$ Report No: RES00145 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF Republic of Congo, Kobikisa Health System Strengthening Project APPROVED ON 02-Jun-2021 TO Republic of Congo Health, Nutrition & Population Western And Central Africa Regional Vice President: Ousmane Diagana Regional Director: Trina S. Haque Country Director: Cheick Fantamady Kante Practice Manager: Carolyn J. Shelton Task Team Leader(s): Djibrilla Karamoko, Ousmane Deme ABBREVIATIONS AND ACRONYMS The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) COVID-19 Coronavirus Disease RoC Republic of Congo CERC Contingent Emergency Response Component FM Financial Management IP Implementation Progress PBF Performance Based Financing MOH Ministry of Health UNICEF United Nations Children’s Fund WBG World Bank Group WHO World Health Organization The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) @#&OPS~Doctype~OPS^dynamics@restrhybridbasicdata#doctemplate BASIC DATA Product Information Operation ID Operation Name Republic of Congo, Kobikisa Health System P167890 Strengthening Project Product/Financing Instrument Geographical Identifier Investment Project Financing (IPF) Congo, Republic of Approval Date Current Closing Date 02-Jun-2021 08-Aug-2024 Environmental and Social Risk Classification (ESRC) Substantial Organizations Borrower Responsible Agency Republic of Congo Ministry of Health and Population @#&OPS~Doctype~OPS^dynamics@restrhybridoperationstatus#doctemplate OPERATION STATUS Project Development Objective (DO) Original Development Objective The objective of the project is to increase utilization and quality of reproductive, maternal and child services in targeted areas, especially among the poorest households. Disbursement Summary (in USD million) Source of Funds Net Commitment Disbursed Balance % Disbursed IBRD -- -- -- 0 IDA 50.00 21.86 28.14 43.73 i The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) Grants -- -- -- 0 Policy Waivers Does this restructuring trigger the need for any policy waiver(s)? No @#&OPS~Doctype~OPS^dynamics@restrhybridmpa#doctemplate @#&OPS~Doctype~OPS^dynamics@restrhybridmpa#doctemplate ii The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) TABLE OF CONTENTS I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING ...........................................1 II. DESCRIPTION OF PROPOSED CHANGES ........................................................................3 III. PROPOSED CHANGES ......................................................................................................4 IV. DETAILED CHANGE(S) .....................................................................................................5 The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Project Status 1. The Republic of Congo Health Systems Strengthening Project (KOBIKISA) was approved by the Board of Directors of the World Bank on June 2, 2021, with financing of US$50 million provided by IDA (IDA-68900). KOBIKISA was declared effective on November 19,2021 with an initial closing date of 8 August 2024. Despite facing several challenges related to implementation, as of 26 June 2024 the disbursement rate was 47.27%. Of the total project funds, US$24.46 million remains to be disbursed by the project’s initial closing date (August 8th 2024). The current annual budget work plan has been revised and budgeted in line with the available funds and the implementation timeframe. As of February 2024, out of a total of 142 activities programmed in the 2023 Annual Budget Work Plan, 69 were successfully executed (equivalent to 48.6 %), 19 were still being carried out, and 54 (38%) were not completed. 2. The Project Development Objective (PDO) aims to increase the utilization and quality of reproductive, maternal, and child services in targeted areas, especially among the poorest households. KOBIKISA has four components: Component 1 (US$43 million) aims at introducing the PBF, support the implementation of free health care for pregnant women and children and fee exemptions for poorest households in targeted regions; Component 2 (US$5 million) aims to support public finance governance, sector PFM, and the health system; Component 3 (US $ 2 million) aims to ensure effective and efficient technical and fiduciary management by strengthening project management and monitoring; and Component 4 is a zero-dollar Contingent Emergency Response Component (CERC) to facilitate an emergency response. 3. The Project Development Objective (PDO) has remained moderately satisfactory since project inception, whereas the project Implementation Performance (IP) rating, after a challenging period from December 2021 to November 2023, has improved from Moderately Unsatisfactory to Moderately Satisfactory as per the latest Implementation Status and Results Reports (ISR) of May 2024. Throughout the project life cycle, a combination of public health emergencies and administrative challenges (mainly delays in recruitment at the PIU level) has slowed project implementation. First, the COVID-19 pandemic and then in 2022 the yellow and measles outbreaks1 that severely affected Pointe Noire, the second largest region of the country after Brazzaville. 4. Overall, KOBIKISA has made remarkable progress towards achieving its PDO by increasing the utilization and quality of healthcare services in the target regions. PDO-level indicators are in good track to achieve their targets through project closing. The total number of people who have received essential HNP services was 327,962 in 2023 (As of April 2024), equivalent to 43% of the intermediate target of 763,944 people. Likewise, the total number of women of childbearing age (15-49) who have used modern contraceptive methods reached 11,757 women in 2023 against the intermediate target of 85,463, equivalent to a completion rate of 13.8%. In addition, the percentage of women with 1As of April 24, 2022, the epidemiological situation of measles in the Republic of Congo was as follows: 6,259 cases were reported, including 132 deaths with the Pointe-Noire department recording 5,488 cases including 112 deaths. Most of these deaths occurred among people admitted late to treatment centers after the failure of self-medication or recourse to traditional practices. Page 1 The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) access to postnatal care reached 35% in 2023, almost halfway from the intermediate target of 77% set for the same year. Finally, quality score of health facilities have substantially improved reaching 31% in 2023 against the intermediate target of 65% set for 2023. 5. To date, significant progress has been made to kickstart the PBF approach on the ground (component 1) and enhance policy dialogue between the health, finance, and budget ministries (component 2). The key milestones to date include the following: i) lifting of the disbursement conditions under component 1 in January 2024, ii) establishment of the PBF National Technical Unit, iii) development of the Indigenous People Care Plan (PPA), iv) development of the Biomedical Waste Management Plan (PGDBM ), v) recruitment of the International PBF Expert, and vi) finalization of the baseline nationwide general evaluation of health facilities to ensure PBF readiness. All of these activities supported the first transfer of investment funds to health facilities at the end of February 2024, with the aim of improving basic infrastructure and enhancing endowment in medical equipment to level up and be ready to start the PBF. 6. In addition, the capacity building of stakeholders involved in the PBF process through training was carried out in 50 out of the 52 health districts of the country (with the two health districts left out of the Likouala region which was part of the LISUNGI social protection safety net project with a PBF component). Contracts, bank accounts of health facilities and districts, capacity building, and the creation of the data collection and verification webtool (PBF web portal) have all been finalized with support from the established national technical unit of the PBF and PIU. Performance contracts at the (a) peripheral, (b) departmental, and (c) central levels have all been signed, and subsidy payments are expected to begin flowing to health facilities by early July 2024. 7. In total, 1088 agents in the first and second cohorts have been trained on the PBF approach, and the creation of a pool of agents in charge of verification and counter verification is ongoing. Under component 2, the first multisectoral budget conference to understand key PFM bottlenecks in the health sector took place in Brazzaville in November 2023. Discussions involving the Ministry of Health, Budget, Finance, Treasury department and other entities involved in the flow of public health spending led to the creation of the first multisectoral committee for the first Public Expenditures Tracking Survey (PETS) in the country. The latter, with the World Bank and the PIU, have kickstarted survey preparation activities, including drafting the sampling methodology and survey instruments. Regarding project management activities under component 3, 36 activities were carried out for a total of 48, equivalent to a completion rate of 75%. All PIU staff have been recruited and working conditions are optimal for an efficient performance. A monitoring evaluation plan and manual were developed, the results framework of the performance indicators was updated four times during the year, and the 2023 Annual Project Implementation report was shared with the World Bank on time. B. Rationale for restructuring 8. This restructuring paper seeks approval for Level 2 restructuring to extend the closing date of the Republic of Congo health systems strengthening project KOBIKISA by a year from 8 August 2024 to 30 August 2025 and revise targets for Page 2 The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) certain core indicators of the results framework, including changes in coverage for some project activities. Considering the importance of keeping at least one active health system strengthening operation in the country still vulnerable to several public health threats and to allow effective completion of the ongoing activities, the KOBIKISA HSS project needs to be modified. The World Bank has agreed to a Level 2 restructuring of the KOBIKISA HSS project with the Ministry of Health and the Ministry of Planning, Statistics, and Regional Integration. This restructuring would extend the project's closing date to allow sufficient time for the implementation of the revised project activities and the disbursement of the remaining funds, such as the payment of second investment funds to health facilities. II. DESCRIPTION OF PROPOSED CHANGES C. Proposed Changes 9. This paper seeks management approval for a Level 2 restructuring with the following proposed main change: (a) Extension of project closing date: Considering that, of the total project funds, US$ $24.46M million remains to be disbursed over the next 1 month, the project closing date will be extended by 13 months from 8 August 2024 to 30 August 2025 allowing sufficient time for KOBIKISA HSS to properly implement the revised activities programed in the annual work plan for the calendar year 2024. Summary of Performance of E&S Risk Compliance The project has the following documents: ESMF, LMP, IPPF, RPF, GBV plan and GRM. And the project has implemented the conditions for the preparation, consultation and disclosure of the Indigenous Peoples Action Plan (IPP) and the Biomedical Waste Management Plan (HCFWMP). The project also operationalized the GRM and recruited the environmental safeguards specialist and the social safeguards specialist in line with the recommendation of the environmental and social audit triggered on the COVID-19 emergency response project (PRUC, P173851) in 2022, which recommended reducing the workload of the environmental safeguards specialist in charge of the three health projects, by recruiting an environmental safeguards specialist and a social safeguards specialist for the Health System Strengthening project (KOBIKISA, P167890). Describe any E&S issues and impacts associated with the change in project design. Identify and describe any potential large scale, significant and/or irreversible impacts. The extension of the closing date will not have an impact on the project design. The planned activities under the Environmental and Social framework will continue to be implement in accordance with the validate action plans. Describe any potential indirect and/or long-term impacts due to anticipated future activities in the project areas. Key potential environmental and social (E&S) risks and impacts are related to the incremental increase in biomedical waste because of the increase in the number of people accessing health facilities, transfusion safety and access to quality blood products, blood transfusion, drug use. Other potential impacts can be related to (i) release of effluents, including wastewater from health Page 3 The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) care and blood transfusion centers; (ii) occupational health and safety due to exposure to infections and diseases, hazardous materials, and waste; and (iii) community health and safety. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. Describe measures taken by the borrower to address E&S policy issues. Provide an assessment of borrower capacity to plan and implement the measure described. Actors involved in the implementation of the project (MoH, MoF, PIU technical committee) have been trained to apply the expanded ESF. The environmental safeguard specialists recruited by the project support the implementation of the activities and helped to mitigate the risks and potential E&S impacts of the project in the ground. Identify key stakeholders and describe the mechanism for consultation and disclosure on E&S policies, with an emphasis of potentially affected people. The project will strengthen citizen engagement in the project areas, drawing from PBF tools such as through the community surveys that will be used for assessing the perceived quality of care by the beneficiaries. Local civil society organizations will be involved in the PBF program and communities informed through information campaigns as to what services to expect from health facilities. Some key examples of citizen involvement are the following: The PBF program organizes an annual meeting with all stakeholders, including heath care providers, district and regional directors, development partners, NGOs, and local authorities; and Communities are also involved in assessing the quality of the health services provided and will play a larger role in ensuring that community members are aware of the preventive services and health care available to them to prevent mortality. 121. Community-based NGOs and local-elected officials will be engaged in the PBF program. These will be implicated in the reporting and monitoring of quality of services, community outreach, and demand promotion for better use of health services by the communities, particularly mothers and children. An intermediate results indicator measuring the level of citizen engagement during the project cycle has been selected in the results framework. Other complementary interventions implemented through the previous HSSP will include a demand generating approach called the ‘Rainbow Program’ in which color-coded vouchers are used to identify those in need of key basic health services and to educate and persuade them to use services. @#&OPS~Doctype~OPS^dynamics@restrhybridsummarychanges#doctemplate Summary changes III. PROPOSED CHANGES Page 4 The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) Operation Proposed Operation Proposed Information Changes Information Changes Loan Closing Date Development Objective No Yes Extension Summary Description No Loan Cancellations No (Operation Abstract) Legal Operational No Reallocations No Policies MFD/PCE No Financial Management No Results No Procurement No Institutional Risks No No Arrangement Implementation Legal Covenants No No Schedule Conditions No Implementation No Modalities Disbursements No Estimates Disbursements No Arrangements DDO No Clients No Appraisal Summary No Components No @#&OPS~Doctype~OPS^dynamics@restrhybriddetailedchanges-disclose#doctemplate IV. DETAILED CHANGE(S) COSTS & FINANCING Private Capital Facilitation Is this an MFD-Enabling Project (MFD-EP)? Is this project Private Capital Enabling (PCE)? Page 5 The World Bank Republic of Congo, Kobikisa Health System Strengthening Project (P167890) LOANS Loan Closing Proposed Original Revised Proposed Loan/Credit/T Deadline for Status Closing Closing(s) Closing rust Fund Withdrawal Applications IDA-68900-001 Effective 08-Aug-2024 08-Aug-2024 30-Aug-2025 31-Dec-2025 ENVIRONMENTAL & SOCIAL Environmental & Social Assessment According to the E/S Specialist are there changes proposed to the No operation’s design that would impact the Bank’s E&S assessment?” Page 6