Latin America and the Caribbean: Lessons Learned from the COVID-19 Pandemic - Executive Summary (English). Washington, D.C.: World Bank Group. Available here 14 Colombia Country Climate and Development Report estimates, World Bank, 2023. Available here Page 12 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 16. Colombia’s vulnerability to climate change further hampers access to healthcare, exacerbating disparities. Around 22 percent of PHC facilities and 26 percent of hospitals are exposed to climate hazards, including floods. Extreme weather events, like intense flooding, disrupt access to health facilities, leading to longer travel times. In marginalized communities of Bogota, floods can add up to 80 minutes to the time needed to reach healthcare. Overall, the health system faces climate-related hazards that can impact service delivery, healthcare access, supply chains for essential medicines, and the general functioning of healthcare facilities. 15 17. Colombia’s public health sector is ill-prepared for future pandemics despite adopting an array of public health measures during COVID-19, such as doubling intensive care unit bed capacity and vaccinating over eighty percent of the population with at least one vaccine. The country endured staggering losses from the pandemic, with over 142,000 deaths. Furthermore, disruptions to essential health services, including vaccinations, school feeding programs and NCD care, will have lasting negative consequences on the health of the Colombian population. The pandemic exposed structural vulnerabilities of the public health system, necessitating investments and reform. A 2022 WB study 16 on how to better prepare Colombia for future pandemics recommended: (i) strengthening national and subnational public health surveillance capacity with a One Health approach; (ii) boosting Colombia's capacity to produce critical supplies such as vaccines; (iii) enhancing governance mechanisms for decisive action in emergencies; (iv) strengthen the governance of health data and surveillance systems, improving sectoral and intersectoral interoperability at national and subnational levels; and (v) leveraging PHC strategies to bolster community-level health emergency surveillance, response and access to essential health services. 18. In response to these challenges, the GoC, in its 2022-2026 National Development Plan (Plan Nacional de Desarrollo, PND), has prioritized improving access to effective health services and bolstering the resilience of the health sector. Key PND health priorities include: (i) improving access to a universal model of care emphasizing the importance of disease prevention, health promotion and risk screening for vulnerable populations; (ii) addressing malnutrition in children under five years of age; (iii) promoting equitable access to medicines and technologies; and (iv) strengthening environmental health and climate change adaptation and mitigation through research, inspection, surveillance and control, policy management, participation, and social mobilization with a climate justice approach. In particular, the MSPS is committed to launching mobile, multidisciplinary health teams to screen vulnerable households for specific health risks and ensure that high-risk households have access to patient-centered PHC services that provide continuity of care, both across time and levels of providers. To improve access to effective PHC, the MSPS aims to ensure that vulnerable populations are registered with these PHC teams close to home. 19. The GoC is currently considering new legislation to reform the health sector. The reform focuses on: (i) eliminating health financing intermediaries; (ii) strengthening PHC, disease prevention and health promotion; and (iii) improving labor conditions for healthcare professionals. The reform proposes reorganizing the health system around PHC centers to reduce disparities between urban and, remote and rural areas. It also proposes a shift in the administration of public resources from EPSs to the Administrator of the Resources of the General System of Social Security in Health (Administradora de los Recursos del Sistema General de Seguridad Social en Salud, ADRES), which would make direct payments to IPSs. EPSs would have two years to transition to the role of third-party administrators, with reduced responsibilities governed by ADRES. This does not imply the disappearance of private or mixed healthcare providers, which would be able to continue offering health services. The reform also aims to improve working conditions for health workers, 15 World Bank estimates. Data from the Ministry of Environment and Sustainable Development and from the MSPS. 16 World Bank. Colombia Assessment of Preparedness Response and Capacities for Future Pandemics and Public Health Threats. 2022. Available here Page 13 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) including better salaries, medical autonomy, enhanced training, continuous professional development, and promotion opportunities, prioritizing those in rural areas. The reform has cleared the initial voting in the Parliament's health commission and must secure approval in the Parliament's plenary session and the Senate to become law. C. Relationship to the CPS/CPF and Rationale for Use of Instrument 20. The proposed PforR aligns directly with the FY16-21 WB Country Partnership Framework (CPF) for Colombia, 17 the Colombia Performance and Learning Review (PLR) 18 and the most recent core diagnostic work that will inform the 2024-2027 CPF. 19 The operation contributes to the current CPF Pillar 1, given its focus on achieving effective access to health services for the vulnerable. It also contributes to CPF Pillar 2: Enhancing Social Inclusion and Mobility through Improved Service Delivery. The Program is closely aligned with the conclusions of the recent Systematic Country Diagnostic Update, 20 which points to staggering inequalities in human capital outcomes, with a need to deliver more effective public services such as health and education to the vulnerable population. The Program is also aligned with the recommendations of the 2023 Colombia Country Climate and Development Report, 21 which emphasizes the importance of building resilience and adaptation through an economy-wide approach and strengthening the focus on protecting the vulnerable. 21. The proposed Program is closely aligned with core WB priorities and would contribute to the WB’s mission of eliminating extreme poverty and boosting shared prosperity on a livable planet. The operation is also aligned with the WB’s Human Capital Project and the WB’s forthcoming Gender Strategy 2024-2030, 22 which advocates for greater investments in health and education to improve their populations' productive capacities and end Gender-based Violence (GBV). The proposed Program also follows the directives of the WB’s LAC Roadmap for Climate Action 2021–2025, which calls for “scaled up, transformational climate action in the region” through the inclusion of measurable improvements in climate change adaptation and resilience, investments aimed at improving public health and climate change surveillance and supporting the sector’s efforts towards low carbon transition. Finally, the operation is consistent with the WB Evolution Roadmap goals of achieving impact at scale with a focus on climate change and its implications for health and the health sector. Program interventions are designed to improve the health system’s overall functioning, achieving impact at scale by strengthening key health system functions. 22. The PforR instrument provides powerful incentives for the MSPS to achieve development results included in the PND. The PforR contributes to an operational and pragmatic definition of key results indicators for the sector, as well as the monitoring and evaluation of key policies proposed in the PND, helping the Government achieve increasingly complex and long-term outcomes. The incentives built into the design of the Program support the GoC in achieving more difficult results over time (Box 1). 17 Report No. 101552-CO, discussed by the WB Board of Executive Directors on April 7, 2016. 18 Report No. 135458-CO, discussed by the WB Board of Executive Directors on April 23, 2019. 19 The Colombia Country Partnership Framework (P500111) for FY24 – FY27 is under development. 20 Colombia Systematic Country Diagnostic. Washington, D.C.: World Bank Group. Available here 21 Colombia Country Climate and Development Report. Washington, DC: World Bank Group. Available here 22 World Bank Gender Strategy 2024-2030: Accelerate Gender Equality for a Sustainable, Resilient, and Inclusive Future. Available here Page 14 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Box 1. Previous Experience with Health PforR in Colombia This proposed PforR builds upon lessons learned from Colombia's first health sector PforR (P169866) financed by the WB from 2020-2024. This initial PforR contributed to valuable institutional strengthening through capacity building and technical assistance. With more than 76 percent of loan proceeds disbursed in 2023, this active operation played a pivotal role in mobilizing the MSPS to advance the implementation of the health sector priorities outlined in the 2016-2022 PND. These priorities encompassed: (i) enhancing quality of care Disbursement Linked Indicator (DLI), (DLI 1&2); (ii) enhancing health system financial sustainability (DLI 3); and (iii) increasing access to care for migrants through their affiliation to the SGSSS (DLI 4). Key results so far include the affiliation of 225,250 migrants to the SGSSS and the realization of US$230 million in savings through more efficient price regulation of medicines and medical technologies. Progress has also been made in updating quality and environmental management standards for healthcare facilities. The proposed PforR will further support improvements in quality of care by continuing to support early breast cancer detection. The adverse impact of the COVID-19 pandemic, particularly on NCD screening and control, has hindered Colombia from achieving the goals outlined in the 2016-2022 PND, particularly those related to reducing disparities in access to essential cancer services, especially in timeliness of diagnostics and treatment. Additional efforts are essential, as reiterated in the Government’s 2022-2026 PND. Building on its predecessor, this PforR aligns with the priorities of the 2022–2026 PND, focusing on improving access to effective health services for vulnerable 23 populations and enhancing the health system’s resilience to climate change and public health threats. 23. The proposed operation aligns with the Paris Agreement, the Colombian National Determined Contributions (NDCs), the Colombian National Adaptation Plan (NAP), and the Long-Term Strategy Colombia 2050 (E2050). 24 25 26 The country is committed to addressing climate change while safeguarding public health and reducing its Greenhouse Gas (GHG) emissions by 51 percent by 2030, surpassing its regional peers. In 2022, Colombia pledged to assess the climate impact of its national health system, making Colombia the first LAC country to do so. The results will inform a Comprehensive Climate Change Management Plan for the Sector (Plan Integral de Gestión del Cambio Climático Sectorial, PIGCCS). Additionally, Colombia's NDCs and NAP prioritize health as a key area for climate adaptation, reducing climate- related health risks and bolstering the resilience of healthcare providers to climate change. Furthermore, Colombia's Long- Term Strategy, known as E2050, focuses on enhancing the population's adaptive capacity in the face of climate-sensitive events. It emphasizes the integration of surveillance systems using a One Health approach, promoting health through governance mechanisms that generate health co-benefits, and developing climate-resilient public health infrastructure with low GHG emissions. II. PROGRAM DESCRIPTION A. Government Program 24. The 2022-2026 PND "Colombia, a Global Power of Life," approved by the Colombian Congress in May of 2023, establishes the objectives, goals, and strategies for the current Government period. The PND focuses on five transformative lines of action: (i) territorial development based on access to water and environmental justice; (ii) human security and social justice; (iii) human right to food; (iv) productive transformation, internationalization, and climate action; and (v) regional convergence. The approved PND has an investment budget of 1.154 trillion pesos (US$245 billion 23 This includes, for example, women, children under five with acute malnutrition and migrants. 24 Government of Colombia. 2020. Available here 25 https://www.minambiente.gov.co/wp-content/uploads/2022/01/1._Plan_Nacional_de_Adaptacion_al_Cambio_Climatico.pdf 26 https://unfccc.int/sites/default/files/resource/COL_LTS_Nsivigilaov2021.pdf Page 15 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) equivalent) for the next four years. 25. Health sector priorities are included in the Human Security and Social Justice and the Human Right to Food transformative chapters of the PND, focusing on health determinants such as clean water and nutrition. The PND aims to ensure that every Colombian is registered with a comprehensive, multidisciplinary PHC team close to home. The PND proposes to launch a program of mobile health teams tasked with screening vulnerable households for specific health risks and ensuring that high-risk households are provided with access to PHC services when needed. Integrated health services will be implemented at departmental and territorial levels to address priority public health issues such as reducing maternal mortality and child mortality from malnutrition, improving cancer screening and access to early treatment, addressing prevalent mental health conditions such as depression, and improving the prevention and control of chronic conditions through integrated and coordinated care. The new model of care emphasizes the importance of social determinants of health and interculturality in healthcare delivery, including environmental health and the consequences of climate change. The PND positions PHC strengthening as a strategy to enhance the system's resilience to future shocks such as public health emergencies and climate change. 26. The PND health priorities are built around transformative lines and organized around three components: (i) guaranteed access to a universal healthcare system based on a predictive and preventive healthcare model; (ii) mental, physical, and social well-being of individuals; and (iii) healthy nutrition practices appropriate to the life course, populations, and territories. Core interventions are supported by cross-cutting investments, such as investments in an integrated health information system promoting the interoperability of electronic health records across providers, insurers, and other government agencies, and investments related to reducing gender gaps, among others. Figure 1. 2022-2026 PND Health Priorities Note: Grey highlighted boxes include interventions supported at least partially by the Program. White boxes are not supported by the Program. Source: PND 2022- 2026 Page 16 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) B. Theory of Change 27. The proposed PforR is structured around two result areas (RAs) aiming to: (i) improve access to effective health services for the vulnerable population; and (ii) enhance the resilience of the health system to climate change and public health threats. Interventions under the first RA include: (i) the implementation of a unified and integrated monitoring and follow-up system for children with acute malnutrition complemented with identification and treatment of advanced malnutrition screening and community surveillance in prioritized departments; (ii) the implementation of an integrated care model with advanced use of telemedicine to reduce lethality from extreme morbidity cases in pregnant women; (iii) the implementation of an integrated care network for better targeting of women at risk of developing breast cancer to achieve higher levels of screening and improve early detection of the disease and the timeliness in initiation of treatment; (iv) the implementation of integrated strategies to achieve effective access to antiretroviral treatment and comprehensive care for eligible migrants with HIV enrolled in the SGSSS subsidiary regime; and (v) the roll-out of multidisciplinary PHC care teams in territorial entities. Interventions related to the second RA include: (i) implementing a new set of infrastructure standards to adapt healthcare provision to the consequences of climate change and developing a plan to support the transition of the health sector to low-carbon emissions; (ii) developing a PIGCCS, and (iii) implementing of new requirements to strengthen public health surveillance capacities at the subnational level through the development and implementation of integrated public health risk communication strategies incorporating a One Health approach and climate change considerations. 28. The RAs complement one another to address key challenges in the health sector identified in the PND: (i) inequality in access to effective health services, especially for the vulnerable population; (ii) fragmented healthcare models; and (iii) health system vulnerabilities to face future public health threats and climate change related shocks. The Program promotes a holistic approach to health, recognizing that both access to effective health services and strong health system resilience are essential to improving the health of the population, especially for the vulnerable population. Page 17 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Figure 2. Theory of Change Activities Outputs Results (short-term) Results (medium-term) Results (long-term) Implementation of an Increased number of children under 5 years of age Increased number of children under 5 Child individualized and online with acute malnutrition notified to the Public Develop individualized years old with acute malnutrition treatment information system Health Surveillance Information System (Sistema malnutrition follow-up strategies for identified, reported, and receiving for acute malnutrition de Información para la Vigilancia en Salud Pública, children with malnutrition treatment for acute malnutrition in (Intermediate Results Indicator, SIVIGILA) information system and receiving follow- Prioritized Departments (DLI1) IRI) up living in prioritized departments (IRI) Develop information system Increased number of pregnant women under and follow-up strategy for Reduction of maternal mortality follow-up care, registered and followed at an Maternal cohorts of pregnant women in prioritized territories through individual level (IRI) Reduction in lethality in cases of RA1: IMPROVE Improved timeliness mortality extreme maternal morbidity in in the initiation of ACCESS TO Develop integrated care the use of an integrated strategy Increased use of tele expertise for the prioritized departments networks strategy to reduce (DLI2) management of cases of extreme maternal treatment for breast EFFECTIVE cancer (Program maternal mortality morbidity (IRI) HEALTH Development SERVICES Breast Increase in the percentage of Indicator, PDI) Develop a plan to accelerate Implementation of interventions Increase in the percentage of vulnerable women vulnerable women diagnosed with cancer the reduction in mortality to augment screening rates for 50-69 years old screened for breast cancer (IRI) breast cancer with early-stage from breast cancer priority populations diagnosis (IIA) (DLI3) HIV in Draft regulation improving Access to effective Increased access to effective access to antiretrovirals and antiretrovirals in accordance migrants Increased screening of migrants for HIV (IRI) treatment for eligible migrants with efficiency in procurement of with WHO clinical practice HIV (DLI4) HIV medicines guidelines Women victims of sexual violence who PHC Roll out organized mobile Increase in the number of receive mental health services (IRI) Increased number of basic health teams in strengthening health teams in territorial trained personnel for basic Number of people screened for operation in territorial entities (IRI) entities health teams mental health services by PHC providers and basic health teams (IRI) Publication of new Increased Develop new infrastructure infrastructure standards for IPSs, percentage of standards and regulations, including energy efficiency territorial entities RA2: ENHANCE Sectoral including energy efficiency standards and adaptation and Increased number of health centers meeting new that adopted a RESILIENCE OF THE adaptation standards mitigation measures to climate requirements for energy efficiency and adaptation climate change change (DLI5) to climate change (IRI) adaptation Plan for HEALTH SYSTEM and Integrated climate change surveillance environmental mitigation to Develop health sector system in operation at the subnational health (PDI) climate adaptation and mitigation level climate change strategy change Carry out baseline Development of a PIGCCS (DLI6) Increase in the percentage of territorial entities measurement of GHG that adopt a risk communication plan for public emissions at the facility health emergencies with a One Health approach level. (IRI) DLIs Monitored Intermediate Indicator Program Development Indicator (PDI) Page 18 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) C. PforR Program Scope 29. The proposed PforR supports three components of the Government’s PND 2022-2026. These are: (i) guaranteed access to a universal healthcare system based on a predictive and preventive care model; (ii) mental, physical, and social well-being of individuals, including environmental health and climate change interventions; and (iii) healthy nutrition practices appropriate to life course, populations, and territories. 30. The boundaries defined for the PforR within the Government’s 2022-2026 PND are presented in Table 1. The PforR will support specific results implemented through two RAs covering the PND’s three components and nine of the thirteen subcomponents in Figure 2. The PforR will support the development of policies and regulations required to achieve the Program’s expected results during its three-year (2023-2026) implementation period. Focusing the PforR on interventions related to access to effective health services and health systems resilience to climate change and public health threats will ultimately contribute to improvements in health for the vulnerable population. Table A2.3 in Annex 2 presents the full scope of the PND, as well as a detailed description of Program boundaries. Table 1. Program boundaries Government program Program supported by the PforR Reasons for non-alignment Objective Guarantee access to a universal To improve effective access to health N/A healthcare system with a focus on services for the vulnerable population vulnerable territories and promote and enhance the resilience of the health health system resilience with climate system in Colombia to climate change change considerations. and other public health threats. Duration 2022-2026 2023-2026 The PND was approved in May of 2023. The PforR will support results from March 15, 2023, onwards. Geographic National with a focus on vulnerable National with a focus on vulnerable N/A coverage territories. populations living in prioritized territories. Results 3 Components and 13 2 RAs covering the 3 Components in the Support for subcomponents Areas (RA) subcomponents. Government program and 9 of the 13 was prioritized based on (i) subcomponents. potential impact in a three- year period, (ii) alignment with PforR development goals, and (iii) alignment with WB commitment in the sector. Overall US$24.89 billion. US$1.65 billion Financing (includes US$300 million of WB financing + US$4.5 million of grant financing). Page 19 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 31. The program's overall objective is to enhance access to effective health services for the vulnerable population. It will do so by strengthening PHC, with a focus on promotion and prevention services and guaranteeing the continuity and availability of health services in priority areas. 32. The proposed PforR is structured around two RAs: • RA1. Improve access to effective health services for the vulnerable population, and • RA2. Enhance the resilience of the health system to climate change and public health threats. 33. Activities and results under RA2 benefit the entire population of Colombia, as they aim to guarantee the availability of health services during emergencies. Activities under RA1, while mainly focused on the vulnerable population, aim to enhance the system's ability to provide effective services to the population at large. By investing in public health monitoring systems, integrated care networks and better access to affordable medicines, RA1 supports activities that will improve the overall functioning of the health system while focusing on the vulnerable population targeted in the PND. Furthermore, the Government-prioritized territories are the ones with the most acute malnutrition cases, the highest number of maternal deaths, 27 and the highest concentration of eligible migrants. 28 34. RA1: Access to effective health services for the vulnerable population. This RA relates to two transformative lines of the PND: human security and social justice and human right to food. It aims to improve access to effective health services for the vulnerable population. Furthermore, all DLIs and intermediate indicators in this RA are disaggregated by the migration status of the target population. The following interventions to be implemented by the MSPS are supported: (a) the implementation of a unified and integrated monitoring and follow-up system for children with acute malnutrition complemented with advanced malnutrition screening and community surveillance in prioritized departments; (b) the implementation of an integrated care model with advanced use of telemedicine to reduce lethality from extreme morbidity cases in pregnant women in prioritized territories; (c) the implementation of an integrated care network for better targeting of women at risk of developing breast cancer to achieve higher levels of screening and improve early detection of the disease and the timeliness in initiation of treatment; (d) the implementation of integrated strategies to achieve effective access to antiretroviral treatment and comprehensive care for eligible migrants with HIV enrolled in the SGSSS subsidiary regime, and (e) the rollout of multidisciplinary PHC teams in territorial entities with a focus on mental health services monitoring and access to effective GBV survivor-related services. 35. RA2: Resilience of the health system to climate change and public health threats. This RA relates to the PND's human security and social justice transformative line. It aims to enhance the ability of the health sector to adapt and mitigate the consequences of climate change and better prepare and respond to future public health threats. This RA 27 Prioritizeddepartments are those that concentrate over 70 percent of cases of children under five years of age who suffer from acute malnutrition (La Guajira, Chocó, Cesar, Bolívar, Antioquia, Arauca, Guainía, Magdalena, Meta, Risaralda, Valle del Cauca, and Vichada); and prioritized territories are those where 85 percent of maternal mortality cases occur (La Guajira, Magdalena, Santa Marta, Barranquilla, Atlántico, Bolívar, Cartagena, Norte de Santander, Córdoba, Cesar, Antioquia, Chocó, Boyacá, Bogotá, Valle del Cauca, Cali, Buenaventura, Cauca, Nariño). 28 Eligible migrant is defined as a regular migrant with PPT, the temporary protection permit, available to Venezuelan migrants as set forth in the Republic of Colombia’s Decree No. 216, published in the Official Gazette on March 1, 2021. Page 20 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) would specifically support the following interventions to be implemented by the MSPS: (a) the implementation of a new set of infrastructure standards to adapt healthcare provision to the consequences of climate change and developing a plan to support the transition of the health sector to low- carbon emissions; (b) the development of a PIGCCS; and (c) the implementation of new requirements to strengthen public health surveillance capacities at the subnational level through the development and implementation of integrated public health risk communication strategies incorporating a One Health approach and climate change considerations. 36. The Program builds on a strong engagement with partners. The Inter-American Development Bank (IDB) will provide separate financing to the GoC (estimated at US$150 million) to support the achievement of complementary objectives, namely: (i) strengthening of the PHC model through the implementation of permanent territorialized interdisciplinary care teams for the promotion of health and prevention of disease; (ii) the operation of PHC centers; (iii) the expansion and enhancement of telemedicine networks to improve access and quality in healthcare; and (iv) the further implementation of electronic health records. The IDB and WB-financed operations share one common intermediary indicator (the implementation of basic health teams at the sub-national level). Furthermore, the WB and the IDB have prepared joint analyses of the whole operation for incorporation into the government’s National Council of Economic and Social Policy (Consejo Nacional de Política Económica y Social). 37. In addition, partner organizations are expected to provide non-concessional financing to support the Program objectives. The Social Sustainability Initiative for All Umbrella Multi-Donor Trust Fund, for which the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) and other donors contribute, will provide an additional US$4.5 million in recipient-executed grant financing to support better access to antiretroviral drugs and effective care for migrants. 29 D. Program Development Objective (PDO) and PDO Level Results Indicators 38. The PDO is to improve access to effective health services for the vulnerable population and enhance the resilience of the health system to climate change and public health threats. 39. One PDO indicator per RA will measure progress in achieving results: (a) For RA1: Improved timeliness in the initiation of treatment for breast cancer. The indicator is calculated as the time elapsed (measured in number of days) between the first histopathologic diagnostic report and the first treatment (chemotherapy, radiotherapy, or surgery). The indicator will be further disaggregated for vulnerable women in the subsidized regime and migrants. (b) For RA2: Percentage of territorial entities that adopted a Climate Change Adaptation Plan with a One Health approach. The indicator will be measured as the development and publishing by territorial entities of Climate Change Adaptation Plans adopting a One Health approach. 29 The Administration Agreement between the GFATM and the WB for the Social Sustainability Initiative for All Umbrella Multi-Donor Trust Fund,amounts US$5 million, out of which the Recipient executed grant associated with this PforR’ s DLRs totalizes US$4.5 million; the remaining funds are administrative costs and Bank executed that will support technical assistance activities related to the Program implementation. Page 21 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) E. DLIs and Verification Protocols RA1: Improved access to effective health services for vulnerable populations (US$203 million) DLI 1. Children under 5 years old with acute malnutrition identified, reported, and receiving treatment for acute malnutrition in Prioritized Departments (US$50.75 million) Disbursement Linked Results (DLR) 1.1. Number of Prioritized Departments with children under 5 years old identified, reported, and receiving treatment for acute malnutrition Rationale. This DLI supports the goal of improving access to effective health services for the vulnerable population through increased screening, monitoring and access to treatment for children who suffer from acute malnutrition in prioritized territories where over 70 percent of cases of children with malnutrition are concentrated. 30 Activities under this indicator will not only support timely care to all children under 5 years of age with acute malnutrition to minimize their risk of mortality but will also strengthen the capacity of territories to report and provide adequate follow-up and treatment. Malnutrition is climate-sensitive in Colombia, and this DLI intends to help the country reduce the vulnerability of populations to malnutrition and, therefore, reduce the risks climate change can pose for malnutrition in the country. Definition of the indicator. The indicator will measure the percentage of children under 5 years of age living in Prioritized Departments with acute malnutrition that receive treatment according to the following formula: Numerator: Number of children under 5 years of age with acute malnutrition notified to SIVIGILA from Prioritized Departments receiving follow-up treatment between January 1 and December 31 of the same year. Denominator: Children under 5 years of age notified of event 113 of SIVIGILA from Prioritized Departments between January 1 and December 31 of the same year. Technical description. Incremental indicator covering children under 5 years of age with acute malnutrition is defined as: children under 5 years of age with a Z-score of weight/height or length indicator below -2DE and/or with the phenotypes of severe acute malnutrition (marasmus, kwashiorkor or marasmic kwashiorkor). Treatment means that the IPS has prescribed the Therapeutic Formula Ready for Consumption (Formula Terapéutica Lista para el Consumo, FTLC) and F75 for children under 5 years of age with acute malnutrition according to Administrative Resolution 2350/2020 of the MSPS. Prioritized Departments are: La Guajira, Chocó, Cesar, Bolívar, Antioquia, Arauca, Guainía, Magdalena, Meta, Risaralda, Valle del Cauca, and Vichada. DLI 2. Reduction of maternal mortality in prioritized territories through an integrated strategy (US$50.75 million) This DLI includes three DLRs: (i) DLR 2.1: Number of prioritized territories with an acceleration plan for reducing maternal mortality that includes a maternal healthcare integrated network (US$20.3 million); (ii) DLR 2.2: Number of IPS trained in obstetric emergencies based on simulation scenarios (US$15.225 million); and (iii) DLR 2.3: ISABEL quality assessment tool used twice yearly in IPS (US$15.225 million). Rationale. This DLI supports the goal of improving access to effective health services for the vulnerable population by increasing access to comprehensive healthcare for pregnant women and newborns in 19 prioritized territories with the highest number of maternal deaths. The MSPS is committed to accelerating the reduction of maternal mortality through the development and subsequent implementation of an integrated strategy to monitor cohorts of pregnant women, ensure the 3072 percent of confirmed cases of acute malnutrition in 2022 were concentrated in nine departments: Bolivar, Cesar, Choco, La Guajira, Antioquia, Magdalena, Meta, Valle del Cauca, and Vichada. Page 22 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) early identification of potential obstetric risks, and establish an integrated network of care to address obstetric emergencies and reduce extreme maternal morbidity effectively. Activities supported under this indicator include the provision of capacity building and training for health professionals, the adoption of a gender and interculturally-sensitive protocol of care, and the use of telemedicine to support effective management of emergencies and care in cases of extreme maternal morbidity, and improved health service provision in the face of disasters or other public health threats. Technical description. The MSPS has defined actions to strengthen access to effective health services for pregnant women and newborns under the Plan to Accelerate the Reduction of Maternal Mortality (circular No. 047 of 2022). This DLI measures the number of prioritized territories that include a maternal health integrated network for articulating and strengthening health delivery capacities in their action plan and promotes training activities for IPS and quality assessment tools to improve the quality of maternal care. DLI 3. Vulnerable women diagnosed with breast cancer with early-stage diagnosis (IIA) (US$50.75 million) DLR 3.1. Percentage of vulnerable women diagnosed with breast cancer with early-stage diagnosis (from in situ to IIA) Rationale. This DLI supports the goal of improving access to effective health services for the vulnerable population through actions to improve the early detection and management of breast cancer. The MSPS will expand routine population screening to promote early detection of breast cancer and to improve breast cancer treatment and outcomes. To this end, DLR 3.1 supports the continuation of the PDI and DLR 2.1 indicators under the Improving Quality of Health Care Services and Efficiency in Colombia Program (P169866). Numerator. Number of individually registered women detected with breast cancer in early stages at diagnostic (0 to IIA) Denominator. Total number of women diagnosed with breast cancer Technical description. Incremental indicator covering the target population and disaggregated by insurance regime. Includes all women registered in the clinical registry and uses the technical definition of the High-Cost Account (Cuenta de Alto Costo, CAC), as included in the Program Operational Manual (POM). DLI 4. Migrants with HIV have accessed effective treatment (US$50.75 million) DLR 4.1. Number of Eligible Migrants that have accessed comprehensive HIV care according to the verification protocol Rationale. This DLI supports the goal of improving access to effective health services for the vulnerable population by focusing on access to treatment for Eligible Migrants living with HIV. Providing migrants access to effective health services for migrants has been a priority for the Government. However, HIV prevalence among migrants is estimated to double that of the overall population, and only a minority of migrants with HIV know their status and receive adequate treatment. Activities under this indicator include increased access to effective HIV prevention and antiretroviral drugs and care for eligible migrants under the SGSSS subsidiary regime. This indicator is aligned with the GFATM goals for Colombia. This DLI will serve as a reference point for monitoring the progress of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets. DLI 4 also supports the continuation of DLR 4.2 under the Improving Quality of Health Care Services and Efficiency in Colombia Program (P169866). Definition of the indicator. Total number of Eligible Migrants living with HIV that have access to comprehensive HIV care, including antiretroviral drugs, such as defined in the national Clinical Practice Guideline. Technical description. Incremental indicator to achieve up to 7,100 eligible migrants with access to comprehensive HIV care. Access to comprehensive HIV care according to the verification protocol means that the patient is: (i) receiving antiretroviral drugs in the reporting period; (ii) having at least one CD4 lymphocyte and viral load measurement in the last 6 months, and Page 23 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) (iii) receiving at least one healthcare service from an expert physician. The measurement will be done based on the number of regular migrants with PPT (eligible migrant), or similar documents as approved by the Borrower for the regularization of said migrants, who start treatment with antiretroviral drugs and remain on treatment at the time of the reporting and who meet the other two conditions established above. RA2: Enhanced health system resilience to climate change and public health threats (US$ 101.5 million) DLI 5. New infrastructure standards for IPSs, including energy efficiency standards and adaptation and mitigation measures to climate change (US$50.75 million) DLR 5.1. Publication of a new framework of infrastructure standards for IPSs, including social and environmental standards and climate change adaptation and mitigation measures Rationale. This DLI supports the goal of enhancing health system resilience through the approval of a new framework for infrastructure works and mandatory enabling standards for IPS to comply with, including energy efficiency and climate- focused adaptation standards. It complements previous efforts from resolution 3100 focused on certification of healthcare providers and quality of care (supported by DLR 1.1 under the Improving Quality of Health Care Services and Efficiency in Colombia Program (P169866), seeking to update the resolution 4445 from 1996, focusing on the infrastructure of healthcare facilities. These standards will include strategies outlined in the Green Hospital Guidance Note, developed by MSPS in 2018. The MSPS will develop the administrative act requiring IPS to comply with: (i) requirements for the location of facilities; (ii) general requirements and characteristics of infrastructure; (iii) conditions for service delivery facilities; (iv) conditions of health services; (v) mandatory areas or stations for health services including emergency services; (vi) food production; (vii) environmental sustainability, and (viii) surveillance and control. Among these codes, several of them build on adaptation and mitigation features in the face of climate change, such as: (i) environmental sustainability and infrastructure; (ii) surveillance and control; (iii) emergency services; (iv) energy efficiency; and (v) requirements for building infrastructure that aim at ensuring that healthcare facilities are in optimal condition for standing natural (i.e., earthquakes) and climate-related hazards (i.e., floods). Environmental sustainability and energy efficiency include: (i) the use of equipment and materials that are energy efficient (> 20 percent more efficient than standard practice); (ii) natural ventilation and lighting, to reduce cooling and illumination needs for buildings, and air conditioning use and costs; (iii) lighting standards (i.e., sensor- controlled lighting) and equipment specifications to reduce consumption and GHG emissions; (iv) efficient heating equipment to reduce consumption and GHG emissions, and improve production and distribution of hot water; and (v) collection and use of rainwater for irrigation of green areas. Technical description. MSPS administrative act published, associated with implementing health services infrastructure, equipment, and human resources, including climate change adaptation and mitigation requirements, adapted to cultural, geographic and/or environmental contexts, modifying current MSPS Resolution 4445/1996 and 3100/2019. Specifically, the administrative act that will be issued and/or modified will include climate change adaptation in the standards related to: (i) climate adaptation measures to ensure health facilities are resilient to anticipated climate shocks (i.e. floods and storms) taking measures beyond standard practice; (ii) location and general conditions of health service providers’ facilities, to minimize climate-related hazards exposure; (iii) public services conditions related to water resources and those that guarantee basic sanitation including waste management; (iv) air management conditions in relation to passive natural and mechanical ventilation, as well as aspects of pollution control, prevention and mitigation, to maximize energy efficiency; (v) the use of energy efficient equipment, including lighting, and air conditioning systems; (vi) efficient heating equipment; (vii) vector control and integrated zoonosis management of climate-sensitive diseases conditions; (viii) chemical safety control conditions; (ix) conditions of infrastructure, thermal comfort and management of climatic conditions; and (x) food safety and food control conditions. Such conditions are further detailed in the POM. Page 24 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) DLI 6. Development of a Comprehensive Climate Change Management Plan for the Sector (PIGCCS) (US$50.75 million) This DLI includes three DLRs amounting to US$ 16.92 million each: (i) DLR 6.1: MSPS administrative act published, setting up the sectoral committee for climate change management, with functions and responsibilities in formulating and implementing the PIGCCS; (ii) DLR 6.2: MSPS roadmap for the adoption of the PIGCCS approved and published; and (iii) DLR 6.3: MSPS adoption of the PIGCCS. Rationale. This DLI intends to strengthen the regulatory framework required to implement Colombia’s climate change adaptation and mitigation strategies to promote an efficient health system response to climate change. To this end, the Program will finance the development of a PIGCCS, that includes three disbursements results: (i) the creation of the sectoral committee for climate change management, with functions and responsibilities in the formulation and implementation of the PIGCCS; (ii) the elaboration of the roadmap for the adoption of the PIGCCS; and (iii) the adoption of the PIGCCS. Technical description. MSPS administrative acts published. The POM provides a detailed description of the content of each MSPS administrative resolution. 40. Verification arrangements. An independent verification of the achievement of the DLIs will be done by the National Planning Department (Departamento Nacional de Planeación, DNP). The DNP is the independent agency responsible for conducting the external verification and reporting of DLI compliance in accordance with the verification protocols agreed with the MSPS and reflected in the POM. Distinct types of DLIs will require different verification methodologies. DLIs reflecting processes, such as developing and approving norms and plans (DLIs 5 and 6), will require desk-based verification. DLIs reflecting access to effective health services with delivery capacity, effective utilization, and individual registration in information systems and clinical registries, such as DLIs 1,3 and 4, will be reported through existing government information systems, particularly the SIVIGILA, the healthcare utilization Registry at Individual Level (Registro Individual de Prestaciones, RIPS), and the CAC among others, all included under the MSPS health management and information system. Finally, DLI 2 will be reported using an ad-hoc platform developed by the MSPS to follow up the acceleration plan to reduce maternal mortality (Plan de aceleración para la reducción de la mortalidad materna, PARE platform). Verification will examine the robustness of the reporting system using a standard data quality audit methodology. Reporting and verification arrangements, processes, protocols, and methodologies acceptable to the WB will be documented in the POM. III. PROGRAM IMPLEMENTATION A. Institutional and Implementation Arrangements 41. The Program will be implemented by the MSPS, which will provide overall oversight of Program execution. The MSPS will be responsible for high-level coordination of the Program with other actors involved in Program implementation. Within the MSPS, Program coordination will be coordinated through the office of the MSPS, which will appoint a Program Coordinator (PC). The PC will work with an interdisciplinary technical team in charge of coordinating Program implementation with the two vice-ministries of the MSPS, divisions, sub-divisions, and other departments of the MSPS involved in Program implementation. The PC will coordinate data collection to monitor indicator performance and reporting of DLIs; and the external verification of indicator achievement with the DNP. Each relevant department responsible for the achievement of Program results, as well as other participating entities, will identify one or two key staff members as focal points that will be responsible for supervising Program implementation in their area of competence and for ensuring timely and close coordination with the PC to achieve the DLI targets. The Program coordination team is staffed with the PC and technical staff members with adequate capacity to support Program implementation. The Page 25 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) coordination of financial matters will be conducted through the Health Sector Financing Division, including the responsibilities of reporting on the financial statements and submitting disbursement requests to the Ministry of Finance and Public Credit (Ministerio de Hacienda y Crédito Público, MHCP). Other responsibilities for Program implementation can be found in the Technical Assessment summary. B. Results Monitoring and Evaluation 42. The monitoring and evaluation data provided by internal and public sources are largely reliable. The progress of indicators related to regulatory changes will be verified in the Official Journal of the Republic of Colombia, which publishes legal acts and public notices of the President, Congress, and government agencies. Data for quantitative indicators will be obtained from several databases, including the Social Protection Integrated Information System (Sistema Integrado de Información de la Protección Social, SISPRO), information from healthcare providers and insurers collected by the CAC, SIVIGILA, information collected to comply with administrative act 202 of 2021, RIPS, Information System for Community and Collective Activities in Sexual and Reproductive Health (Sistema de Información de Actividades Comunitarias y Colectivas en Salud Sexual y Reproductiva, SISCO SSR) as well as other administrative data sources as detailed in the verification protocol (Annex 1). Process indicators will be monitored according to the verification of milestones and processes described in the verification protocol. 43. The PC of the MSPS will oversee the Program implementation. The PC will collect the information required to ensure DLI compliance and submit it to the independent verification agency. The Division of Sectoral Financing (Division de Financiamiento Sectorial) will be responsible for submitting the disbursement requests based on DLI achievement. The PC will ensure that technical and analytical areas of the MSPS report the timely progress of Program indicators (DLIs, Intermediary Indicators and PDO Indicators). The PC will serve as the WB's focal point for Program supervision and will submit progress reports as required. The WB will provide analytical, administrative, and technical support to the Program Coordination unit and other units involved in Program implementation based on the Implementation Support Plan (ISP), (Annex 6). C. Disbursement Arrangements 44. The Program funding will be based on the achievement of DLI targets as certified in accordance with the independent verification protocol. The disbursement arrangements and sequence are as follows: (i) Program funds will flow from the WB Loan Account to the MHCP USD-nominated foreign account at the Central Bank of Colombia or in a commercial bank accepted by the WB, upon the achievement and verification of DLI targets to the WB’s satisfaction. Disbursement requests to the WB will be made by the MSPS, according to the agreed disbursement schedule; (ii) funds in this account will be managed through the national Integrated Financial Information System, which coordinates, integrates, centralizes, and standardizes the national public financial management to promote greater efficiency and security in the use of the resources of the general budget of the nation. Funds will be transferred in Colombian Pesos (COP), at the request of the MSPS, to ADRES and will be reflected in the budgetary execution of these two entities; 31 (iii) up to US$ 24.39 million of the IBRD loan amount may be based on verification that agreed DLIs have been achieved prior to the signing of the Legal Agreement and after March 15th, 2023; and (iv) the timeframe for achieving each DLR considers the Government’s need for budget predictability and flow of funds. There is no restriction on early achievement of DLRs; payment will be disbursed as and when targets are achieved and verified. Scalable DLIs have been identified, and no period limitation for achievement applies. 31 Before transferring to ADRES, the funds will be re-allocated from domestic funding to external financing. Page 26 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) D. Capacity Building 45. The Program will be implemented using existing institutions and arrangements. As part of the technical assessment, the following topics have been identified for capacity building and institutional strengthening under each of the RAs: (i) capacity building of technical teams in information systems for real-time monitoring of selected indicators of access to effective health services and monitoring of the vulnerable population, and in training of health professionals in climate change and health adaptation and mitigation measures for the health sector; (ii) DLI reporting and verification: capacity building in the process of collecting the data for reporting the DLIs, and for the DNP to strengthen the verification process of compliance with the DLIs, among others to be included in the Program Action Plan (PAP); (iii) general close implementation support to be provided by the WB during execution as part of the FSA. Furthermore, the WB will provide capacity enhancement support to the Colombia General Comptroller of the Republic (Contraloría General de la República, CGR) to ensure that the audit of Program activities is carried out during the financing period; and (iv) implementation support for all necessary external TA and other key capacity building activities through a combination of different financing sources. IV. ASSESSMENT SUMMARY A. Paris Alignment 46. The proposed operation fully aligns with the Paris Agreement on climate change adaptation and mitigation goals and actively invests in measures to strengthen climate adaptation and mitigation. Table 2. Paris Alignment measures to reduce risks related to climate change adaptation and mitigation Type Assessment of related risks and mitigation measures Adaptation Floods, accounting for 45 percent of the country’s total natural hazards, are expected to worsen due to climate change and pose the primary climate-related risk to Program activities. Additionally, the Program may be affected by other climate-related hazards, such as landslides and storms, particularly in the northernmost and central Andean regions. These climate-related hazards can potentially hinder population access to health services and impact healthcare infrastructure, specifically for DLIs 1 to 4. For DLI 5 and 6, no significant climate-related risks would impact-related activities. The risks of climate hazards and extreme weather events will be managed through new infrastructure standards and the PIGCCS, which are to be financed by the Program as part of DLI 5 and DLI 6. Verification criteria for DLI 2 include having in place a tele-expertise or tele-support process that could ensure the provision of health services for pregnant women in the face of climate hazards. For DLIs that are related to health service provision (DLI 1 to 4), climate risks will be managed through the new infrastructure standards for IPS (DLI 5), improving the adaptive capacity of healthcare facilities to ensure the provision of services in the face of climate hazards. For example, the new infrastructure standards will include provisions for infrastructure such as walls, ceilings, location of the facility, and general integrity of the building to ensure that facilities are in adequate condition to withstand natural or climate-related hazards. Lastly, developing the PIGCCS will include strategies and activities to strengthen the health system's adaptive capacity. Mitigation The Program's activities do not include rehabilitation or construction of new facilities nor purchasing electrical equipment that could slow down the country’s mitigation goals or create GHG lock-ins. Overall, the activities related to DLIs 1-4 pose low to no risk for meeting the mitigation goals of the country. On the other hand, to ensure that the development of the health system in Colombia remains on track with a low-emissions pathway, this operation supports – via DLI 5 – new infrastructure standards that include energy efficiency measures that will ensure that buildings are at least 20 percent more energy efficient than standard practice. Moreover, the operation includes a DLI for PIGCCS (DLI 6), that will carry out a baseline assessment of the GHG emissions at the facility level of the Page 27 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) health sector. This DLI will also: (i) create the sectoral committee for climate change management, with functions and responsibilities in the formulation and implementation of the PIGCCS (DLR 6.1); (ii) elaborate a roadmap for the adoption of the PIGCCS (DLR 6.2); and (iii) publish the action plan for the implementation of the PIGCCS. The PIGCCS, will include strategies and activities for mitigation and adaptation in line with the NDCs, NAP, and LTSs. B. Technical Strategic Relevance and Technical Soundness of the Program 47. Despite Colombia’s progress in achieving UHC and limiting out-of-pocket expenditure, the country faces challenges due to large inequalities in access to effective health services. Public investments in expanded coverage and low out-of-pocket payments have not materialized in better health results for the vulnerable population, including those living in rural and remote areas. Moreover, unbalanced incentives favor cost containment requirements over the need to deliver quality care, especially to the vulnerable population. The PND aims to improve the well-being and health of Colombians, strengthen the health system, and increase its capacity to meet present and future challenges, including the impact of climate change and future pandemics. The PND emphasizes specific results in areas such as maternal mortality, child mortality from malnutrition, mental health, and survival from breast cancer. Specifically, the Government intends to: (i) implement policies and programs to ensure that all children have access to adequate and sufficient nutrition; (ii) implement policies and programs to ensure that all women have access to safe and quality prenatal and delivery services to reduce maternal mortality; (iii) implement prevention, early detection, and timely treatment programs for breast cancer to reduce mortality; and (iv) implement interventions to address the consequences of climate change. 48. The specific policy interventions supported under the Program draw on the WB's extensive analytical work and technical assistance through its health sector engagement in Colombia. Several recent studies led by the WB are relevant and aligned with the Program's objectives and have provided specific recommendations to the GoC, including the cost of prioritized interventions. These studies have contributed to further substantiating the need to improve access to effective health services and enhance the resilience of the health sector. A 2021 WB study on PHC system performance 32 and a 2022 WB study on better preparing Colombia for future pandemics 33 were co-developed with the MSPS and the DNP and are part of the evidence base mobilized for the new PND. Finally, the WB has recently finalized a study on health sector resilience to climate change, 34 which provides additional recommendations for better adaptation and mitigation of climate change for the health sector. Program Expenditure Framework (PEF) 49. As per Colombia’s 2023-2026 Medium-term Fiscal Framework, the total projected public resources from the Central Government for the health sector amount to 117 COP$ trillion, equivalent to US$24,893 million. The Program will marginally support two of the main budget lines of the MSPS: (i) health insurance, claims and health services for the subsidized regime, which represent close to 97 percent of the Program’s budget; and (ii) salaries, as shown in Table 3 below. The PforR financing is estimated to be US$1,647 million over three years. This amounts to 6.6 percent of the total Government program. The Program loan and additional grant financing amount to US$304.5 million or 1.3 percent of the Government program. 32 World Bank. 2020. Primary Healthcare Vital Signs Profile Assessment for Colombia. Available here 33 World Bank. 2022. Evaluación de las Capacidades de Preparación y Respuesta ante Futuras Pandemias y Emergencias en Salud Pública. Available here 34 World Bank. 2023. Impact of Climate Change in Health in Colombia and Recommendations for Mitigation and Adaptation. Available here Page 28 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 50. This PEF follows the successful design of the PEF of the ongoing PforR in the health sector in Colombia. The budget lines supporting the PforR are sufficient to cover all activities identified in the Program’s results chain. The PEF assessment and supervision of the ongoing PforR (P169866) confirms that the SGSSS’s capitation payments finance a broad range of activities related to healthcare service delivery, which are prominent in RA1. Similarly, developing regulations and strengthening existing systems are financed predominantly through MSPS staff salaries. The Program is careful not to finance procurement activities or infrastructure investments that would require support from additional budget lines. Table 3. PforR Expenditure Framework 2023-2026 Operation WB and Grant Financing and % of Executing Financing which is PforR PforR Expenditure Framework Entity US$ million US$ million % PforR (i) Insurance premium (UPC) for prioritized vulnerable groups in the ADRES 1,611 subsidized regime (ii) Salaries MSPS 36 Total 1,647 304.5 18.48% Economic justification 51. The economic analysis conducted for the proposed Program shows positive results through a cost-benefit estimation. The Program focuses on two RAs: improving access to effective health services for the vulnerable population and enhancing the resilience of the health system to climate change. The total financing for the Program is US$ 304.5 million. The costs and benefits are analyzed in monetary terms, and the full cost-benefit analysis, including detailed calculations and data, can be found in Annex 1. The analysis indicates a positive Net Present Value (NPV), a high Internal Rate of Return (IRR), and a benefit-cost ratio of 11, supporting the economic viability of the Program. 52. Program benefits are estimated based on the reduction in the burden of disease and the avoidance of infrastructure damage. The Program is expected to produce an NPV surplus of US$3.7 billion, with an IRR of 291 percent and a benefit-cost ratio of 11. In addition, the Program would avert a significant number of Disability Adjusted Life Years (DALYs) and contribute to mitigating 15.2 percent of the country’s annual disease burden. The sensitivity analysis further confirms the positive outcomes of the Program under different scenarios. Overall, the economic analysis provides a solid justification for the Program’s implementation, both in terms of economic benefits and improvements in population health outcomes. Including the full cost-benefit analysis in Annex 1 allows for a more comprehensive examination and validation of the economic viability of the proposed Program. Page 29 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Table 4. Summary of cost-benefit indicators supporting the economic justification for the Program NPV Costs $358,327,875 Discounted DALYs savings value $3,800,711,574 Discounted monetary savings value $272,344,325 NPV Benefits $4,073,055,899 IRR (first 20 years) 291% Cost-benefit ratio 11 NPV surplus $3,714,728,024 Total DALYs averted 110,866 % DALYs 2019 15.20% 53. Public investment for achieving these benefits is justified and preferred over private investment, given the characteristics of Colombia's health market and the health system. The healthcare system in Colombia operates under a mixed public-private model, with EPS playing a central role in providing coverage to all citizens through the subsidized or contributory regime. EPS receives financial resources from public transfers and contributions to ensure access to health services, while the MSPS and the Health Superintendent oversee the health system. Public involvement in healthcare service delivery in Colombia is justified for multiple reasons. It generates public returns that surpass private returns through initiatives like public health surveillance and vaccination programs, and it allows for risk pooling and insurance provision to mitigate health and financial risks for a wide population. Furthermore, public intervention ensures equitable access to essential services, regardless of socioeconomic status, supporting the basic human right to health. Given known market failures in the health sector, such as information asymmetry, public intervention becomes crucial in guaranteeing fair and inclusive access to effective health services for all. C. Fiduciary Aspect 54. The Program’s fiduciary systems capacity and performance have been assessed, 35 and its conclusions are reflected below. The Fiduciary Systems Assessment (FSA) covered the MSPS and the ADRES, as they are responsible for administrating the health system resources and payments (onwards Program executing entities). The assessment considered the executing entities’ fiduciary capacity and performance for the last three (3) years and the satisfactory fiduciary capacity and performance of the WB’s first health sector PforR for Colombia. As per the Program’s expenditure framework, no procurable activities were identified. The assessment concluded that, overall, the Program fiduciary systems’ capacity and performance, with the implementation of the proposed mitigating measures and agreed actions to strengthen the systems (as reflected in the FSA paragraph 4), are adequate to provide reasonable assurance that the Program funds will be used for the intended purposes, with due attention to the principles of economy, efficiency, effectiveness, transparency, and accountability. 36 35 WB Policy dated November 2017, WB Directive dated September 2020, WB Guidance PforR FSA Guidance Note dated June 2017; and Interim Guidance Note Systematic Operations Risk-Rating Tool (SORT) dated June 25, 2014. 36 The objective of the FSA is to determine whether the Program fiduciary systems provide reasonable assurance that the financing proceeds will be used for the intended purposes, with due attention to the principles of economy, efficiency, effectiveness, transparency, and accountability. The FSA also is identifying development activities to support the Program’s implementation and/or as risk mitigation measures to counter against key fiduciary risks, to be included in the PAP. The FSA entailed a review of the capacity of the participating entities with respect to their ability to: (a) record, control, and manage all Program resources and produce timely, understandable, relevant, and reliable information for the Borrower and the WB; (b) ensure that implementation arrangements are adequate; and (c) identify and address risk of fraud and corruption and effectively handle public grievances and complaints. Page 30 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 55. The active PforR (P169866) has had a satisfactory fiduciary performance, with disbursements reaching over 76 percent of the total loan proceeds during the first two years of implementation. The MSPS reported semi-annual unaudited financial reports on budget execution to the WB within the agreed deadlines and content. The CGR has executed annual audits of the two implementing entities, in accordance with the provisions of the Memorandum of Collaboration (MoC) between the WB and the CGR; audit reports have included unmodified audit opinions for MSPS and ADRES’s Financial Statements and budget execution; these audits did not disclose any material weaknesses or audit findings for the Program. The MSPS and the ADRES have formulated improvement plans for the CGR’s findings, which are monitored on a quarterly basis in the CGR’s Integrated Management System. The PAP has been executed as established; the MSPS and the ADRES are periodically following up on the CGR improvement plans and other actions; the MHCP has approved the reclassification of the budget financing source for each WB payment. Findings derived from the special audit of the Unique Affiliate Database (Base de Datos Única de Afiliados, BDUA) 37 were closed as of December 31, 2021, and the CGR assessed the improvement plan as satisfactory. D. Environmental and Social Assessment 56. Environmental and Social Systems Assessment (ESSA) was carried out as per the WB PforR Financing Policy (OPS 5.04-POL 107). The ESSA evaluated the systems that promote environmental and social sustainability; and assessed the barriers for vulnerable groups, including indigenous peoples, to access or participate in the Program and the mechanisms for consultation, participation and attention to complaints and grievances. Specific objectives included: (i) identifying the Program's potential environmental and social benefits, risks, and impacts; (ii) reviewing the policy and legal framework related to the management of environmental and social impacts of Program interventions; (iii) assessing the institutional capacity for environmental and social management; (iv) assessing the performance of national systems against the core principles of the PforR instrument and identify gaps, if any; and (v) submitting recommendations and a PAP to address gaps and improve performance during Program implementation. Key findings are reported in Table 5 below, with more details in Annex 4. The ESSA was publicly disclosed before appraisal for consultations with Program stakeholders. 57. The combined risk assessed at entry is low. The ESSA confirms that the environmental aspects of the Program are reasonably covered by the regulations and institutional capacity of the entities involved, where the MSPS establishes the policies and the decentralized authorities carrying out actions of inspection, oversight, and sanitary control. The findings from the ESSA are intended to ensure that the Program is implemented in a manner that maximizes potential environmental and social benefits and avoids, minimizes, or mitigates adverse environmental and social impacts and risks. The PAP includes activities that would bridge the remaining gaps in the environmental and social management systems. Table 5. Summary of findings from ESSA against core principles applied to the Program ESSA Core Principles Summary findings Core principle 1 Colombia has an adequate legal and regulatory framework incorporating good environmental Environmental and social and social assessment practices. Program activities are intended to improve effective access to management the Colombian health system for the vulnerable population and generate greater resilience of the system to the effects of climate change and public health threats. The Program is expected to have positive social impacts on the population's health, including vulnerable women, children and migrants. Main environmental risks and impacts of the Program relate to: (i) the management and disposal of biomedical, solid, and hazardous waste; (ii) the potential generation of Waste Electrical and Electronic Equipment (WEEE); and (iii) the impacts of natural 37 BDUA: It is a single database of people covered by the health insurance system, database of affiliation. Page 31 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) ESSA Core Principles Summary findings disasters and those caused by the effects of climate change. The PAP includes several actions to reduce and mitigate these risks and impacts. Core principle 2 No adverse impacts on natural habitats or physical cultural resources are expected because of Impacts on natural habitats the Program. There will be no construction or intervention in areas associated with cultural and physical cultural heritage, and actions and investments will not affect areas of biodiversity protection. resources Core principle 3 Certain medical practices could expose IPS and beneficiaries to hazardous materials, infections, Protect public and worker radiation, as well as sharp instruments, etc. The ESSA confirmed the general adequacy of the safety. environmental systems and the institutional and legal framework for managing medical waste by healthcare facilities. The PAP includes recommendations for adequately managing Healthcare Waste (HCW), Electrical and Electronic Equipment (EEE) and WEEE. Core principle 4 There is no land acquisition, resettlement, or loss of access to natural resources. Land acquisition and loss of access to natural resources Core principle 5 The Program is expected to have overall positive social impacts given actions to ensure cultural Cultural appropriateness and and social appropriateness of, and equitable access to, health services, paying attention to equitable access to program gender and interests of ethnic groups (Indigenous people, Afro-Colombian and Rom benefits communities) and to the needs of traditionally excluded groups in rural and dispersed areas. Yet, there may be risks of excluding vulnerable groups in the targeting of populations or prioritization of territories, including indigenous communities, and thus, specific strategies are recommended to mitigate these risks. Core principle 6 There are no risks of exacerbating social conflicts as no exclusion of any group in terms of class, Avoid exacerbating social religion or geography is expected. On the contrary, the Program will help eliminate barriers to conflict effective health services for the vulnerable population. 58. Addressing key gender gaps. The Program will support the GoC’s strategic efforts to improve women’s health and reduce gender gaps in access to effective health services. It will do so by focusing on two of the most important causes of avoidable mortality in women: breast cancer and maternal mortality. In both cases, the GoC efforts address important bottlenecks in providing effective health services by strengthening information systems, providing technical capacity to identify and manage risks and setting up integrated care networks. An intermediary indicator related to access to mental health services for female victims of GBV is part of the PND and has been included in the results framework. 59. Citizen Engagement. The proposed Program supports the new healthcare model proposed by the MSPS, which promotes citizen and patient engagement. RA1 presents a territorial approach centered on PHC centers that aims to bring the health system closer to its users by engaging families and communities in caring for pregnant women and children, generating awareness of the factors that make morbidity and mortality avoidable, and in helping identify complications that need an immediate response from the health sector. In addition, the Social Participation in Health Policy (Política de Participación Social en Salud) aims to guarantee the citizens’ right to be informed and have a voice in the decision-making that affects them. Ethnic groups and native peoples have specific requirements for consultation and engagement. A mechanism for petitions, complaints, claims, and suggestions (Petición, Queja, Reclamo, Sugerencia o Denuncia, PQRSD) is institutionalized across Government agencies and implemented by the MSPS. The provision of timely responses to the Page 32 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) PQRSD sent to the MSPS will be monitored through an intermediate indicator in the results framework. 38 60. Grievance Redress. Communities and individuals who believe that they are adversely affected as a result of a WB-supported operation, as defined by the applicable policy and procedures, may submit complaints to the existing program grievance mechanism or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed to address pertinent concerns. Program-affected communities and individuals may submit their complaints to the WB’s independent Accountability Mechanism (AM). The AM houses the Inspection Panel, which determines whether harm occurred or could occur because of WB's non-compliance with its policies and procedures, and the Dispute Resolution Service, which provides communities and borrowers with the opportunity to address complaints through dispute resolution. Complaints may be submitted at any time after concerns have been brought directly to the WB's attention and WB Management has been given an opportunity to respond. For information on how to submit complaints to the WB’s GRS, please visit http://www.worldbank.org/GRS. 61. The Program has been assessed for climate change and disaster risks. Risks to the Program’s activities are considered moderate. The country faces constant floods and landslides, which are exacerbated by the El Niño phenomena. Changes in temperature and precipitation and increasing extreme weather events put pressure on Colombians livelihoods, increasing risks for NCDs, as well as communicable diseases such as dengue and malaria. Moreover, nutrition and food security remain a challenge for the health sector, which is expected to be exacerbated by climate change. The Program addresses climate-related vulnerabilities through DLIs that directly support the Colombian health system’s adaptation, resilience, and mitigation, as documented in Table A2.1 of Annex 2. V. RISK 62. The overall risk rating for the Program is categorized as Substantial, primarily resulting from risks associated with the recent health reform currently under discussion by Congress. 63. Political & Governance Risk is rated Substantial. The recent draft legislation presented to Congress poses inherent risks to the health system. The reform may affect the Program’s funding, a high-priority expenditure for the Government. The Government is actively engaging with political parties to discuss amendments to the reform and address concerns. Congress's support has been insufficient to allow for the reform to pass. The WB will work with MSPS staff to ensure alignment with Government priorities and closely monitor how negotiations of the reform unfold during Program implementation so that risk mitigation measures can be adjusted as needed. 64. Sector Strategies and Policies Risk is rated Substantial. To mitigate uncertainty and risks associated with the reform, the proposed Program concentrates only on priorities that meet the following three criteria: (i) having well- defined plans included in the PND; (ii) requiring minimal reliance on the organizational structure of the health system to achieve results, and (iii) enjoying widespread stakeholder support. The goals under the proposed Program have garnered broad support from all political parties and stakeholders, irrespective of their stance on the Government’s reform proposal. 38The PQRSD is processed by the Citizen Assistance Group, in accordance with the guidelines established in Resolution 3687 of August 17, 2016. According to the type of petition, the deadlines are established between 10 and 30 days; to support this output, the Program includes an intermediate indicator for measuring the percentage of citizen consultations and claims submitted and solved on time. Page 33 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience(P180534) ANNEX 1. RESULTS FRAMEWORK MATRIX @#&OPS~Doctype~OPS^dynamics@padpfrannexpolicyandresult#doctemplate Program Development Objective(s) To improve access to effective health services for the vulnerable population and enhance the resilience of the health system to climate change and public health threats. PDO Indicators by Outcomes Baseline Closing Period Improved access to effective health services for vulnerable populations Improved timeliness in the initiation of treatment for breast cancer (Days) Dec/2021 Jun/2026 63.6 45.00 Enhanced health system resilience to climate change and public health threats Percentage of Territorial Entities that adopted a Climate Change Adaptation Plan with a One Health approach (Percentage) Jun/2023 Jun/2026 8.00 30.00 Intermediate Indicators by Results Areas Baseline Closing Period Improved access to effective health services for the vulnerable populations Children under 5 years of age notified to event 113 of SIVIGILA living in Prioritized Departments with follow-up (Percentage) Jun/2023 Jun/2026 0 100.00 Page 34 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience(P180534) Implementation of an information system for online monitoring, at Prioritized Departments, of the treatment of cases of acute child malnutrition that have been reported to the SIVIGILA with code 113 (Yes/No) Jun/2023 Jun/2026 No Yes Use of tele expertise for management of cases of extreme maternal morbidity (Number) Jun/2023 Jun/2026 0 5440.00 Pregnant women under follow-up care registered at individual level (Percentage) Jun/2023 Jun/2026 0.00 70.00 Vulnerable women 50-69 years of age screened for breast cancer (Percentage) Dec/2021 Jun/2026 32.80 40.00 Women victims of sexual violence who receive mental health services (Percentage) Dec/2022 Dec/2025 36.00 48.00 Migrants screened for HIV (Number) Dec/2022 Dec/2025 16,266.00 151,515.00 Number of basic health teams in operation in territories (Number) Jul/2023 Jun/2026 580.00 1622.00 Number of people screened for mental health services by primary health providers and basic health teams (Number) Dec/2022 Jun/2026 1031401 1175000 Enhanced health system resilience to climate change and public health threats Health centers meeting new requirements for energy efficiency and adaptation to climate change (Percentage) Jun/2023 Jun/2026 0.00 90.00 Percentage of territorial entities that adopted a Risk Communication Plan for public health emergencies with One Health and Climate Change approach (Percentage) Jun/2023 Jun/2026 53.00 100.00 Percentage of citizen consultations and claims submitted through the internet site of the MSPS solved on time according to resolution 3687 of 2016 (PQRSD) (Percentage) Page 35 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience(P180534) Dec/2022 Jun/2026 83.00 87.00 Disbursement Linked Indicators (DLI) Period Period Definition Timeline Period 0 Prior Results 15-Mar-2023 to 27-Feb-2024 Period 1 2024-2026 28-Feb-2024 to 30-Jun-2026 Baseline Period 0 Period 1 1 : DLI 1. Children under 5 years old with acute malnutrition identified, reported, and receiving treatment for acute malnutrition in Prioritized Departments. (Number ) 0 - - 0.00 0.00 0.00 DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67%  1.1 : DLR 1.1. Number of Prioritized Departments with children under 5 years old identified, reported, and receiving treatment for acute malnutrition. (Number ) 0 0 10 0.00 0.00 50,750,000.00 DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67% 2 : DLI 2. Reduction of maternal mortality in prioritized territories through an integrated strategy. (Number ) - - - 0.00 0.00 0.00 DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67%  2.1 : DLR 2.1. Number of prioritized territories with an acceleration plan for reducing maternal mortality that includes implementing a maternal health integrated network. (Number ) 0 7 12 0.00 7,478,947.37 12,821,052.63 DLI allocation 20,300,000.00 As a % of Total Financing Amount 6.67%  2.2 : DLR 2.2. IPS trained in obstetric emergencies based on simulation scenarios. (Number ) Page 36 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience(P180534) 0 0 130 0.00 0.00 15,225,000.00 DLI allocation 15,225,000.00 As a % of Total Financing Amount 5.0%  2.3 : DLR 2.3. ISABEL quality assessment tool used twice yearly in IPS. (Number ) 0 0 312 0.00 0.00 15,225,000.00 DLI allocation 15,225,000.00 As a % of Total Financing Amount 5.0% 3 : DLI 3. Vulnerable women diagnosed with breast cancer with early-stage diagnosis (IIA). (Percentage ) - - - 0.00 0.00 0.00 DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67%  3.1 : DLR 3.1. Percentage of vulnerable women diagnosed with breast cancer with early-stage diagnosis (from in situ to IIA). (Percentage ) 50.88 0 57.00 0.00 0.00 50,750,000.00 DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67% 4 : DLI 4. Migrants with HIV have accessed effective treatment. (Number ) - - - 0.00 0.00 0.00 DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67%  4.1 : DLR 4.1. Number of Eligible Migrants with HIV that have accessed comprehensive HIV care according to the verification protocol. (Number ) 2364 0 7100 0.00 0.00 50,750,000.00 DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67% 5 : DLI 5. New infrastructure standards for healthcare providers, including energy efficiency standards and adaptation and mitigation measures to climate change. (Yes/No ) - - - 0.00 0.00 0.00 DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67%  5.1 : DLR 5.1. Publication of a new framework of infrastructure standards for healthcare providers, including social and environmental standards and climate change adaptation and mitigation measures (Yes/No ) NO - YES 0.00 0.00 50,750,000.00 Page 37 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience(P180534) DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67% 6 : DLI 6. Development of a PIGCCS. (Yes/No ) - - - 0.00 0.00 0.00 DLI allocation 50,750,000.00 As a % of Total Financing Amount 16.67%  6.1 : DLR 6.1. MSPS administrative act published, setting up the sectoral committee for climate change management, with functions and responsibilities in formulating and implementing the PIGCCS. (Yes/No ) NO YES 0 0.00 16,916,666.66 0.00 DLI allocation 16,916,666.66 As a % of Total Financing Amount 5.56%  6.2 : DLR 6.2. MSPS roadmap for the adoption of the PIGCCS approved and published. (Yes/No ) NO - YES 0.00 0.00 16,916,666.67 DLI allocation 16,916,666.67 As a % of Total Financing Amount 5.56%  6.3 : DLR 6.3. MSPS adoption of the PIGCCS. (Yes/No ) NO - YES 0.00 0.00 16,916,666.67 DLI allocation 16,916,666.67 As a % of Total Financing Amount 5.56% Page 38 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Monitoring & Evaluation Plan: PDO Indicators by PDO Outcomes Monitoring & Evaluation Plan: PDO Indicators Indicator Name Definition/Description Frequency Data Source Methodology for Responsibility Data Collection for Data Collection Improved timeliness The indicator measures the time Annual EPS reports to MSPS MSPS Promotion in the initiation of elapsed (in number of days) MSPS - MSPS Administrative and Prevention treatment for breast between the first histopathologic verifies with the Resolutions Direction – Sub- cancer diagnostic report and the first information 247/214; direction of NCDs treatment (chemotherapy, provided by CAC. 3339/2019, MSPS Department radiotherapy, or surgery) for Nacional Cancer of Regulation of women diagnosed with breast Plan and as further Benefits, Costs cancer who had initiated described in the and Rates of treatment. POM. Health Insurance. Minuend: date of first histopathologic diagnostic report Subtrahend: date of first treatment (chemotherapy, radiotherapy, or surgery) The indicator will further disaggregate results for vulnerable women in the SGSS's subsidized regime and PPT status. Percentage of Numerator: Number of territorial Annual Administrative Publication of the MSPS Promotion territorial entities entities prioritized that adopt by act from the administrative act and Prevention that adopted a administrative act a Climate territorial entity. on the territorial Direction Sub- Climate Change Change Adaptation Plan for entities webpage. direction Adaptation Plan with Environmental Health environmental a One Health Denominator: Total number of health. approach territorial entities prioritized. Monitoring & Evaluation Plan: Intermediate Results Indicators Indicator Description Frequency Data source Methodology for Responsibility Name Data Collection for Data Collection Children under Numerator: Number of children Annual SIVIGILA (event The Reporting National Health 5 years of age under 5 years of age notified to event 113) Units (i.e., Institute notified to 113 of SIVIGILA living in Prioritized Colombian (Instituto event 113 of Departments with follow-up Institute of Family Nacional de SIVIGILA living Denominator: Number of children Welfare (Instituto Salud, INS), in Prioritized under 5 years of age notified to event Colombiano de Nutritional Page 39 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Monitoring & Evaluation Plan: Intermediate Results Indicators Indicator Description Frequency Data source Methodology for Responsibility Name Data Collection for Data Collection Departments 113 of SIVIGILA living in Prioritized Bienestar Familiar health, food, and with follow-up. Departments. (ICBF)) and/or the beverages Primary data Department. Prioritized Departments are: Bolívar, generating units Cesar, Chocó, La Guajira, Antioquia, EPS (IPS or TEs) Magdalena, Meta, Valle del Cauca, report the event Vichada, Arauca, Guainía, and 113 in the Risaralda. SIVIGILA. A case of acute malnutrition The indicator allows monitoring the is defined in behavior of acute malnutrition in children under 5 children under 5 years of age in the years of age when prioritized departments in a given the Z-score of the period of time, in accordance with weight/height or the provisions of Resolution 2350 of length indicator is 2020. below -2DE and/or presents the The indicator will be disaggregated by phenotypes of PPT status and gender. severe acute malnutrition (marasmus, kwashiorkor or marasmic kwashiorkor). It is associated with recent weight loss or inability to gain weight, of primary etiology, given in most cases by low food intake and/or the presence of infectious disease. The INS reviews the event 113 database, a process that culminates in the second semester of the following year. Implementation The indicator measures implementing Annual MSPS MSPS Technology MSPS of an an Information System for online Technology of of Information Technology of information nominal monitoring, at Prioritized Information and and Information and system for Departments, of treatment of acute Communication Communication Communication Page 40 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Monitoring & Evaluation Plan: Intermediate Results Indicators Indicator Description Frequency Data source Methodology for Responsibility Name Data Collection for Data Collection online malnutrition in children. The System Office. Office is Office with the monitoring at will be accessible by those responsible developing the technical support Prioritized for key programs for acute information of Promotion & Departments of system with the Prevention malnutrition (MSPS, ICBF), the treatment technical support Direction (Sub- of cases of incorporated into the SISPRO of the Promotion direction acute child applications environment, and & Prevention nutritional malnutrition interact and complement with other Direction (Sub- health, food, and that have been sources of information from the MSPS direction beverages). reported to the (RIPS, BDUA, MIPRES, Identification nutritional health, SIVIGILA with Evolution Table). food, and code 113 The system will take the cases of acute beverages). malnutrition reported by the primary data-generating units defined by the surveillance protocol for event 113, to the SIVIGILA. Prioritized Departments are: Bolívar, Cesar, Chocó, La Guajira, Antioquia, Magdalena, Meta, Valle del Cauca, Vichada, Arauca, Guainía, and Risaralda. Use of tele The indicator measures the number Annual Reporting system The EPS reports to MSPS Promotion expertise for of pregnant women with extreme for the follow-up the MSPS the and Prevention management of maternal morbidity who receive care of pregnant cases of extreme Direction. cases of with support from telemedicine or women maternal extreme telehealth in prioritized territories. SGD126GEST. morbidity that maternal Prioritized territories are: La Guajira, have a tele- morbidity Magdalena, Santa Marta, expertise or tele- Barranquilla Atlántico, Bolivar, support Cartagena, Norte de Santander, consultation, Córdoba, Cesar, Antioquia, Chocó, considering the Boyacá, Bogotá, Valle del Cauca, Cali, defined variables. Buenaventura, Cauca, Nariño. This will be The indicator will be disaggregated by verified through PPT status. the application for the follow-up system for the cohort of pregnant women SGD126GEST, developed by the MSPS. Pregnant This indicator measures the Annual Reporting system The EPSs are MSPS Promotion Page 41 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Monitoring & Evaluation Plan: Intermediate Results Indicators Indicator Description Frequency Data source Methodology for Responsibility Name Data Collection for Data Collection women under percentage of pregnant women for for the follow-up responsible for and Prevention follow-up care the cohort under follow-up care of pregnant the nominal data, Direction Circular registered at registered in the monitoring system women and for capturing 047/20. individual level at individual level. SGD126GEST. the information and reporting to Numerator: Number of women the territorial included in the monitoring system for health entities and the cohort of pregnant women in the MSPS. The prioritized territories. MSPS consolidates Denominator: Number of pregnant the information women estimated in the cohort in and constructs the prioritized territories. final indicator. Each cohort will be Effective care and its continuity followed up until mean: In accordance with the six weeks provisions of Resolution 3280 of postpartum to 2018, the EPSs have the responsibility ensure women to establish and follow up the cohort receive the of pregnant women. The monitoring interventions of the cohort of pregnant women is included in the defined as a mechanism for the Integrated nominal monitoring of all pregnant Maternal- women, through which the Perinatal registration and monitoring of Healthcare route. prenatal care, childbirth and In cases of puerperium care are performed. extreme maternal morbidity, follow- Prioritized territories are: La Guajira, up will be carried Magdalena, Santa Marta, out up to six Barranquilla, Atlántico, Bolívar, months after the Cartagena, Norte de Santander, termination of Córdoba, Cesar, Antioquia, Chocó, pregnancy. Boyacá, Bogotá, Valle del Cauca, Cali, Buenaventura, Cauca, Nariño. The indicator will be disaggregated by PPT status. Vulnerable The indicator measures the Annual Resolution 202 The Epidemiology MSPS Promotion women 50-69 percentage of women who have had BDUA and RIPS and Demography and Prevention years of age a mammography in the last two (Individual Direction collects Division screened for years. Health Service the information, MSPS breast cancer Delivery which is then Epidemiology Numerator: Number of women aged Records). reviewed by the and Demography 50 to 69 years with a mammography Promotion and Direction in the last two years. Prevention MSPS Costs and Page 42 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Monitoring & Evaluation Plan: Intermediate Results Indicators Indicator Description Frequency Data source Methodology for Responsibility Name Data Collection for Data Collection Denominator: Number of women Direction and Tariffs Direction. between 50 and 69 years of age. delivered to the Department of The indicator will be disaggregated by Costs and Tariffs. regimen. Resolution 3280/2018. Women victims This indicator measures the Annual RIPS and SIVIGILA Information on MSPS Promotion of sexual percentage of women victims of the numerator and Prevention violence who sexual violence who have received comes from RIPS: Direction– Sexual receive mental mental health services in a year. CIE codes for and health services clinical diagnoses Reproductive Numerator: number of women with of sexual violence Health clinical diagnoses related to sexual are T742, Y050 Coordination. violence who have received and Y059; for psychological evaluations in a year. psychological evaluations CUPS Denominator: total number of are 890108, women reported to SIVIGILA as a 890208, 890297, possible case of sexual violence in the 890308, 890397, same year 890408, 890608, The indicator will be disaggregated by 940900, 940901, PPT status of the population. 943102, and 990206. Information on the denominator comes from SIVIGILA. Migrants This indicator measures the number Annual SISCO_SSR Through the Directorate of screened for of migrants living in Colombia, (Information SISCO_SSR it is Promotion and HIV regardless of their immigration System on possible to Prevention status, screened for HIV. Community and identify the Direction - Population- number of Sexuality, Sexual Number of migrants who had been based SRH immigrants who Rights and screened for HIV during the reporting activities) and have received an Reproductive period and who are informed of their RIPS. HIV test and its Rights Group. results. The report corresponds result, given that mainly to rapid HIV tests. the report corresponds The indicator will be disaggregated by mainly to rapid gender. HIV tests. The territorial entities and other system agents, such as IPS and Non- governmental Page 43 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Monitoring & Evaluation Plan: Intermediate Results Indicators Indicator Description Frequency Data source Methodology for Responsibility Name Data Collection for Data Collection Organizations upload the information in the SISCO_SSR. For the years 2022- 2025, the system and its information outputs are being strengthened, and it is expected that, during this period, the adoption of this source by the MSPS and its incorporation into the SISPRO will be achieved. The purpose is to make nominal cross-checks of databases with other SISPRO information sources to identify other migrants who have received HIV testing through other services that do not report to SISCO SSR, but without duplicating their report. Number of basic This indicator monitors the Annual Monitoring Tool Reports from the MSPS Promotion health teams in implementation of Basic Health for Conformation MSPS Promotion and Prevention operation in Teams operating in territories. and Operation of and Prevention Direction. territories Basic Health Direction. Measurement: Number of Basic Teams Health Teams operating in prioritized Regulatory territories. support Law 1438 of 2011, The team comprises a minimum of a articles 15 and medical professional, a nursing 16. Page 44 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Monitoring & Evaluation Plan: Intermediate Results Indicators Indicator Description Frequency Data source Methodology for Responsibility Name Data Collection for Data Collection professional, a psychology professional or social worker, technical or auxiliary nursing staff, or health promoters. The teams’ functions are established in Article 16 of Law 1438 of 2011, within the PHC framework and according to MSPS guidelines. prioritized territories have been selected based on the concentration of migrant population, and are: Bogotá D.C, Antioquia, Valle del Cauca, Norte de Santander, Atlántico, La Guajira, Cundinamarca, Bolívar, Santander, Magdalena, Cesar, Risaralda, Arauca, Meta, and Boyacá. Number of This indicator measures the number Annual RIPS Periodic follow-up MSPS Promotion people of people screened for mental health and monitoring of and Prevention screened for interventions registered under RIPS reporting Direction. mental health selected CUPS Codes. people screened services by for Mental Health primary health CUPS Codes providers and (890208 and basic health 940901), teams disaggregated by those attended by basic health teams and by the PPT status of the population. Health centers The indicator measures compliance Annual Special Registry The IPS that seeks MSPS Service meeting new with the new climate change of Health Service to obtain its Delivery and requirements adaptation and mitigation Providers qualification must Primary Care for energy requirements in health centers (IPS) (Registro Especial fully comply with Direction. efficiency and since the publication of the norm de Prestadores the requirements adaptation to 3100/2019 amendment. de Salud, REPS). of the newly climate change. defined standards, Numerator: Number of qualified IPS including climate that have implemented technical change adaptation requirements related to climate standards. change adaptation Territorial health Denominator: Number of IPS under Secretariats carry the qualification process out the (habilitación). verification and qualified IPS are Page 45 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Monitoring & Evaluation Plan: Intermediate Results Indicators Indicator Description Frequency Data source Methodology for Responsibility Name Data Collection for Data Collection reported in REPS. The MSPS consolidates the information and the reporting. Percentage of The indicator measures developing Annual Register of Quarterly MSPS territorial and implementing a risk regulations reporting of Epidemiology entities that communication plan with a One issued by progress and and Demography adopted a Risk Health and climate change approach territorial registry of norms Division. Communication in all sub-national territorial entities entities issued by the Plan for public of the country, a total of 37 DIVIPOLA. territories. health departments and districts. Decree 780 of emergencies 2016 Chapter 8 with One Health Numerator: Number of territorial Public Health and Climate entities with risk communication plan Surveillance Change adopted. System, approach Denominator: 37 Departmental and International District territorial entities Health Activities. Regulations 2005 and as described 1. Preparation of the regulations for in the POM. adopting the Risk Communication Plan in each territory. 2. Issuance of the regulation to adopt the Risk Communication Plan. 3. Dissemination of the standard for the Risk Communication Plan in each territory. Percentage of The objective is to increase the Annual Report PQRSD The MSPS will MSPS citizen percentage of citizen consultations system. report the consultations and claims submitted through the percentage of and claims MSPS's webpage, on time according citizen submitted to the norm. consultations and through the claims submitted internet site of trough the MSPS´s the MSPS web page and solved on time solved on time. according to resolution 3687 of 2016 (PQRSD) Page 46 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Verification Protocol Table: DLIs DLI 1 Children under 5 years old with acute malnutrition identified, reported, and receiving treatment for acute malnutrition in Prioritized Departments. Formula See DLR 1.1 Description See DLR 1.1 Data source/ Agency See DLR 1.1 Verification Entity See DLR 1.1 Procedure See DLR 1.1 DLR 1.1 Number of prioritized departments with children under 5 years old identified, reported, and receiving treatment for acute malnutrition. Formula US$ 5,075,000 per each Prioritized Department, up to US$ 50,750,000. Description The indicator will measure the number of Prioritized Departments that accomplished that at least 90 percent of children under 5 years of age with acute malnutrition notified to SIVIGILA are receiving treatment between January 1 and December 31 of the same year, according to the following formula once in the lifetime of the Program: Numerator: Number of children under 5 years of age with acute malnutrition notified to SIVIGILA from Prioritized Departments receiving Treatment between January 1 and December 31 of the same year. Denominator: Children under 5 years of age notified of event 113 of SIVIGILA from Prioritized Departments between January 1 and December 31 of the same year. Prioritized Population: Children under 5 years of age with acute malnutrition notified to SIVIGILA living in the 12 prioritized departments under the Plan to Accelerate Progress in Reducing Under-five Mortality Due to Malnutrition. Prioritized Departments are: La Guajira, Chocó, Cesar, Bolívar, Antioquia, Arauca, Guainía, Magdalena, Meta, Risaralda, Valle del Cauca, Vichada. Children under 5 years of age with acute malnutrition are defined as: children under 5 years of age with a Z-score of weight/height or length indicator below of -2DE and/or with the phenotypes of severe acute malnutrition (marasmus, kwashiorkor or marasmic kwashiorkor). Treatment means: The IPS has prescribed the FTLC or F75 for children under 5 years of age with acute malnutrition according to MSPS Administrative Resolution 2350/2020. Data source/ Agency The Reporting Units (i.e., ICBF) and/or the Primary data generating units (IPS or TEs) report the cases of children under 5 years of age with malnutrition identified to the SIVIGILA. Children are followed up through the report generated by the EPS on the treatment received (with FTLC or F75) in accordance with the Guidelines for the integrated management of moderate and severe acute malnutrition in children aged 0-59 months stipulated in Resolution 2350 of 2020 and are validated by the MSPS (MSPS Promotion & Prevention Direction Sub-direction nutritional health, food, and beverages) and INS. Verification Entity DNP Procedure Review information on the prescription and provision of treatment with FTLC and/or F75 in a nominal manner and cross- check with the base of event 113. Page 47 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) DLI 2 Reduction of maternal mortality in prioritized territories through an integrated strategy. Formula See DLR 2.1 to 2.3 Description See DLR 2.1 to 2.3 Data source/ Agency See DLR 2.1 to 2.3 Verification Entity See DLR 2.1 to 2.3 Procedure See DLR 2.1 to 2.3 DLR 2.1 Number of prioritized territories with an acceleration plan for reducing maternal mortality that includes implementing a maternal health integrated network. Formula US$ 1,068,421.05 for each prioritized territory with an acceleration plan, up to US$ 20,300,000. Description The MSPS has defined actions to strengthen access to effective healthcare services for pregnant women and newborns under the Plan to Accelerate the Reduction of Maternal Mortality (circular No. 047 of 2022). This indicator measures the number of prioritized territories that include a maternal health integrated network (Hospital Padrino) for articulating and strengthening health delivery capacities in their action Plan. Prioritized territories are: La Guajira, Magdalena, Santa Marta, Barranquilla, Atlántico, Bolívar, Cartagena, Norte de Santander, Córdoba, Cesar, Antioquia, Chocó, Boyacá, Bogotá, Valle del Cauca, Cali, Buenaventura, Cauca, Nariño. Data source/ Agency PARE platform Verification Entity DNP Procedure The inclusion of the territorial strategy in the PARE platform. It will be verified in the platform that the MSPS has designed to host the territorial plans. DLR 2.2 IPS trained in obstetric emergencies based on simulation scenarios Formula US$ 117,115.38 for each IPS trained, up to US$ 15,225,000. Description Based on simulation scenarios, the indicator measures the number of selected IPS trained in obstetric emergencies. Selected IPS are those that concentrate 80 percent of birth deliveries in prioritized territories. Trained IPS accomplished at least two training activities related to obstetric emergencies based on simulation scenarios. Data source/ Agency PARE platform Verification Entity DNP Procedure This will be verified through technical assistance or training acts. Page 48 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) DLR 2.3 ISABEL quality assessment tool used twice yearly in IPSs. Formula US$ 48,798.08 for each IPS assessed (or re-assessed) twice a year, up to US$ 15,225,000. Description The indicator measures the number of selected IPS implementing the ISABEL quality assessment tool twice a year. Selected IPS are those that concentrate 80 percent of birth deliveries in prioritized territories. IPS can implement the ISABEL quality assessment tool twice a year, more than once during the Program's lifetime. Data source/ Agency PARE platform Verification Entity DNP Procedure This will be verified through the publication of the report on PARE platform. DLI 3 Vulnerable women diagnosed with breast cancer with early-stage diagnosis (IIA). Formula See DLR 3.1 Description See DLR 3.1 Data source/ Agency See DLR 3.1 Verification Entity See DLR 3.1 Procedure See DLR 3.1 DLR 3.1 Percentage of vulnerable women diagnosed with breast cancer with early-stage diagnosis (from in situ to IIA). Formula US$ 4,146,241.83 per 0.50 percent increase up to US$50,750,000 in Period 1 from BL and Period 2&3 from the highest previously disbursed result. Description Numerator: Number of women detected with breast cancer in early stages at diagnosis (0 to IIA) included in situ and registered at the individual level. Denominator: Total number of women diagnosed with breast cancer. The indicator will be disaggregated by PPT status of the population and regimen. Data source/ Agency Sources: Periodic information requested by the Regulation of Benefits, Costs and Rates of Health Insurance Direction. Responsible: Regulation of Benefits, Costs and Rates of Health Insurance Direction. Verification Entity DNP Procedure The EPS will report the information in the parameters defined by the MSPS. Quality processes will be performed and verified with the annual information delivered by the CAC within the framework of Resolution 247 of 2014. Normative resolutions: Resolution 247 of 2014, Resolution 3339 of 2019, and the National Cancer Plan Page 49 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) DLR 3.1 similarly supports the continuation of DLR 2.1 indicator under the Improving Quality of Health Care Services and Efficiency in Colombia Program (P169866) and follows its same procedure. DLI 4 Migrants with HIV have accessed effective treatment. Formula See DLR 4.1 Description See DLR 4.1 Data source/ Agency See DLR 4.1 Verification Entity See DLR 4.1 Procedure See DLR 4.1 DLR 4.1 Number of Eligible Migrants with HIV that have accessed comprehensive HIV care according to the verification protocol. Formula US$ 10,715.79 for each Eligible Migrant with access to comprehensive care according to protocol, up to US$50,750,000. Description Number of Eligible Migrants living with HIV that have access to comprehensive HIV care according to verification protocol. Access to comprehensive HIV care according to verification protocol means: a. Receiving antiretroviral drugs in the reporting period; b. Having at least one CD4 lymphocyte and viral load measurement in the last 6 months, and c. Receiving at least one healthcare service from an expert physician during the reporting period. The measurement will be made on the number of Eligible Migrants who initiate treatment with antiretroviral drugs and remain on treatment at the time of the reporting and who meet the other two conditions established above. This indicator will also serve as a reference point for monitoring the progress of the UNAIDS 95-95-95 targets. This indicator is aligned with the GFATM goals for Colombia. Eligible Migrants are defined as those migrants with a PPT or similar document as approved by the Borrower for the regularization of said migrants. The indicator will be disaggregated by gender. Data source/ Agency CAC (or other source of information that replaces it) and Promotion and Prevention Directorate- Sexuality, Sexual Rights and Reproductive Rights Group. Verification Entity DNP Procedure CAC reports or reports from other sources (in case CAC is replaced). Reporting period: February 1 to January 31 of the following year. DLI 5 New infrastructure standards for IPSs, including energy efficiency standards and adaptation and mitigation measures to climate change. Formula See DLR 5.1 Page 50 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Description See DLR 5.1 Data source/ Agency See DLR 5.1 Verification Entity See DLR 5.1 Procedure See DLR 5.1 DLR 5.1 Publication of a new framework of infrastructure standards for IPSs, including social and environmental standards and climate change adaptation and mitigation measures. Formula Administrative act published. Description MSPS administrative act published, associated with implementing health services infrastructure, equipment, and human resources, including climate change adaptation and mitigation requirements, adapted to cultural, geographic and/or environmental contexts, modifying current MSPS Resolution 4445/1996. Specifically, the administrative act that will be issued and/or modified will include climate change adaptation the standards related to: (i) Climate adaptation measures to ensure health facilities are resilient to anticipated climate shocks (i.e. floods and storms) taking measures beyond standard practice; (ii) location and general conditions of health service providers’ facilities, to minimize climate- related hazards exposure; (iii) public services conditions related to water resources and those that guarantee basic sanitation including waste management; (iv) air management conditions in relation to passive natural and mechanical ventilation, as well as aspects of pollution control, prevention and mitigation, to maximize energy efficiency; (v) the use of energy efficient equipment, including lighting, and air conditioning systems; (vi) efficient heating equipment; (vii) vector control and integrated zoonosis management of climate-sensitive diseases conditions; (viii) chemical safety control conditions; (ix) conditions of infrastructure, thermal comfort and management of climatic conditions, and (x) food safety and food control conditions. Environmental sustainability and energy efficiency include using equipment and materials that are at least 20 percent more efficient than standard practice. Such conditions are further detailed in the POM. Data source/ Agency Service Provision and Primary Care Division and Infrastructure Sub-Division. Verification Entity DNP Procedure New or modified administrative acts published in the Official Journal of the Republic of Colombia. DLI 6 Development of a PIGCCS Formula See DLR 6.1 to 6.3 Description See DLR 6.1 to 6.3 Data source/ Agency See DLR 6.1 to 6.3 Verification Entity See DLR 6.1 to 6.3 Procedure See DLR 6.1 to 6.3 Page 51 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) DLR 6.1 MSPS administrative act published, setting up the sectoral committee for climate change management, with functions and responsibilities in formulating and implementing the PIGCCS. Formula Administrative Act published. Description MSPS Administrative Resolution for creating the sectoral committee for climate change management, with functions and responsibilities in formulating and implementing the PIGCCS; published. Data source/ Agency Planning and Sectoral Studies Advisory- Direction of Promotion and Prevention, Environmental Health Sub-direction. Verification Entity DNP Procedure MSPS Administrative Act for the approval of the sectoral committee published in the Official Journal of the Republic of Colombia as further described in the POM. DLR 6.2 MSPS roadmap for the adoption of the PIGCCS approved and published. Formula Publication on the MSPS website. Description MSPS adopted and published the Roadmap for the Adoption of the PIGCCS on its webpage. Data source/ Agency Direction of Promotion and Prevention, Environmental Health, Environmental Health Sub-direction. Verification Entity DNP Procedure MSPS roadmap for adopting the PIGCCS approved and published on the MSPS website. DLR 6.3 MSPS adoption of the PIGCCS. Formula Administrative Act published. Description MSPS Administrative Act with the approval of the PIGCCS. Data source/ Agency Environmental Health Sub-direction. Verification Entity DNP Procedure MSPS Administrative Act with the approval of the PIGCCS published in the Official Journal of the Republic of Colombia. Page 52 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) ANNEX 2. TECHNICAL ASSESSMENT SUMMARY A. Strategic Relevance and Technical Soundness 1. The PDO is directly aligned with the health sector goals as stated in Colombia’s PND for 2023-2026 and with the strategic vision of the MSPS. In fact, the Program addresses each of the specific dimensions included in the health chapter of the PND, aiming at striving “towards a system of universal guarantee, based on a preventive and predictive healthcare model”. Universality is addressed by the special emphasis placed on vulnerable groups often disadvantaged in access to effective health services; actions to strengthen resilience and prevent disruption of health services due to external shocks; and preventive care is emphasized by strengthening PHC at sub-national level, screening, and early diagnosis. 2. The Program is aligned with the WB’s mission to eliminate extreme poverty and boost shared prosperity on a livable planet by supporting Colombia in accelerating progress toward achieving UHC. The Program is closely aligned with the SDGs, which stress the importance of achieving UHC. Furthermore, the proposed Program addresses three of the four focus areas for health identified by the WB: (i) strengthening health systems and pandemic preparedness; (ii) health and climate change, and (iii) nutrition. As such, the actions of the Program, corporate priorities and Government strategies are aligned and take similar views on the most pressing issues for improving health in Colombia. 3. The Program design considers barriers that have prevented Colombia from achieving desired results in the health sector in the past years. On the one hand, structural and long-standing bottlenecks to access to effective health services revolving around PHC capacity and inequality in care provision across the country remain. In addition, the country has experienced several shocks over the last five years that have considerably impacted population health: the COVID-19 pandemic, climate change, and the migration crisis from Venezuela. These factors explain a paradox in Colombia: despite having close to universal access to health insurance (more than 98 percent of the population is enrolled in the SGSSS), the burden of disease remains high, and the financial sustainability of the health sector remains fragile. 4. Poor quality of PHC has translated into a lack of access to effective health services, which is especially high among specific vulnerable population groups. PHC does not fully cover population health needs currently. Although 45 percent of PHC facilities are licensed to provide essential maternal and child health services, only a quarter (26 percent) provide essential services for infectious disease care, and even fewer (19 percent) are licensed to provide specific services for NCDs care. Furthermore, health workers adhere poorly to clinical practice guidelines. Nearly 35 percent of pregnant women do not receive HIV counseling and testing, 49 percent of women aged 20 to 69 do not receive cervical cancer screening, and 33 percent of women aged 50 to 69 do not receive a mammogram as required by clinical practice guidelines. 39, 40 5. Poor access to effective health services is especially troublesome among the vulnerable population. While only one percent of Colombians in the SGSSS contributory regime report facing financial barriers to healthcare, the percentage goes up to 12 percent in the subsidized regime. 41 The Atlas of Health Inequality in Colombia paints a broad picture of inequalities in access to care. While the prenatal care rate among the top income quintile reaches 92 percent, it is only 76 percent among the bottom quintiles. While care for depression is 740 for every 100,000 in the top quintile, it is only 140 39 Ministerio de Salud y Protección Social. Observatory for Quality of Care in Health (OCAS). 2018 40 Ministerio de Salud y Protección Social. Report for Resolution 4505. Technical Annex No. 1. 2018. 41 Departamento Administrativo Nacional de Estadística. (2017). Encuesta de Calidad de Vida de Colombia 2017. Page 53 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) per 100,000 in the bottom quintile. 42 6. Recent global and regional shocks such as COVID-19, climate change, and Venezuelan migration have aggravated long-standing structural flaws in the Colombian health system. In Colombia alone, more than 142 thousand people died from the disease, and it is estimated that around $50 billion USD (16 percent of GDP in 2019) were lost mainly due to disruption of economic activity, unemployment and decline in tourism. 7. The Program is structured to respond to these challenges by introducing two RAs focused on improving access to effective health services and improving health system resilience. The first RA supports actions to strengthen primary care and early-stage interventions across a range of critical health conditions. As such, interventions seek to promote screening, monitoring and access to treatment for child malnutrition, maternal morbidity, breast cancer and HIV, with a focus on prioritized territories and vulnerable populations such as migrants. The second RA supports actions to build health system resilience against climate change and public health threats by supporting the strengthening of public health surveillance and infrastructure, as well as efforts to mitigate and adapt to the impacts of climate change. Table A2.1 below outlines how the Program’s DLIs contribute to climate change adaptation and mitigation. Table A2.1. Interventions addressing Program climate-related vulnerabilities DLI and Climate-Related Description Financing Amount DLI 1. Children under 5 years old Malnutrition is a climate-sensitive disease in Colombia, especially in departments such as La with acute malnutrition Guajira, which is affected by severe droughts, having individual follow-up strategies, enabling real- identified, reported, and time detection for acute and chronic malnutrition, is critical to treating affected children and receiving treatment for acute reducing their vulnerability to future food security risks, thereby strengthening the country’s malnutrition in prioritized resiliency to climate-related risks. departments (US$50.75 million) DLI 2. Reduction of maternal This DLI includes having in place a tele-expertise or tele-support process that would ensure the mortality in prioritized provision of health services for pregnant women in the face of climate or natural hazards. This territories through an integrated would reduce the vulnerability of pregnant women to climate change and increase the resilience strategy (US$50.75 million) of health service delivery mechanisms. DLI 5. New infrastructure New infrastructure standards for IPSs will include measures that strengthen health facilities’ standards for IPSs, including infrastructure in the face of climate-related hazards while also ensuring quality of care. These energy efficiency standards and standards will incorporate measures outlined in the Green Hospital Guidance Note developed by adaptation and mitigation MSPS. In detail, the new infrastructure standards will provide codes for: (i) the location of the measures to climate change facilities accounting for climate-related and natural hazards such as floods or landslides, or any (US$50.75 million) other hazard that can affect the stability and functions of the facility; (ii) general requirements for the construction of healthcare facilities, including measures for potable water, water tanks and reserves for water provision in the face of climate or natural hazards or other health emergencies, water treatment, waste management, and atmospheric pollutants, ensuring the use of materials with low-embedded GHG emissions; (iii) general requirements for the design of facilities, including measures for environmental sustainability and energy efficiency: (a) the use of equipment and materials that are energy efficient, being at least 20 percent more efficient than standard practice; (b) building design for lower energy consumption, i.e. natural ventilation and lighting, to reduce cooling and illumination needs for buildings, and air conditioning use and costs; (c) energy Atlas of Health Inequality in Colombia. Atlas Nacional de Equidad en Salud Sostenible: Colombia. Washington, D.C.: Organización Panamericana de la Salud y 42 Ministerio de Salud y Protección Social de Colombia; 2022. Licencia: CC BY-NC-SA 3.0 IGO. Available here Page 54 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) management systems such as sensor-controlled lighting and equipment specifications to reduce consumption and GHG emissions; (d) efficient heating equipment to reduce consumption and GHG emissions, and improve production and distribution of hot water, ensuring that how water is 100 percent being provided by solar energy, and (e) collection and use of rainwater for irrigation of green areas, and for reducing overall water use; (iv) conditions of the facilities for health service provision; (v) characteristics of the general offices within the facilities; (vi) special characteristics for infrastructure by health service. This will include norms for emergency rooms in healthcare facilities, which are critical for response mechanisms of the health system in the face of climate hazards; (vii) environmental sustainability and infrastructure, including at least 30 percent of external spaces being plant-covered to reduce the heat island effect, at least 5 percent of parking space for bikes, and 10 percent for electric vehicles, adoption of LED lights or any other that is more efficient, the use of solar energy for basement and parking spaces; (viii) infrastructure consideration for health-related educational facilities, and (ix) surveillance and vector control standards, which are critical for the management of climate-sensitive diseases such as dengue, malaria, and cardiovascular and respiratory diseases. The standards will be aligned with Criteria 9.1 of the ‘Buildings, public installations and end-use energy efficiency’ section of the of the Multilateral Development Bank Mitigation Finance Methodology. DLI 6. Development of the This DLI supports the development of the PIGCCS through: (i) carrying out a baseline assessment PIGCCS (US$50.75 million) of GHG emissions of the health sector at the healthcare facility level; (ii) establishing the sectoral committee for climate change management, with functions and responsibilities in the formulation and implementation of the PIGCCS (DLR 6.1); (iii) elaborating the roadmap for the adoption of the PIGCCS (DLR 6.2), and (iv) publishing the action plan to implement the PIGCCS (DLR 6.3). B. Program Goals and Results Chain RA1: Access to effective health services among the vulnerable population 8. Child acute malnutrition. In response to rising and alarming increases in child mortality due to acute malnutrition, which was responsible for 308 deaths among children under 5 years in 2022, the Government has prioritized efforts to identify, treat, and monitor acutely malnourished children, a majority of whom are concentrated in the country’s poorest departments of La Guajira, Chocó, and parts of Antioquia. The Program will support those efforts through actions critical to ensuring adequate follow-up of individual cases to reduce nutrition-related mortality. Activities include support to the development of a nominal information system that allows identification (IRI) and real-time tracking of malnourished children from diagnosis through treatment (DLI), providing the opportunity for targeted follow-up actions as needed. 9. Maternal Health. Increases in maternal mortality in Colombia, primarily due to hypertension, obstetric sepsis, and unsafe abortion, are equally troubling. Most cases are concentrated in poorer departments and bottom income quintiles among populations in Chocó, Arauca, La Guajira, Nariño, Magdalena, Norte de Santander, Bolívar, and Cauca. 43 The maternal mortality inequality also correlates with unequal access to prenatal care: while 91.5 percent of pregnant women in the top income quintile have at least one prenatal control, the percentage goes down to 77 percent among pregnant women in the bottom quintile. 44 This has led the Government to develop the National Plan to Accelerate Reduction of Maternal Mortality, which the proposed Program would support. Activities include: (i) the development and implementation of a maternal mortality care network Strategy (DLI) that enables the identification of a maternal mortality 43 Plan de aceleración para la reducción de la mortalidad materna. 44 Atlas of Health Inequality in Colombia. Atlas Nacional de Equidad en Salud Sostenible: Colombia. Washington, D.C.: Organización Panamericana de la Salud y Ministerio de Salud y Protección Social de Colombia; 2022: CC BY-NC-SA 3.0 IGO. Available here Page 55 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) care network at the territory level, and (ii) the implementation of an information system to monitor cohorts of pregnant women, including telemedicine consultations with reference hospitals in the care network for extreme cases (IRI). 10. Breast Cancer. In recent years, breast cancer has become a serious public health problem for women in Colombia, having the highest incidence (37.5 per 100,000 women) and mortality (11.3 per 100,000 women) among all cancer pathologies among women between 2012 and 2016. 45 This is partly because screening and early detection rates worsened during the pandemic. The Program supports the Government’s Plan to Accelerate the Reduction of Breast Cancer, which aims to increase the breast cancer screening rate among vulnerable women (IRI) and the rate of early detection of breast cancer among vulnerable women with a positive diagnosis (DLI). 11. Migrants living with HIV. The 2.9 million Venezuelan migrants living in Colombia are exposed to dire socioeconomic conditions and poor access to the health system, increasing their risk of morbidity and mortality. This is the case with HIV: prevalence among migrants is double that of the native population (0.9 percent and 0.5 percent, respectively). 46 Thus, the Government is prioritizing the regularization of migrants and providing them with access to the health system. The Program seeks to support these efforts by: (i) advancing centralized procurement of generic antiretrovirals; (ii) increasing screening of migrants for HIV (IRI), and (iii) promoting access to effective treatment among migrants with HIV (DLI). 12. Primary Healthcare. In Colombia, access to health promotion, preventive care and screening at the primary level does not fully cover the population's health needs. The MSPS is committed to rolling out a program of mobile, extramural, multidisciplinary health teams tasked with screening vulnerable households for specific health risks and ensuring that high-risk households have access to PHC services that implement integrated and comprehensive strategies to address priority public health issues. The Program provides explicit support to the multidisciplinary primary healthcare strategy through an IRI on the number of multidisciplinary teams operating on the ground, the number of women victims of sexual violence who receive mental health services, and the number of people screened for mental health services by primary healthcare providers and basic health teams. RA2: Strengthening Health System Resilience 13. Climate Change. Given the vulnerability of Colombia’s population and health infrastructure to climate hazards from extreme weather events such as intense flooding, combined with a thirty percent increase in the last decade in emissions from the healthcare sector, the PforR is supporting the implementation of a new framework of infrastructure standards for IPS including energy efficiency standards and adaptation and mitigation measures to climate change (DLI). In the context of the new health model, public and private low, medium, and high healthcare providers; the integrated healthcare networks (Redes Integradas de Servicios de Salud, RISS) must supply services or make agreements to provide quality, equitable, comprehensive, integrated, timely, and continuous healthcare in a coordinated and efficient manner. The RISS must guarantee an infrastructure adequate to the geographic and population conditions oriented not only to guarantee the quality and safety of the patient but also by the criteria of adaptation to climate change. The Program, therefore, also includes support to (i) increase the number of primary healthcare facilities implementing this new framework for infrastructure (IRI), and (ii) implement the Integral Plan for Climate Change Sectoral Management (IRI). 45 Colombia National Public Health Institute. 2022. 46 UNAIDS Page 56 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 14. Future pandemics. Colombia´s public health surveillance and laboratory network were under significant stress during the COVID-19 pandemic. The Program proposes increasing the percentage of Territorial Entities that adopt a Risk Communication Plan for public health emergencies with the One Health and Climate Change approach as an IRI. C. Monitoring and Evaluation 15. The monitoring and evaluation data provided by internal and public sources are largely reliable. The progress of indicators related to regulatory changes will be verified in the official journal of the Republic of Colombia, which publishes legal acts and public notices of the President, Congress, and Government agencies. Data for quantitative indicators will be obtained from several databases, including the SISPRO information collected by the CAC database from healthcare providers and health insurance companies, SIVIGILA, information collected to comply with Administrative Act 202 of 2021, RIPS, SISCO, as well as several other administrative data sources as detailed in the verification protocol (Annex 1). Qualitative indicators will be monitored according to the verification of milestones and processes described in the verification protocol (Annex 1). D. Institutional Arrangements 16. The Program will be implemented by the MSPS, which will provide oversight of Program execution. The MSPS will coordinate high-level program coordination with other actors involved in Program implementation. Within the MSPS, Program coordination will be coordinated through the office of the Minister of Health, who will appoint a PC. The PC will work with an interdisciplinary technical team in charge of coordinating Program implementation with the two vice- ministries of the MSPS, divisions, sub-divisions, and other departments of the MSPS involved in Program implementation. The PC will be responsible for: coordinating data collection to monitor indicator performance and reporting of DLIs; and coordinating the external verification of indicators with the DNP. Relevant departments responsible for the achievement of Program results within the MSPS and other participating entities will identify a team of one or two key staff members as focal points. These focal points will supervise Program implementation in their areas of competence and ensure timely and close coordination with the PC to achieve the DLI targets. The Program coordination team is staffed with the PC and technical staff members with adequate capacity to support Program implementation. The financial matters will be coordinated through the Health Sector Financing Division, including reporting on the financial statements and submitting disbursement requests to the MHCP. Other responsibilities for Program implementation are defined in Table A2.2 below. Table A2.2. Role and Responsibilities of Entities linked with the Program Responsible Responsibility in Program Implementation. entity ADRES 47 ADRES is responsible for administrating the health system resources and payments according to the information provided by the consolidated database of people enrolled in the SGSSS managed in the MSPS. EPS The EPS is responsible for providing health insurance schemes to the population. The EPS receives the UPC from ADRES, times the number of persons that they insure. Territorial The territorial entities are responsible for planning healthcare services and public health at the department and entities municipal levels and supervise public hospitals and PHC. 47ADRES is a decentralized organization associated to the MSPS, with administrative and financial autonomy and independent assets. ADRES operates in a similar way to a private institution. Its legal framework is established in article 66 of Law 1753 of 2015. Page 57 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) CGR The CGR is responsible for conducting annual financial audits of the MSPS; as well as of ADRES; covering the Program transfers made by the MSPS to ADRES and the BDUA. 17. The DNP is legally responsible for monitoring the performance of the indicators defined in the PND. As the Program results framework indicators and DLIs are aligned with those in the PND, the DNP will be the independent agency responsible for conducting the external verification and reporting of DLIs compliance in accordance with the verification protocols agreed with the MSPS and reflected in the POM. The DNP is an Administrative Department reporting directly to the Presidency of the Republic; as part of its functions, the DNP is responsible for planning, evaluating, and coordinating the actions required for the implementation and development of the National System of Evaluation of Management and Results. DNP is also responsible for the evaluation of public policies and for strengthening results-oriented management at national and territorial levels. In this sense, it must develop and implement mechanisms for monitoring and evaluating the impacts of programs and projects executed by national and territorial Government institutions. E. Program Expenditure Framework 18. Colombia stands out for its growing share of health expenditure. By 2011, total health expenditure amounted to 4.8 percent of GDP, growing steadily until reaching 7.1 percent of GDP in 2021, above the minimum level suggested by the WHO for public investment in health necessary to achieve UHC (6 percent). As per WHO Health Accounts, by 2019, Colombia’s health expenditure (7.7 percent) had surpassed the average in the region (6.7 percent), although it is still below the average for OECD countries (12.5 percent). In Purchasing Power Parity terms, total health expenditure in Colombia amounted to $1,204 per person, compared to $1,161 average in LAC and $5,528 in OECD. Source: World Bank, 2022 Source: World Bank, 2022 19. More importantly, the share of public expenditure on health is significant. For the past decade, the share of health expenditure financed by the Government has exceeded 70 percent, reaching 72 percent in 2019. This stands out as it significantly surpasses the share of public expenditure in health both in LAC countries (55.6 percent) and in OECD countries (61.7 percent). Conversely, domestic private expenditure share is smaller in Colombia than for LAC and OECD averages. In addition, health also stands out as a priority as compared to other sectors. It comprises 16.8 percent of total public expenditure, compared to 13.5 percent in LAC and 18 percent in OECD countries. Page 58 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Source: World Bank, 2022 Source: World Bank, 2022 20. This high level of total and public expenditure largely explains UHC in Colombia. Currently, 98 percent of the population is enrolled in mandatory health insurance. This has resulted in widespread health financial protection for Colombia’s population, with out-of-pocket expenditure oscillating around 15 percent of total health expenditure for the past decade. This more than halves the out-of-pocket average in LAC of 33 percent of total health expenditure and is close to the OECD’s average of 14 percent. Source: World Bank, 2022 Source: World Bank, 2022 21. Program Boundaries. The PforR will support priorities for the health sector included in the PND 2023 – 2026 under the Human Security and Social Justice and the Human Right to Food transformative lines. These priorities are organized under three components and subcomponents of the two transformative lines. The three components for the health sector are: (i) guaranteed access to a universal system based on a predictive and preventive healthcare model; (ii) mental, physical, and social well-being of individuals, including environmental health and climate change adaptation and mitigation interventions, and (iii) healthy nutrition practices appropriate to the life course, populations, and territories. Table A2.3 below presents the full scope of the health priorities under the PND 2023-2026, as well as the Program boundaries and the focus of the two proposed RAs. Detailed Program activities are described in the Program theory of change. Page 59 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Table A2.3. Scope of the Government program PND for Health 2023-2026 and the PforR PND Health 2023- 2026 PforR RAs 48 Transformative Subcomponent Activities Lines and Components 1. Human Security and Social Justice Guaranteed access a. PHC based on a (i) Territorialized interdisciplinary teams; (ii) comprehensive RA.1 Access to to a Universal preventive and and integrated care networks; (iii) strengthening public hospital Effective Health healthcare system predictive model. network, and (iv) Healthcare workers policy. Services. based on a preventive and predictive b. Social (i) Sexual and reproductive rights policy; (ii) promotion of RA.1 Access to healthcare model determinants of healthy habits focusing on life course; (iii) public health actions Effective Health health. to reduce NCDs; (iv) early detection, prevention, timely access, Services. and control of cancer; (v) strengthening the resilience capacity RA.2 Resilience of of the health system, and vi) update of the immunization the Health System. program. c. Health Sector (i) Decentralization of surveillance and control; (ii) RA.1 Access to Governance, and improvement of the public health and sanitary surveillance Effective Health stewardship, and system; (iii) institutional strengthening of Government and Services. improved capacities government agencies, and (iv) interoperable information RA.2 Resilience of in digital health and system and expanding digital health. the Health System. information systems. d. Sustainability of (i) Review of healthcare spending; (ii) strengthening of the RA.1 Access to health resources. payment system; (iii) health taxation; (iv) co-financing by Effective Health departments to serve migrants, and (v) alignment of funding Services. needs with healthcare needs. e. Equal access to (i) New pharmaceutical policy; (ii) initiatives to produce RA.1 Access to medicines, medical strategic health technologies; (iii) generic drug promotion; (iv) Effective Health devices, and other centralized procurement strategy; (v) price regulation; (vi) Services. technologies. human talent qualification; (vii) patent policy, and (viii) information systems for medicine supply. f. Science and Technology for Health and Health Innovation Policies. 48Table A2.3 shows the Program boundaries in relation with the PND health priorities under the three Components and Subcomponents; to this end, the activities under each subcomponent are covered partially by the PforR. Detailed Program activities are described in the Program theory of change. Page 60 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Physical, mental, a. Promotion, (i) Update the current policy, and (ii) expand coverage of RA.1 Access to and social wellbeing prevention, and psychosocial rehabilitation, particularly in the most remote Effective Health of the population comprehensive care areas. Services. of mental health disorders. b. Health, (i) Contribution to climate change adaptation and mitigation RA.2 Resilience of environment, and through Research, inspection, surveillance & control for climate the Health System. climate change. change adaptation and mitigation; (ii) social mobilization with a focus on climate justice; (iii) action plan of integrated environmental health policy (PISA); (iv) health regulation for productive and infrastructure projects, and (v) environmental standards for the protection of the health of people and communities. c. Road Safety 2. Human Right to Food Healthy nutrition a. Promotion of (i) Ten-Year Breastfeeding and Complementary Nutrition Plan, RA.1 Access to practices breastfeeding and and (ii) Food-Based Dietary Guidelines. Effective Health appropriate to the complementary Services. life course, feeding. populations, and territories b. Healthy nutrition. (i) Food and Nutrition Education strategy for the life course, and RA.1 Access to (ii) food and beverages regulation for children and adolescents. Effective Health Services. c. Food promotion and traditional cuisines. d. Overcoming (i) Careful feeding and nutrition practices and prevention of RA.1 Access to malnutrition. nutritional disorders from pregnancy to adolescence; (ii) Effective Health models and prediction exercises based on social determinants Services. to prioritize territories, and (iii) national monitoring system for overcoming malnutrition. e. Safe water supply throughout the national territory. Source: PND 2023-2026 22. The proposed PforR is aligned with the main priorities of the PND and structures them into two RAs. RA1 seeks to improve access to effective health services for vulnerable populations. Complementarily, RA2 aims to enhance health system resilience in the face of Climate change and public threats. As such, the PforR focuses on: (i) improving access to a universal model of care, emphasizing the importance of disease prevention, health promotion and risk screening for vulnerable populations, including children under five with malnutrition, vulnerable pregnant women, women at risk of Page 61 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) breast cancer, and migrants; (ii) addressing malnutrition for children under five years of age; (iii) promoting equitable access to medicines and technologies, and (iv) strengthening environmental health and climate change adaptation and mitigation processes through research, inspection, surveillance and control, policy management, participation, and social mobilization with a climate justice approach. 23. Expenditure Framework. The total projected public resources for the health sector from the Central Government, according to the country’s Medium-term Fiscal Framework for the period 2023-2026 is 117 COP$ trillion, equivalent to USD 24,893 million. The PforR will marginally support two of the main budget lines of the MSPS: (i) health insurance claims and health services, which represent close to 98 percent of the program’s budget, and (ii) salaries, as shown in Table A2.5 below. 24. The first budget line finances insurance premiums for vulnerable populations within the SGSSS subsidized regime for 2023-2026. Resources in this budget line are managed and executed by ADRES, which pools resources from the MSPS, subnational governments, and other earmarked sources and, in turn, finances the SGSSS subsidized regimen. In turn, through specific DLIs, the Program targets malnourished children, women of reproductive age, women at risk of breast cancer, and migrants. Hence, the Program only supports a fraction of per capita premium allocation that is proportionate to this beneficiary population. 49 This fraction of the total per capita premium allocation for four years (2023- 2026) amounts to USD 1.6 billion. Table A2.4 below shows the breakdown by year and targeted group. Table A2.4. Total Insurance premium -per capita- for prioritized vulnerable groups in the Subsidized Regime Vulnerable Group Million USD 2023 2024 2025 2026 Total Malnourished children 62 63 65 67 258 Pregnant women 143 141 139 137 561 Breast cancer 5 6 7 7 25 Migrants 165 182 200 220 768 Total 376 393 411 432 1,611 25. The second budget line is transversal to the Human Resource component across both focus areas in the PforR. The MSPS administers the line and covers 50 percent of all salaries allocated by the MSPS during the period 2023-2026 as deemed necessary to support the implementation of the first line. The resulting amount for this line is US$36 million. 26. These two budget lines comprise the total Government funding within the PforR to which the WB is making significant contributions. Out of the total US$ 1.647 billion, US$ 1.611 billion is allocated to per capita premiums in the SGSSS subsidized regime and US$ 36 million for salaries to support the implementation of the previous line. In sum, total financing in the PforR is disaggregated into US$ US$1.647 billion from Government resources, US$300 million from WB financing and US$4.5 million from donor financing. This means that WB financing and additional grant financing amount 49 The Program covers 4.72 percent of the Insurance premium -per capita- within the SGSSS subsidized regime (2023-2026), which is equivalent to the amount for prioritized vulnerable groups. Page 62 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) to 18.48 percent of the Government’s contribution to the PforR as shown in Table A2.5 below. Table A2.5. PforR Expenditure Framework 2023-2026 PforR Expenditure Framework Executing Operation WB and Grant Financing and % of Entity Financing total Operation financing US$ Million US$ Million % PforR (i) Insurance premium (UPC) for ADRES 1,611 prioritized vulnerable groups in the subsidized regime (ii) Salaries MSPS 36 Total 1,647 304.5 18.48% 27. The funding for the Program is adequate, sustainable, and aligned with the intended results under the Program’s Result Framework. The activities and expenditures under the Program will be funded from the budget assigned by the MHCP to the MSPS. In addition to normative commitment expressed in the PND and its companion Pluriannual Investment Plan, historical analysis of budget execution demonstrates sustainability over the years. In addition, there is high rigidity and political pressure in maintaining budget execution commitments, particularly along the first budget line, as it pays for the health expenses of the population affiliated with the SGSSS. The MSPS is constitutionally mandated to pay for those affiliated with the subsidized regime. In its sentence T‐760 of 2008, the Colombian Constitutional Court ordered the MSPS that benefits provided to the subsidized regime should match those provided under the contributive regime. Economic Justification of the Program 28. Economic analysis of the Program, through cost-benefit estimation, yields positive results for the proposed investments. The Cost-benefit Analysis (CBA) expresses costs but also benefits in monetary terms, adjusted for the time value of money, and is mainly used to determine the soundness and rationality of investment decisions and allows for comparison with other projects. The CBA proposed here follows three main steps: (i) identification of the Program’s interventions to be analyzed, which in this case are related to DLIs; (ii) identification of costs related to each intervention, and (iii) estimation of the difference between the NPV of both costs and benefits, also called the net benefits of the Program. The latter is also represented in monetary terms to compare monetary costs and benefits accrued in population health. 29. The costs of the Program are represented by the total proposed financing for activities and the operating cost included in the two RAs. Program total financing amounts to US$304.5 million, divided into US$ 203 million for RA1 for improving access to effective health services for vulnerable populations and US$ 101.5 million for RA 2 for enhancing the resilience of the health system to climate change and public health threats. Financing of RA1 includes: (i) reaching 90 percent of notified cases of acute infant malnutrition in prioritized regions that receive treatment (US$50.75 million); (ii) 100 percent of prioritized departments that implement the Maternal Network integrated care strategy (US$ 50.75 million); (iii) 57.5 percent of vulnerable women diagnosed with breast cancer with early-stage diagnosis (US$50.75 million), and (iv) 7,100 eligible migrants with HIV that have accessed to effective treatment according to protocol (US$ 50.75 million). Financing for RA2 includes: (i) the approval of a new framework of infrastructure and mandatory enabling standards for health service provision, including social and climate change adaptation standards adopted (US$ 50.75 million), and (ii) Page 63 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) the development of a PIGCCS for the Health Sector (US$ 50.75 million). By Q1 of 2025, it is planned that all financing for RA 2 will be disbursed, while financing for RA1 will be fully disbursed by 2026 Q3. Likewise, for the operating cost, an additional 10 percent of the total cost of the investment per year has been considered for each DLI, applying it from the first year of investment. 30. Benefits accrued from RA1 are estimated by the monetary value of reduced burden of disease in the population. To carry out such estimation, first, it is necessary to estimate the effectiveness of proposed activities and targets in reducing the burden of disease (DALYs). For this purpose, each intervention's effectiveness parameters were collected from previous similar experiences recorded in the literature. To estimate the total number of DALYs averted by the interventions, the effectiveness parameters are applied to four baseline scenarios of projected DALYs for child malnutrition, maternal morbidity, breast cancer, and HIV in migrants in a 20-year period in the absence of the Program interventions. The four projection scenarios are based on the trend of estimated DALYs by the Institute for Health Metrics and Evaluation in the Global Burden of Disease study for the conditions above from 2000 to 2019, as shown below. 50 At last, total DALYs averted in the 20-year period are brought into monetary terms by setting the equivalence of a DALY to the average daily GDP per capita as projected by the IMF World Economic Outlook. Total benefits accrued from interventions in RA1 amount to 110,866 DALYs, equivalent to US$3.7 billion between 2024 and 2044. 31. Conversely, interventions in RA2 generate economic benefits from avoiding infrastructure damage from natural disasters and the increased burden of disease during the interruption of services. Operation and infrastructure standards promoted by the Program under RA2 ensure that the physical integrity and healthcare delivery service are not affected by the regular occurrence of natural disasters in Colombia, including flooding and landslides. According to previous WB analysis, 4.416 PHC facilities and 143 hospitals are exposed to disruptive flooding, while 549 PHC facilities and 20 hospitals are exposed to high-risk landslides. By analyzing historical trends in infrastructure damage from natural disasters in Colombia, it is estimated that, on average, US$ 22.8 million in health infrastructure are affected annually. A baseline scenario of 80 percent effectiveness of the measures promoted in DLI 5 and DLI 6 would produce up to US $272 million of savings between 2024 and 2044. 32. The additional benefit flows from both focus areas total US$ 4 billion until 2043, which is utilized to estimate a series of metrics to evaluate the economic viability of the Program. First, the total cost and total accumulated benefits of the Program during its three years of implementation are brought to NPV— the total of US$304.5 million to be disbursed throughout the Program’s cycle amounts to US$358 million in NPV, while the NPV of the total expected flow of benefits is US$4.07 billion. This yields an NPV of US$ 3.71 billion. This translates into an IRR of 291 percent and a benefit-cost ratio of 11. In addition, benefits can be expressed directly in better health outcomes for the population, amounting to 110.866 DALYs averted between 2024 and 2044, which amounts to 15.2 percent of the total country’s burden of disease in 2019. Under the analysis parameters, the Program has a strong economic justification based on a significant economic surplus in NPV. 50 Institute for Health Metrics and Evaluation. Global Burden of Disease Study (2019). Available here Page 64 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Table A2.6. Cost-Benefit Indicators for Economic Justification NPV Costs US$358,327,875 Discounted DALYs savings value US$3,800,711,574 Discounted monetary savings value US$272,344,325 NPV Benefits US$4,073,055,899 IRR (first 20 years) 291% BENEFIT COST RATIO 11 NPV SURPLUS US$3,714,728,024 TOTAL DALYs SAVED 110,866 % DALYs 2019 15.20% 33. A sensitivity analysis was conducted to test the robustness of the positive economic outcomes of the estimation by estimating Program benefits under less favorable scenario assumptions. The estimation considers several assumptions, including the effectiveness rate of various activities. As listed in the table below, these effectiveness rates translate into the percentage reduction of DALYs for targeted conditions in DLIs 1, 2, 3, and 4 and for mitigation of infrastructure damage for DLIs 5 and 6. Similarly, the base scenario utilizes a discount rate of 3 percent. The discount rate is the rate at which future benefits and costs are discounted. To test the robustness of the Program’s results under less favorable assumptions, a sensitivity analysis is conducted in which the assumptions are stressed to yield fewer positive results. A similarly plausible positive scenario is projected for benchmarking purposes. The parameters tested for each scenario are also listed in the table below. Results, included below, continue to yield positive results for the Program. The low scenario still yields a positive NPV of US$ 2.5 billion, an IRR of 207 percent, a benefit-cost ratio of 8.82, and a total of 92.119 DALYs averted (12.6 percent of 2019 burden of disease). Conversely, the highest scenario yields a positive NPV of US$4.8 billion, an IRR of 378 percent, a benefit-cost ratio of 14.19, and a total of 129.613 DALYs averted (17.8 percent of the 2019 burden of disease). Table A2.7. Results CBA with scenarios Low Sc (worst High Sc Medium Sc Base SC case) (best case) NPV Costs (M$) 320 338 358 366 Discounted DALYs savings value (M$) 2,715 3,222 3,801 4,812 Discounted Monetary savings value (M$) 104 184 272 374 NPV Benefits (M$) 2,819 3,405 4,073 5,186 IRR (first 20 years) 207% 251% 291% 378% Benefit Cost Ratio 8.82 10.07 11.37 14.19 Surplus (M$) 2,500 3,067 3,715 4,821 Total DALYs saved 92,119 101,492 110,866 129,613 % DALYs 2019 12.6% 13.9% 15.2% 17.8% Page 65 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Table A2.8. Sensitivity analysis scenarios Concept Low Medium Base High (worst case) (best case) Discount rate savings 9.00% 6.00% 3.00% 2.00% Discount rate DALY'S 5.00% 4.00% 3.00% 2.00% DALY REDUCTIONS DLI1 Child Malnutrition Annual reduction in DALY's child malnutrition 13% 14% 15% 17% DLI2 Maternal morbidity Annual reduction in DALY's maternal morbidity 1% 2% 3% 5% DLI4 Migrants with HIV Annual reduction in DALY's migrants HIV 3% 4% 5% 7% DLI3 Breast cancer Annual reduction in DALY's breast cancer 0% 1% 2% 4% MONETARY REDUCTIONS DLI5 and DLI6 PHC Infrastructure and Climate Change Effectiveness in mitigating infrastructure damage 50% 70% 80% 100% Technical Risks and Mitigation Measures 34. Technical Design Risks. The technical design risk is rated as moderate. The operation will support an ongoing Program that does not contemplate radical design changes to the system. Several regulatory changes are expected to be implemented by the MSPS, which has shown technical proficiency in conducting these tasks, to comply with the indicators. Furthermore, the activities supported are part of the PND. 35. Institutional capacity for implementation and sustainability risks is rated as moderate. As mentioned above, the PforR will support an ongoing Government program and no institutional changes are expected from this operation. In addition, this is the second PforR with the MSPS in Colombia, meaning there has been a valuable accumulation of experience and lessons. In addition, ADRES has become an experienced institution since its creation in 2015. 36. An implementation support and capacity-building plan will be elaborated to mitigate these risks. A PC will be appointed to ensure the day‐to‐day implementation of the relevant milestones related to the DLIs, and a team of key staff will be designated as the focal point in the relevant departments of MPSP and ADRES to ensure timely coordination for the activities to support the achievement of the DLI targets. In addition, implementation support and key capacity-building activities will be provided through: (a) the implementation support budget and (b) the use of Trust Fund resources. Resources from the GFATM will support activities related to HIV screening and treatment among migrants. Page 66 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) ANNEX 3. FIDUCIARY SYSTEMS ASSESSMENT SUMMARY Section 1. FSA Summary 1.1 Reasonable assurance 1. An assessment of the Program’s Fiduciary systems capacity and performance has been conducted 51 and its conclusions are reflected below. The Fiduciary System assessment (FSA) has been carried out for the MSPS and the ADRES, as they are responsible for the administration of the health system resources and payments (onwards Program executing entities). The assessment considered the executing entities’ fiduciary capacity and performance for the last three (3) years and the satisfactory fiduciary capacity and performance of the WB’s first health sector PforR for Colombia - Improving Quality of Health Care Services and Efficiency in Colombia Program (P169866). According to the Program expenditure framework, no procurable activities were identified. The conclusion of the assessment is that, overall, the Program fiduciary systems’ capacity and performance, with the implementation of the proposed mitigation measures and agreed actions to strengthen the systems (reflected in the FSA - section 4), are adequate to provide reasonable assurance that the Program funds will be used for the intended purposes, with due attention to the principles of economy, efficiency, effectiveness, transparency, and accountability. 52 2. The current PforR (P169866), which has disbursed over 76 percent of total loan proceeds during the first two years of implementation, has had a satisfactory fiduciary performance. The MSPS reported Semiannual unaudited financial reports on budget execution to the World Bank within the agreed deadlines and content. The Colombia Supreme Audit Institution (Contraloría General de la República, CGR) has executed annual audits of the two implementing entities, in accordance with the provisions of the Memorandum of Collaboration (MoC) between the World Bank and the CGR; audit reports have included unmodified audit opinions for MSPS and ADRES’s Financial Statements and Budget execution; these audits did not disclose any material weaknesses or audit findings for the Program. The MSPS and the ADRES have formulated improvement plans for the CGR’s findings, which are monitored on a quarterly basis in the CGR’s Integrated Management System. The fiduciary Program Action Plan (PAP) has been executed as established; the MSPS and the ADRES, periodically follow up on the CGR improvement plans and other actions; the MHCP has approved the reclassification of budget financing source for each Bank payment. Findings derived from the special audit of the BDUA 53 were closed as of December 31, 2021, and the improvement plan was assessed by the CGR as satisfactory. 51 WB Policy dated November 2017, WB Directive dated September 2020, WB Guidance PforR FSA Guidance Note dated June 2017; and Interim Guidance Note Systematic Operations Risk-Rating Tool (SORT) dated June 25, 2014. 52 The objective of the FSA is to determine whether the Program fiduciary systems provide reasonable assurance that the financing proceeds will be used for the intended purposes, with due attention to the principles of economy, efficiency, effectiveness, transparency, and accountability. The FSA also is identifying development activities to support the Program’s implementation and/or as risk mitigation measures to counter against key fiduciary risks, to be included in the Program Action Plan. The FSA entailed a review of the capacity of the participating entities with respect to their ability to: (a) record, control, and manage all Program resources and produce timely, understandable, relevant, and reliable information for the Borrower and the WB; (b) ensure that implementation arrangements are adequate; and (c) identify and address risk of fraud and corruption and effectively handle public grievances and complaints. 53 BDUA: It is a single database of people covered by the health insurance system, database of affiliation. Page 67 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 1.2 Risk Assessment 3. The overall integrated fiduciary systems risk to the achievement of the PDO is assessed as Moderate. The Program and the executing entities are governed by the PFM country system, which has been satisfactorily assessed in previous FSA, 54 in the latest PEFA assessment, 55 and during supervision of the current PforR Program (P169866). However, the following factors identified during the FSA pose a moderate element of risk: first, the recent draft legislation presented by the Government to Congress increases inherent risks to the Program fiduciary systems performance due to the uncertainty of: (a) the Program flow of funds and the budget lines could be modified; (b) the possible changes of the regulatory framework and institutional arrangements; (c) the strategy and definition of a transition period, (d) the need of a structured plan to strengthen the ADRES to assume new responsibilities if that is the case. Second, insufficient staff to support the additional fiduciary functions because of the new PforR Program operation. Third, the CGR may not deliver financial audits and reports on fraud and corruption and complaints handling for the Program on an annual basis. And finally, the recurring risk associated with control weaknesses that could arise in the quality and sufficiency of information of the affiliates of the subsidized regime, which affects the adequate aggregate amount of UPC done from ADRES to SGSSS and the Program internal control system. 4. The proposed systems and capacity strengthening and/or mitigation measures, to address the above risks include the following: (i) close monitoring of the reform progress and the ongoing evaluation of its impact on the Program fiduciary system; (ii) strengthen the Program coordination team, with a FM profile for the specific requests and tasks related to the external financing (WB financing and other multilaterals); (iii) maintain effectively the BDUA’s internal control system and share with the WB the results and improvement plans of any special audit of the BDUA, conducted by the CGR, the statutory auditor and other authorities; (iv) follow-up with the CGR to reach the necessary agreements for the signing of the MoC between the WB and the CGR to agree on the Program’s annual financial audit and ACG aspects; (v) close implementation support to be provided by the Bank’s fiduciary team, and (vi) preparation of a POM that must include all fiduciary requirements and procedures including BDUA’s internal controls, fiduciary roles and responsibilities, arrangement in terms of financial report and audit aspects, among others. 1.3 Procurement exclusions 56 – N/A see section 2 below. 54 Program for Improving Quality of Health Care Services and Efficiency in Colombia (P169866) and Program for improving learning outcomes and socioemotional education - PROMISE (P176006). 55 A Public Expenditure and Financial Accountability Assessment (PEFA) for Colombia dated October 14, 2016, concluded that Colombia's PFM system exhibits reasonable alignment with international good practice at the national government level. 56 Although no procurable activities were identified within the Program's expenditure framework, the basic characteristics of the national procurement system are briefly presented below. Colombia has a strong national procurement system and has made considerable progress in recent years in strengthening the performance of its procurement systems. Procurement is based on the legal framework provided in Law 1150 of 2007 and ruling decrees, the most recent being Decree 1510 of 2013. The Public Procurement Agency (Colombia Compra Eficiente, CCE) oversees and leads procurement regulatory reforms. CCE's current programmatic priorities include: (i) adopting a more strategic approach to procurement as an essential component of public sector expenditure management; (ii) universalizing the use of the transactional electronic procurement system SECOPII; (iii) professionalizing the procurement staff; and, most recently, and (iv) using public procurement as a tool to promote the popular economy. By Law, all public entities must publish all the procurement activities in one of the e-Gp systems (SECOP I, SECOP II). Based on public information published by CCE:(i) 41 percent of the activities are published in SECOP I (28 percent of the amount) and 59 percent in SECOP II (72 percent of the amount); (ii) 53 percent of the amount of public procurement was awarded following non-competitive methods; (iii) there are not performance indicators available, and (iv) the procurement information is available to the public. The current principal priority of CCE is the promotion of Standard Procurement Documents (SPD). The Congress of Colombia approved the Procurement Documents Law, Law 2022 of 2020, which mandates that CCE adopt Standard Bidding Documents (SBD) that will be mandatory in the contractual activity of all entities subject to the General Contracting Statute of the Public Administration. As of today, CCE has approved SBD for the following sectors: transport, water and sanitation infrastructure, multipurpose cadaster, and social infrastructure. CCE has developed a Control Dashboard for using SBD based Page 68 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Section 2. FSA Scope 5. The size of the financing Program is US$1,647.00 million 57 over three years; of which the World Bank will finance US$300 million, the Government will finance US$ 1,291.00 million, and the Program will receive grant financing of US$4.5 million from the GFATM through the Social Sustainability Initiative for All Umbrella Multi-Donor Trust Fund. The Program will marginally support the main budget lines of the MSPS and ADRES: (i) health insurance, claims and health services for the subsidized regime, and (ii) salaries. The first budget line finances insurance premiums for the vulnerable population within the SGSSS subsidized regime for 2023-2026, expenditures related to the health insurance scheme, which are transferred from the MSPS to the ADRES as the responsible for the administration of the health system resources and payments. The ADRES is the executor for the first budget line. The second budget line finances salaries from the MSPS during the period 2023-2026 as deemed necessary to support Program implementation. This Program expenditure framework is delimited to include only those specific expenditures that are indispensable for the achievement of the Program results. The scope and type of expenditures under the Program lead to 100 percent of non-procurable expenses; consequently, no procurable activities were identified, and no specific Procurement arrangements are needed. 6. The scope of the FSA covered the Program's institutional framework, fiduciary capacity and performance, and institutions and systems responsible for governance and anti-corruption aspects within the Program. According to the Program expenditure framework, the MSPS and ADRES are the Program’s executing entities, which have fiduciary responsibilities. The FSA reviewed the fiduciary capacity and performance of the Program executing entities in terms of: (i) planning and budgeting; (ii) budget execution, treasury management and funds flow, accounting, and financial reporting; (iii) internal controls (including Program governance and anticorruption arrangements), and (iv) auditing. The FSA focused only on those aspects that are to be used for the implementation of the PforR Program, according to the WB Guidance note. 7. The SGSSS is structured by insurance schemes managed by the MSPS and administered by ADRES. Funds for the insurance premiums for vulnerable population within the SGSSS subsidized regime follow the Government’s budgetary system in which the MSPS executes its budget line, transferring the funds to ADRES. The ADRES manages the various sources of financing for the Colombian health system, including these contributions from the General Budget of the Nation 58. The ADRES is a special entity of the decentralized level of the national order assimilated to a State-owned enterprise (SOE); with legal, administrative, and financial autonomy; 59 and is subject to the budgetary provisions contained in Decree 115 of 1996, whereby rules are established on the preparation, formation, and execution of the SOEs’ budgets. For the purposes of this FSA, the scope of the review of ADRES’s Budgeting System is limited to the contributions from the General National Budget. on a sample of 7,127 activities of 1,180 agencies, the average number of received bids is 16, and the average savings (awarded value vs. estimated amount) is 3.9 percent. Regarding the resolution of complaints, there is no possibility of challenging the decisions of the contracting entity at the administrative level. The only way to challenge procurement decisions is through the judiciary system, which meets the criteria of independence and capacity but is not necessarily effective or efficient. 57 6.6 percent of the total government program, according to the expenditure framework (see additional information in the Annex 3. (Summary) Technical Assessment – section of expenditure framework). 58There are more than fourteen sources of financing of the Colombian health system, among them: private contributions, solidarity contributions for Exception and Special Regimes, resources of the General Participation System (health), resources of the Family Subsidy of the Family Compensation Funds, contributions from the General Budget of the Nation, royalties’ compensation, specific taxes, and others. https://www.adres.gov.co/nuestra-entidad/acerca-de-adres 59 Article 66 of Law 1753 of 2015 created the Administrative Entity for the resources of the General Social Security Health System (SGSSS) - ADRES, as an Entity attached to the MSPS, with legal personality, administrative and financial autonomy, and independent assets, in charge of managing health system resources. Page 69 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 8. Other GoC entities, such as the MHCP, DNP, and CGR, are also involved and considered in the Program fiduciary system, due to their related SGSSS responsibilities. Furthermore, to further clarify the Program flow of funds, the assessment includes a review of the role of EPS and IPS, 60 which are part of the SGSSS. 60 Currently, there are approximately 29 public, private, and public/private EPS, which have legal, administrative, and financial autonomy. Page 70 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) ANNEX 4. ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT SUMMARY 1. An ESSA to the “Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience” (the Program) was carried out according to the WB's Operating Policy OPS 5.04-POL 107. Specific objectives of the ESSA include: (i) identify potential environmental and social benefits, risks, and impacts applicable to Program interventions; (ii) review the policy and legal framework related to the management of environmental and social impacts of Program interventions; (iii) assess the institutional capacity for environmental and social management systems within the Program system; (iv) assess the performance of the Program system against the core principles of the PforR instrument and identify gaps, if any, and (v) submit recommendations and a PAP to address gaps and improve performance during Program implementation. The ESSA evaluated the systems that promote environmental and social sustainability; assessed the barriers to accessing or participating in the Program for vulnerable groups, including indigenous peoples, and assessed the mechanisms for consultation, participation and attention to complaints and grievances. The ESSA public consultation was held on July 24, 2023. 2. The main environmental risks and impacts of the Program are: (i) HCW; 61 (ii) the potential generation of WEEE, motivated by the dismantling generated by the programmed obsolescence of electronic equipment necessary for the effective and efficient provision of quality health services, and (iii) the impacts of natural disasters and those caused by the effects of climate change, both for their direct effects in interfering with the dynamics of the provision of health systems, and for interrupting telecommunications services or impacting the health of health workers. 3. This Program is expected to generate important social benefits, particularly through the improvement of quality and efficiency in health services, through: (i) the training of health personnel with a gender and intercultural lens; (ii) technical assistance to territorial entities to implement PHC services with a gender and intercultural perspective, and (iii) the development and dissemination of communication strategies that contribute to gender and intercultural perspectives and the identification of relevant health priorities in territories. 4. The social risk is moderate. Although the Program is expected to have positive impacts on vulnerable and systematically excluded groups, additional strategies may be needed to reach them. Several factors may increase the risk of not reaching the most vulnerable population, such as: limited resources in territorial strategies for the identification of vulnerable populations and excluded groups; lack of unified tools to focus and prioritize the vulnerable population; restricted access to ethnic communities due to geographical and security reasons; lack of data to track people who do not yet have their defined immigration status, among others. This risk will be mitigated by strengthening the intercultural health, gender, and diversity approach, strengthening information systems for tracking the prioritized population, implementing a solid communication strategy, and promoting stakeholder participation and attention to complaints and grievance actions through the PQRS of the MSPS. Moreover, there is no land acquisition, resettlement, or loss of access to natural resources included in the Program, and there is no serious risk of exacerbating social conflicts, therefore, variations in property regimes, including common property resources, customary or traditional rights to use land or resources, and indigenous people’s rights, are not expected. 61WHO points out that the waste generated by the activities of healthcare facilities, from contaminated needles, sharps, chemical, cytotoxic, and radioactive waste, have a higher potential risk of causing injuries and infections than any other type of waste and their improper management can have serious consequences on public health and an appreciable impact on the environment. Page 71 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) 5. The ESSA concludes that the Program will contribute to generating benefits through expanding access to and use of quality, effective health services, especially for vulnerable populations. The MSPS has developed an appropriate system for managing the social aspects of the Program, with strong technical capacity, experience, and infrastructure for implementation. There is a regulatory framework in place, as well as guidelines and protocols that ensure sufficient attention is paid to key social aspects such as citizen participation and differential approaches to health. 6. The environmental risk is moderate because minor increases in HCW and WEEE are expected. There will be no construction or intervention in areas associated with cultural heritage, and actions and investments will not affect areas of biodiversity protection. However, possible (minor) increases in the HCW may be due to improved quality of services and early diagnosis and treatment of diseases such as cancer. In addition, the operational phase may present certain risks and impacts associated with the management of medical waste and other solid and liquid waste within health facilities (segregation or selective collection by category, packaging, and temporary storage), its transportation, treatment, and final disposal of solid medical waste, with special care being paid to hazardous waste. If poorly managed, these activities will threaten the environment, public health, and occupational safety. The institutional setup can potentially develop the capacity to address potential environmental risks and challenges. Dispersed populations present disadvantages for the final treatment of HCW and WEEE, linked to operational difficulties. 7. The ESSA confirms that regulations and institutional capacities reasonably cover the current system for managing the environmental aspects of the Program. The MSPS establishes the guiding policies of HCW through an intramural compliance management system, under the responsibility of each facility, and an extramural management system regulated by the environmental authority of each jurisdiction. The legal framework regulates the integrated environmental and sanitary management of waste generated in healthcare and other activities. At the sub-national levels, territorial entities are responsible for managing WEEE. The existing environmental legal and regulatory framework provisions are adequate and require an enabling institutional and technical capacity to comply with them. The destinations contemplated for WEEEs as post-consumer materials within hospital management are not yet clearly established. 8. The ESSA findings identified an overall satisfactory level of implementation and compliance with current standards for medical waste management. Yet, verifying a national integration of HCW at the Regional level for remote or isolated populations has not been possible. 9. To maximize the benefits of the Program, the ESSA recommends social and environmental actions as part of the PAP. Key social actions include: (i) the strengthening and adoption of the intercultural approach to health, working in a participatory manner with the country’s indigenous peoples and ethnic communities; (ii) the unification of information systems supporting the rollout of the basic health teams; (iii) technical assistance for the development of capacities of territorial entities in public health management, including social and gender perspectives, and (iv) the development of information, education and communication strategies for inclusive and locally relevant population health improvement strategies, to allow populations a dialogue about the benefits of this Program and present their concerns and proposals freely. Key environmental actions include the management and final disposal of HCW, especially in the most remote places; the design of plans for better recovery and management of WEEE; and ensuring that occupational health and safety of doctors, health workers, patients, and caregivers are taken into consideration when remodeling PHC Centers. The main impacts of climate change on health should be specially monitored in view of the increased frequency of extreme events in different areas of the country. 10. Actions included in the PAP must also address aspects of adaptation and mitigation to climate change in the health sector. Priority actions to be implemented relate to: (i) adaptation measures of the health system to climate Page 72 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) variability; (ii) the institutional agreements that allow the analysis of information on climate-sensitive health events and support public health surveillance actions, and (iii) the analysis of vulnerability to climate variability of healthcare providers. Actions also include the approach to the adequacy and mitigation of infrastructure for healthcare providers and the guidance and encouragement in adopting mitigation measures. Page 73 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) ANNEX 5. PROGRAM ACTION PLAN @#&OPS~Doctype~OPS^dynamics@padpfrannexprogramactionplan#doctemplate Action Completion Description Source DLI# Responsibility Timing Measurement Adaptation to the Environmental NA Subdirectorate Recurrent Yearly 1) Technical CC of the health and Social of document for each system.Advancing Systems Communicable of the Dengue and towards the Diseases Malaria climate design of an Early prediction pilots. Warning System 2) Create a methodological guideline for the analysis of climate- sensitive diseases. CGR will provide Fiduciary NA CGR Recurrent Yearly Information on to the Bank Systems Fraud and information on Corruption, and allegations of complaints fraud and handling, sent to corruption, the WBG. handling of said allegations, and final findings, all related to the Program Climate Change Environmental NA Subdirectorate Recurrent Yearly 1.1 Evaluation of Mitigation.1) and Social of GHG generation at Baseline for the Systems Environmental the facility level. generation of Health 1.2 Training of the GHG of the Climate Impact Health System.2) Monitoring tool; Prepare a guide Report to guide and encourage 1.3 Estimation of facilities in GHG from the adopting Colombian health Page 74 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) mitigation sector at the measures national level. 2. Adopting mitigation measures; Technical document Future scenarios Environmental NA Subdirectorate Recurrent Semi- 1) Identification of of HCW and Social of Annually a mechanism for management Systems Environmental intra- and Health interregional articulation for management and final disposal. 2) Preparation of technical reports of conclusions treatment capacity and final disposal. Implementation Environmental NA MSPS Office of Recurrent Semi- Education and of educational and Social Social Annually communication and Systems Promotion strategies oriented communication to stakeholders, strategies developed MSPS and ADRES Fiduciary NA ADRES Recurrent Semi- Report on Agreed will maintain the Systems Annually actions submitted internal control to the WB system of the BDUA; and will share the results and improvement plans of the audits carried out to the BDUA, by the CGR, the statutory auditor, the internal audit, Page 75 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) and other control entities. MSPS will Technical NA MSPS Recurrent Semi- Financial reports strengthen the Annually acceptable to the Program WB, submitted in a coordination timely manner team, with a financial management -FM profile for specific activities resulting from external financing (WB and other multilateral financing). Registration Plan Environmental NA Subdirectorate Recurrent Yearly 1) Good practices the obsolescence and Social of document on the of EEE in health Systems Environmental operation of EEE centers for post- Health and proposals for consumer post-consumption recovery and recovery in the comprehensive health system. management of 2) Preparation of WEEE technical document for a WEEE recovery program Strengthening the Environmental NA MSPS Office of Due Date 31-Dec- Administrative acts adoption of an and Social Social 2024 to register health intercultural Systems Promotion information for approach to ethnic groups, health issued Strengthening the Fiduciary NA MSPS and Recurrent Semi- Reporting on cases application of Systems ADRES Annually of allegations of Anticorruption fraud and Guidelines corruption, handled according to their respective Page 76 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) mandates and regulations. Reporting on the verification to confirm that contracts are not awarded to debarred or suspended firms or individuals. Technical Environmental NA Vice-Ministry Recurrent Yearly Technical assistance to and Social Public Health assistance plan for improve public Systems and Delivery ET to improve health their capacities in management public health care at PHC level, developed. Unification of Environmental NA Directorate of Recurrent Yearly Unified tools for the and Social Promotion and information tools, management of Systems Prevention socialized with information territorial teams Page 77 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) ANNEX 6. IMPLEMENTATION SUPPORT PLAN A. Focus of ISP 1. The ISP is in line with the WB’s PforR operational guidelines. The Borrower is responsible for the implementation of all Program activities in support of the achievement of the agreed DLIs, as well as of the resolution of bottlenecks identified in the fiduciary, environmental, and social assessments. The WB will tailor implementation support in technical, fiduciary, environmental and social aspects to: (a) Review the Program implementation progress and achievement of Program results and monitor and help the Borrower as needed with institutional capacity building and implementation issues; (b) Provide technical advice to the implementation of the activities under the RAs as needed, the achievement of DLIs and the implementation of the PAP; (c) Advise and review documentation prior to serving as evidence for the fulfillment of DLIs as appropriate; (d) Monitor compliance with legal agreements, keep records of risks and propose remedy actions to improve Program performance, if and as needed; (e) Provide support in resolving any operational issues pertaining to the Program; (f) Monitor the performance of fiduciary systems and potential changes in fiduciary risks of the Program; (g) Monitor the Program financial statement preparation process and assist the Borrower as necessary; (h) Review the Program’s annual financial audit report, discuss with the Borrower and monitor the implementation of the auditor’s recommendation, and (i) Based on the information provided by the audit reports, assess and analyze changes in the fiduciary performance of the Program and propose remedial actions as needed. 2. The following major categories of support are envisioned: (a) Implementation support and capacity building relating to the result areas and DLIs that require technical assistance and support from WB staff and consultants, as well as global partners such as the GFATM. Examples include: (i) capacity building for strengthening information systems (essential to achieving DLI 1, 2 and 3); (ii) technical assistance for service delivery to migrants (essential for DLI 4); (iii) capacity building and sensibilization of health workers on the integration of gender and intercultural perspective at territorial level, and (iv) capacity building on the implementation of key climate change adaptation and mitigation strategies (essential to DLIs 5 and 6), and (b) Supervision of operation, technical and fiduciary review: supervision will be conducted regularly. Page 78 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) Time Focus Skills Needed Resources Estimate Partner Role First 12 POM development Operations and 6 weeks of consultant months implementation support. support. M&E. Strengthening information systems to ensure effective care Information One consultant full Technical assistance for pregnant women, systems, data time. from France and from undernourished children under 5 analytics the Netherlands. and vulnerable women at risk of developing breast cancer. Developing integrated care networks at territorial level to Quality of care One consultant part United Nations ensure effective care of and time. Population Fund pregnant women at risk of service delivery. (UNFPA) providing complications, undernourished additional technical children under 5 and vulnerable assistance. women at risk of developing breast cancer. Strengthening PHC teams in territories for adequate Quality of care and One consultant part identification, follow-up, and service delivery. time. treatment of patients at risk of Co-financed with the developing NCDs. IDB. Capacity building, training and sensibilization of health workers Quality of care and One consultant part in territories with a gender and service delivery. time. interculturality perspective. UNFPA provides additional technical Planification of implementation assistance. of strategy for HIV treatment for migrants, as well as for training One consultant full in application of HIV rapid tests. time. Supported by the GFATM through BETF. 12-36 Capacity building on Environmental One consultant part- Co-financed with the months implementation of key climate engineer and time. IDB. change adaptation and project mitigation strategies in PHC management. Pan-American Health facilities. Organization. Page 79 The World Bank Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) B. Task Team Skills Mix Requirements for Implementation Support Table A6.1. Task Team Skills Mix Requirements for Implementation Support (per year) Number of Staff Skills Needed Number of Trips Comments Weeks Lead Health Specialist (co-TTL) 8 2-4 International Senior Health Specialist (Co-TTL) 8 0 Country-based Health Economist 8 2-4 Country-based FM Specialist 5 0 Country-based Environmental and Social Specialist 3 2 Country-based Technical Consultants As required As required International and country-based Table A6.2. Role of Partners in Program Implementation Institution/Coun Name Role try TA to the MSPS in supporting the development of capacity building at the Global Fund to Fight AIDS, Geneva, sub-national level to support the delivery at scale of better screening Tuberculosis & Malaria Switzerland programs for HIV for migrants and capacity building to improve compliance with key components of clinical practice guidelines. TA related to the implementation of strategy in prioritized departments Bogotá, UNFPA to scale up integrated interventions to improve access to effective health Colombia services for pregnant women, migrants living with HIV and victims of GBV. TA in building capacity at the sub-national level for implementation of Pan-American Health Bogotá, interventions related to maternal mortality, child mortality from Organization Colombia malnutrition, climate change, and One Health. TA related to measurement of baseline of GHG emissions in hospitals. TA related to innovations in improving service delivery and targeting of at-risk populations for breast cancer. Government of France TA related to key interventions to improve adaptation to climate change and mitigation in the health sector. Government of the TA related to innovations in improving service delivery and targeting of Netherlands at-risk populations for breast cancer. International Organization TA in capacity building for access to screening and effective health for Migration services for migrants. UN High Commissioner for TA in capacity building for access to screening and effective health Refugees services for migrants. Page 80