The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) Djibouti Health System Strengthening (P178033) MIDDLE EAST AND NORTH AFRICA | Djibouti | IBRD/IDA | Investment Project Financing (IPF) | FY 2022 | Seq No: 5 | Archived on 14-Oct-2024 | ISR00364 Implementing Agencies: Ministry of Health 1. OBJECTIVE 1.1 Development Objective Original Development Objective (Approved as part of Approval package on 25-May-2022) To improve the utilization of quality reproductive, maternal, neonatal, child, adolescent health and nutrition (RMNCAH-N) services, with priority given to underserved areas, refugees and host communities Has the Development Objective been changed since Board Approval of the Project Objective? No 2. COMPONENTS Name Component 1: Strengthening service delivery platforms:(Cost 16,500,000.00) Component 2: Strengthening institutions, citizen engagement and project management:(Cost 3,000,000.00) Component 3: Contingent Emergency Response Component - CERC:(Cost 0.00) 3. OVERALL RATINGS Name Previous Current Progress towards achievement of PDO Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Overall Risk Rating Substantial Substantial 4. KEY ISSUES & STATUS Oct 14, 2024 Page 1 of 11 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) 4.1 Implementation Status and Key Decisions The Djibouti Health System Strengthening Project (P178033) was approved on May 26, 2022. The financing agreement was signed by the Government of Djibouti on June 7, 2022 and the project became effective on February 1, 2023. The project was launched with a new Performance-Based Financing (PBF) pilot in all regions and Djibouti City along with an alternative innovative financing mechanism called Direct Facility Financing (DFF) in primary-level health facilities in two regions in Djibouti – Obock and Ali Sabieh. Following the approval of two strategic documents, the service optimization plan and the review of the central drug store (CAMME), the component on service optimization of select public health facilities is also underway. 5. SYSTEMATIC OPERATIONS RISK-RATING TOOL Rating at Approval Last Approved Rating Risk Category Approval Package - ISR Seq. 04 - 05 Apr Proposed Rating 26 May 2022 2024 Political and Governance Moderate Moderate Moderate Macroeconomic Moderate Moderate Moderate Sector Strategies and Policies Moderate Moderate Moderate Technical Design of Project or Program Moderate Moderate Moderate Institutional Capacity for Implementation and Substantial Substantial Substantial Sustainability Fiduciary Substantial Substantial Substantial Environment and Social Substantial Substantial Substantial Stakeholders Moderate Moderate Moderate Overall Substantial Substantial Substantial Oct 14, 2024 Page 2 of 11 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) 6. RESULTS 6.1 PDO Indicators by PDO Outcomes Improve utilization of quality RMNCAH-N, prioritizing underserved areas, refugees & host communities Baseline Actual (Previous) Actual (Current) Closing Period Indicator Name Value Month/Year Value Date Value Date Value Month/Year Children fully immunized 50.00 May/2022 45.30 30-Nov-2023 45.10 30-Jun-2024 80.00 May/2027 before their first birthday Comments on Poor quality of immunization registered filling. Continued difficulties with coordination, (Percentage) achieving targets planning and outreach. 50.00 No value 45 80.00 Among girls Comments on Disaggregated data submitted by the client in their March 2025 semestrial report (Percentage) achieving targets 50.00 No value No value 80.00 Among refugees Comments on Disaggregated data submitted by the client in their March 2025 semestrial report (Percentage) achieving targets 66.00 56 52 80.00 Among host community Comments on A "host community resident" is any patient receiving services in any health facility in the residents (Percentage) achieving targets suburb of Balbala. Regions in which over 0.00 0.00 0 6.00 80% of children are fully immunized before their first birthday (Number) Pregnant women having 4+ 8.00 May/2022 17.40 30-Nov-2023 15.30 30-Jun-2024 18.00 May/2027 Page 3 of 12 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) ANC visits (Percentage) Comments on This indicator has already surpassed its target. achieving targets 8.00 No value No value 18.00 Among refugees Comments on Disaggregated data submitted by the client in their March 2025 semestrial report (Percentage) achieving targets 11.00 10.11 15 18.00 Among host community Comments on A "host community resident" is any patient receiving services in any health facility in the residents (Percentage) achieving targets suburb of Balbala. Regions in which over 0.00 2 0 6.00 18% of pregnant women have 4+ ANC visits (Number) 14.00 May/2022 89 30-Nov-2023 39.60 30-Jun-2024 25.00 May/2027 Births in appropriate facilities Comments on Appropriate facilities are defined as facilities either (i) offering Comprehensive Emergency (Percentage) achieving targets Obstetric and Neonatal Care (CEmONC) or (ii) within 5 km of facilities with CEmONC Among refugees 5.00 No value No value 25.00 (Percentage) 5.00 78.80 41 14.00 Among host community Comments on A "host community resident" is any patient receiving services in any health facility in the residents (Percentage) achieving targets suburb of Balbala Regions in which over 0.00 4 67 6.00 25% of births are in Comments on Baseline was entered as 67 in error as there are only 5 regions plus Djiboutiville so a maximum appropriate facilities achieving targets of 6; This will be reviewed and fixed during the upcoming MTR (Number) Women having at least 1 5.00 May/2022 8.60 30-Nov-2023 14 30-Jun-2024 30.00 May/2027 postpartum visit within 1 Comments on This indicator should be in "Percentage" and not "Number"; This error will be corrected week after birth (Number) achieving targets following the MTR Among refugees 5.00 No value No value 30.00 Page 4 of 12 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) (Number) Comments on A total of 59 women were recorded to have had at least 1 postpartum visit within 1 week after achieving targets birth among the refugee population which is 40% of women who delivered in the same period within the same population; This indicator will be redefined as "Percentage" following the MTR since "Number" was a mistake from the beginning 5.00 No value 19 30.00 Comments on A total of 685 women were recorded to have had at least 1 postpartum visit within 1 week Among host community achieving targets after birth among the host community population which is 37% of women who delivered in residents (Number) the same period within the same population; This indicator will be redefined as "Percentage" following the MTR since "Number" was a mistake from the beginning Regions in which over 0.00 0.00 0 6.00 30% of women have at least 1 postpartum visit within 1 week after birth (Number) Average facility quality score 46.00 Dec/2021 55.20 30-Nov-2023 51.90 30-Jun-2024 60.00 May/2027 as assessed by the PBF quality Comments on INSERT COMMENT check list (Percentage) achieving targets 6.2 Intermediate Results Indicators by Components Component 1: Strengthening service delivery platforms Baseline Actual (Previous) Actual (Current) Closing Period Indicator Name Value Month/Year Value Date Value Date Value Month/Year People who have received 0.00 May/2022 20,318 30-Nov-2023 20.30 30-Jun-2024 390,000.00 May/2027 essential health, nutrition, Comments on The previous actual of 20.3 was erroneously entered as a percentage of the target population. and population (HNP) services Page 5 of 12 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) (Number) achieving targets The related number of people receiving services in the previous period was 115,018 People who have 0.00 0 14 270,000.00 received essential health, nutrition, and population (HNP) services - Female (RMS requirement) (Number) Number of children 0.00 May/2022 1,871 30-Nov-2023 4.10 30-Jun-2024 120,000.00 May/2027 immunized (Number) Number of women and 0.00 May/2022 0 30-Nov-2023 1.40 30-Jun-2024 180,000.00 May/2027 children who have received basic nutrition services (Number) Number of deliveries 0.00 May/2022 4,731 30-Nov-2023 12.80 30-Jun-2024 90,000.00 May/2027 attended by skilled Comments on The previous actual was entered as a percentage in error. The related number of deliveries health personnel achieving targets was 14,911 (Number) 0.00 No value 6 7,800.00 Of which refugees Comments on The previous actual was entered in terms of percentage in error. The related number of (Number) achieving targets refugees was 119; The target will be reviewed during the MTR as it seems unreasonably high Of which host 0.00 1,645 4 78,000.00 community residents Comments on Similarly, the previous actual was entered as a percentage in error. The related actual was (Number) achieving targets 4629 and the target will be reviewed during the MTR as it seems unreasonably high Maternal wards which either 12.00 May/2022 12 30-Nov-2023 67 30-Jun-2024 18.00 May/2027 (i) offer CemONC or (ii) are Comments on The previous actual was erroneously entered as 67 referring to percentage which is 12 in within 5 km of CemONC achieving targets terms of number and this has remained unchanged (Number) Health facilities successfully 0.00 May/2022 0.00 31-Mar-2024 0.00 30-Jun-2024 25.00 May/2027 Page 6 of 12 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) rehabilitated based on the Comments on Roughly 20 facilities were identified for optimization in the Service Optimization Plan; optimization plan, including achieving targets However, once the costed plans are finalized, expected in May 2025, this number may be CHVA recommendations further reduced due to available budget under this sub-component for the renovation window (Percentage) Children under 5 years old 16.00 May/2022 11.90 30-Nov-2023 11.20 30-Jun-2024 45.00 May/2027 supplemented with vitamin A in the last 12 months (Percentage) Among girls 16.00 No value 11 45.00 (Percentage) Among refugees 16.00 No value No value 45.00 (Percentage) 16.00 11 17 45.00 Among host community Comments on A "host community resident" is any non-refugee resident of the commune of Balbala. residents (Percentage) achieving targets Children under 5 years old 0.00 May/2022 758 30-Nov-2023 30.60 30-Jun-2024 80.00 May/2027 whose growth monitoring is Comments on This indicator has massively improved during the PBF/DFF pilot period (September 2023 to recorded and reported in a achieving targets March 2025) with routine quarterly discussions with chief doctors; The target will be re- central database evaluated during the MTR (Percentage) Among girls 0.00 No value No value 80.00 (Percentage) Among refugees 0.00 No value No value 80.00 (Percentage) Among host community 0.00 No value 32 80.00 residents (Percentage) Public health facilities with 5.00 May/2022 0.00 31-Mar-2024 63 30-Jun-2024 50.00 May/2027 safe disposal of sharps waste Comments on Majority of public health facilities dispose already safe disposal of sharps waste. However, (Percentage) achieving targets improvement is still needed on efficient use of the disposal safe. Page 7 of 12 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) Facilities receiving PBF 0.00 May/2022 0.00 31-Mar-2024 100 30-Jun-2024 80.00 May/2027 payment within 30 days of Comments on There were delays in disbursements from OGPP to health facilities participating in the PBF/DFF submission of verification of achieving targets schemes for the initial disbursement at the very beginning of the pilot but this has been results (Percentage) resolved since June 2024 Average user experience 0.00 May/2022 No value 31-Mar-2024 90 30-Jun-2024 60.00 May/2027 score among PBF/DFF Comments on User experience score is a zero if not collected. participating facilities achieving targets (Percentage) Primary health facilities with 0.00 May/2022 No value 31-Mar-2024 No value 30-Jun-2024 80.00 May/2027 functional Facility Community Comments on Based on the verification/counter-verification reports, 18 health facilities have set up a Committee assessed by the achieving targets functional facility community committee, however, only 1 was assessed as PBF quality checklist "functional/operational" by the PBF quality check list (Number) Communities with functioning 0.00 May/2022 0.00 31-Mar-2024 0.00 30-Jun-2024 60.00 May/2027 community health workers Comments on The National Community Health Strategy is formulated and a proposal to hire 500 community per the norms set by the achieving targets health workers is made to the Minister of Health for consideration. National Community Health Strategy (Percentage) Communities that have 0.00 May/2022 0.00 31-Mar-2024 0.00 30-Jun-2024 60.00 May/2027 formally declared the abandonment of the practice of FGM (Percentage) Component 2: Strengthening institutions, citizen engagement and project management Baseline Actual (Previous) Actual (Current) Closing Period Indicator Name Value Month/Year Value Date Value Date Value Month/Year Facilities with DHIS-2 35.00 May/2022 100 31-Mar-2024 98 30-Jun-2024 65.00 May/2027 implementation (DHIS-2 data Comments on Based on PBF/DFF, some health facilities are using DHIS-2 directly and others are tracking data entry at the facility level) achieving targets on paper and submitting them immediately. (Percentage) Page 8 of 12 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) 0.00 May/2022 22.40 31-Mar-2024 0 30-Jun-2024 65.00 May/2027 Facilities that are connected Comments on 23 out of 62 health facilities are connected to mSupply. The initial pilot of 15 health facilities to the National Logistics achieving targets was financed by the Global Fund. The expansion of mSupply is financed by both GAVI and the Management Information Bank with the Bank focusing on the ensuring mSupply is implemented in the selected facilities System (eLMIS) (Percentage) for service optimization. Health surveys conducted and 0.00 May/2022 1 31-Mar-2024 0 30-Jun-2024 2.00 May/2027 results made public Comments on Partners are planning to co-finance the MICs, to be launched in September 2025. (Number) achieving targets Expectant women using a 0.00 May/2022 0.00 31-Mar-2024 0.00 30-Jun-2024 20,000.00 May/2027 transport voucher or staying in a maternal waiting home to ensure safe deliveries (Number) Of which refugees 0.00 0.00 0.00 200.00 (Number) Of which host 0.00 0.00 0.00 2,000.00 community residents (Number) Completion of annual regional No May/2022 0.00 31-Mar-2024 0.00 30-Jun-2024 Yes May/2027 and national health fora with adopted resolutions (Yes/No) Complaints successfully 0.00 May/2022 0.00 31-Mar-2024 0.00 30-Jun-2024 100.00 May/2027 resolved within 30 days, as communicated to the public (Percentage) Maternal, child, and neonatal 0.00 May/2022 0.00 31-Mar-2024 0.00 30-Jun-2024 40.00 May/2027 deaths that are audited (verbal and clinical) (Percentage) Page 9 of 12 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) Among women's and 0.00 0.00 0.00 40.00 girls' deaths (Percentage) Among refugees' deaths 0.00 0.00 0.00 40.00 (Percentage) Among host community 0.00 0.00 0.00 40.00 residents' deaths Comments on A "host community resident" is any non-refugee resident of the commune of Balbala. (Percentage) achieving targets PBF verification visits with the 0.00 May/2022 0.00 31-Mar-2024 14 30-Jun-2024 100.00 May/2027 participation of the regional health management team (Percentage) Page 10 of 12 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) 7. DATA ON FINANCIAL PERFORMANCE 7.1 Cumulative Disbursements 7.2 Disbursements (by loan) Loan/Credit/TF Status Original Revised Cancelled Disbursed Undisbursed % Disbursed Historical Disbursed IDA-E0540 Effective 5.00 5.00 0.00 0.42 4.46 8.34% 5.00 IDA-71340 Effective 14.50 14.50 0.00 1.19 12.64 8.18% 14.50 7.3 Key Dates (by loan) Loan/Credit/TF Status Approval Signing Effectiveness Orig. Closing Rev. Closing IDA-71340 Effective 26-May-2022 07-Jun-2022 01-Feb-2023 31-May-2027 31-May-2027 Oct 14, 2024 Page 10 of 11 The World Bank Implementation Status & Results Report Djibouti Health System Strengthening (P178033) IDA-E0540 Effective 26-May-2022 07-Jun-2022 01-Feb-2023 31-May-2027 31-May-2027 8. KEY DATES Key Events Planned Actual Approval 26-May-2022 26-May-2022 Effectiveness 01-Feb-2023 01-Feb-2023 Mid-Term Review No. 01 30-Sep-2025 Operation Closing/Cancellation 31-May-2027 9. RESTRUCTURING HISTORY 10. ASSOCIATED OPERATION(S) There are no associated operations Oct 14, 2024 Page 11 of 11