Document of. The World Bank FOR OFFICIAL USE ONLY RESTRUCTURING PAPER ON A OF AN INTEGRATED HEALTH AND WATER MANAGEMENT PROJECT LOAN NUMBER IBRD-7951

Transcription

1 Public Disclosure Authorized Document of The World Bank Public Disclosure Authorized FOR OFFICIAL USE ONLY Report No: RES22987 Public Disclosure Authorized RESTRUCTURING PAPER ON A PROPOSED 2 ND PROJECT RESTRUCTURING Public Disclosure Authorized OF AN INTEGRATED HEALTH AND WATER MANAGEMENT PROJECT LOAN NUMBER IBRD-7951 APPROVED NOVEMBER 2, 2010 TO THE 1

2 STATE OF BAHIA WITH THE GUARANTEE OF THE FEDERATIVE REPUBLIC OF BRAZIL April 20, 2016 Health Nutrition and Population Global Practice Brazil Country Management Unit Latin America and the 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. 2

3 ABBREVIATIONS AND ACRONYMS BAREMA CERB IBRD IID IMR IMA INEMA INGA PDO PDI SESAB SEPLAN SEFAZ SIM SUS SWAp TA TCE A composite outcome indicator that includes 10 intermediate effectiveness performance indicators Bahia Water, Engineering, and Sanitation Company (Companhia de Engenharia Hídrica e de Saneamento da Bahia) International Bank for Reconstruction and Development (World Bank) Infectious intestinal diseases Infant Mortality Rate Bahia State Environmental Insitute (Instituto do Meio Ambiente) Environment and Water Resources Institute (Instituto do Meio Ambiente e Recursos Hídricos) Water and Climate Management Institute (Institute de Gestão das Águas e Clima) Project Development Objective Project Development Intermediate Indicator Bahia State Health Secretariat (Secretaria de Saúde do Estado da Bahia) Bahia State Secretariat of Planning (Secretaria do Planejamento do Estado da Bahia) Bahia StateSecretariat of Finance (Secretaria da Fazenda do Estado da Bahia) System for Mortality Information (Sistema de Informações sobre Mortalidade) Unified Health System (Sistema Único de Saúde) Sector-wide Approach Technical Assistance Bahia State Court of Auditors (Tribunal de Contas do Estado da Bahia) ii

4 Regional Vice President: Country Director: Senior Global Practice Director: Practice Manager: Task Team Leader: Jorge Familiar Martin Raiser Timothy Grant Evans Daniel Dulitzky Fernando Lavadenz BRAZIL INTEGRATED HEALTH AND WATER MANAGEMENT PROJECT iii

5 CONTENTS A. SUMMARY OF PROPOSED CHANGES... 2 B. PROJECT STATUS... 3 C. PROPOSED CHANGES... 4 ANNEX 1: RESULTS FRAMEWORK ANNEX 2: MONITORING OF TARGETS AND RESULTS OF THE BAREMA INDICATOR. 19 ANNEX 3: OUTPUT DISBURSEMENT ARRANGEMENTS ANNEX 4: PER-CAPITA DISBURSEMENT ARRANGEMENTS iv

6 DATA SHEET Brazil Integrated Health and Water Management Project (SWAP) (P095171) LATIN AMERICA AND CARIBBEAN Health, Nutrition & Population Report No: RES22987 Basic Information Project ID: P Lending Instrument: Specific Investment Loan Regional Vice President: Jorge Familiar Calderon Original EA Category: Partial Assessment (B) Country Director: Martin Raiser Current EA Category: Partial Assessment (B) Senior Global Practice Director: Timothy Grant Evans Original Approval Date: 02-Nov-2010 Practice Manager: Daniel Dulitzky Current Closing Date: 30-Apr-2016 Team Leader(s): Fernando Lavadenz Borrower: Responsible Agency: Secretaria de Planejamento (Secretariat of Planning) - SEPLAN Secretaria da Fazenda (Secretariat of Finance) - SEFAZ, Municipality of Salvador - Secretaria da Fazenda 1

7 Restructuring Type Form Type: Full Restructuring Paper Decision Authority: Country Director Approval Restructuring Level: Level 2 Financing ( as of 16-Dec-2015 ) Key Dates Project Ln/Cr/TF Status Approval Date Signing Date Effectiveness Date Original Closing Date Revised Closing Date P IBRD Effective 02-Nov Jul Aug Dec Apr-2016 Disbursements (in Millions) Project Ln/Cr/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P IBRD Effective USD

8 Policy Waivers Does the project depart from the CAS/CPF in content or in other significant respects? Yes [ ] No [ X ] Does the project require any policy waiver(s)? Yes [ ] No [ X ] A. Summary of Proposed Changes The Brazil Integrated Health and Water Management Project (Bahia SWAp), Loan will be restructured to: (a) change the implementing agency from the Secretariat of Planning (SEPLAN) to the Secretariat of Finance (SEFAZ); (b) revise and update the Results Framework; (c) extend the closing date of the Project by 18 months from April 30, 2016 to October 31, 2017; (d) change the disbursement arrangements; (e) reallocate funds among categories; (f) change the disbursement estimates; and (g) change to components to revise the definition of beneficiaries for the per-capita premium and specific Project activities. The proposed changes take into account (i) the restructuring request of the State of Bahia through letter No. 146/2015, from the State s Secretariat of Finance, dated June 16, This request was approved by the Federal Government through Recomendação no. 06/0268, dated December 9, The National Treasury s communication was sent to the Bank through electronic message on February 22, 2016; and (ii) the need to ensure effective utilization of Project resources consistent with government priorities, and adjust for delays in effectiveness and implementation of Project activities. Change in Implementing Agency Yes [ X ] No [ ] Change in Project's Development Objectives Yes [ ] No [ X ] Change in Results Framework Yes [ X ] No [ ] Change in Safeguard Policies Triggered Yes [ ] No [ X ] Change of EA category Yes [ ] No [ X ] Other Changes to Safeguards Yes [ ] No [ X ] Change in Legal Covenants Yes [ ] No [ X ] Change in Loan Closing Date(s) Yes [ X ] No [ ] 3

9 Cancellations Proposed Yes [ ] No [ X ] Change to Financing Plan Yes [ ] No [ X ] Change in Disbursement Arrangements Yes [ X ] No [ ] Reallocation between Disbursement Categories Yes [ X ] No [ ] Change in Disbursement Estimates Yes [ X ] No [ ] Change to Components and Cost Yes [ X ] No [ ] Change in Institutional Arrangements Yes [ ] No [ X ] Change in Financial Management Yes [ ] No [ X ] Change in Procurement Yes [ ] No [ X ] Change in Implementation Schedule Yes [ ] No [ X ] Other Change(s) Yes [ ] No [ X ] Appraisal Summary Change in Economic and Financial Analysis Yes [ ] No [ X ] Appraisal Summary Change in Technical Analysis Yes [ ] No [ X ] Appraisal Summary Change in Social Analysis Yes [ ] No [ X ] Appraisal Summary Change in Environmental Analysis Yes [ ] No [ X ] Appraisal Summary Change in Risk Assessment Yes [ ] No [ X ] B. Project Status The Bahia SWAp Project was approved by the Board on November 2, 2010 and declared effective on August 30, As of March 2016, US$21.35 million (36%) of the total loan amount of US$60 million have been disbursed. 4

10 The Project Closing Date was extended from December 31, 2015 to April 30, 2016 through the simple Level II Restructuring approved by the Brazil Country Director on November 30, 2015, with the purpose of allowing the completion of a full Level II Project Restructuring, proposed in this Restructuring Paper. The PDO is to: (i) Increase access to clean water, sanitation and basic health care in at least 10 selected municipalities most affected by infectious intestinal diseases (IID); and (ii) improve neonatal health in 25 selected hospitals using a Barema indicator of quality and efficiency. The Barema is a composite outcome indicator that includes 10 intermediate effectiveness performance indicators. The Project has two components. Component 1 contributes to Reducing the IMR (neonatal and post-neonatal) in the State of Bahia, and is divided into subcomponents 1A Contribute to reducing State post-neonatal mortality and morbidity due to IID, and 1B Contribute to reducing neonatal mortality in 25 selected hospitals. The second component provides Technical Assistance for the Institutional Modernization of Health, Water, and Planning Sectors. Progress towards achieving the PDO is currently rated Moderately Satisfactory (MS). According to the most recent ISR (January 27, 2016), there has been significant progress in PDO indicators 2 and 3, and little progress in indicators 1 and 4. PDO indicator 1 (the number of people served by simplified water systems) has shown little progress because only 14 systems (out of 200 originally expected under the Project) have been concluded to date. PDO indicator 2 (investigation of hospitalizations of children under five due to IID) reached the end target of 50% a year in advance. PDO indicator 3 (percentage of Barema indicators improved in the 25 reference maternity hospitals) reached 71.6% in 2014 while the end target is 80%. Lastly, there had been difficulties in establishing a methodology to calculate PDO indicator 4 (number of the 25 hospitals that have achieved at least 80% of Barema indicators). This indicator was measured in August 2015, showing five out of the 25 hospitals having reached at least 80% of the Barema in 2014 (Annex 2 details the Barema indicator). Nine of the 17 PDI indicators have also shown progress with four of those achieving Project s end targets a year in advance. The overall implementation progress (IP) rating remains as MS after being upgraded from Moderately Unsatisfactory (MU) to MS in the July 2015 ISR due to improvements in disbursement and implementation of activities in the water and health sectors. Procurement processes for most activities of the water sector have been concluded, and construction of 100 simplified water systems and 350 sanitary modules has started. As per the health sector, the new mechanism in place to verify enrollment of youth pregnant women at risk in the health system for per capita payment purposes, was able to 5

11 validate a total of 14,000 pregnant adolescents and increase the capita disbursement for the second year of the Project. After two and a half years with no disbursements, the Project registered significant increase in disbursements in four months, increasing from 19% (US$11.15 million) in April 2015 to 32% (US$18.95 million) in August An additional US$2.4 million were disbursed in December The Project s objectives continue to be achievable, and the Project is in compliance with the conditions for closing date extensions outlined in OP/BP There is no outstanding audit report or audit reports that are not satisfactory to the WBG. C. Proposed Changes Change in Implementing Agency As informed in last ISRs, the agency responsible for the implementation and coordination of the Project, the Superintendence for Technical and Financial Cooperation, was moved from SEPLAN to SEFAZ, following the January 2015 change in State Government leadership. All project staff have been transferred to SEFAZ, and project implementation has proceeded without any institutional problems. Thus, specific parts of the loan agreement would be revised to reflect this change. The Portal is currently reflecting IA change as a result of structural modifications in the State. Implementation remains adequate following the transition. Implementing Agency Name Type Action Secretaria da Fazenda (Secretariat of Finance) - SEFAZ Implementing Agency No Change Municipality of Salvador - Secretaria da Fazenda Implementing Agency Marked for Deletion Development Objectives/Results Project Development Objectives Original PDO 6

12 The objectives of the Project are to: (a) increase access to clean water, sanitation and basic health care in at least 10 Selected Municipalities most affected by infectious intestinal diseases (ID); and (b) improve Neonatal health care in 25 Selected Hospitals using a Barema indicator of quality and efficiency. Change in Project's Development Objectives No changes Change in Results Framework Explanation: Monitoring and Results Framework The Monitoring and Results Framework (Annex 3 of the PAD) has been revised to: (a) update the baselines for all indicators, to ensure consistency and reflect the date of effectiveness using new accruable data to 2010 values, as per State s request. A number of indicators included 2009 preliminary baseline values using existing data, which upon later revision proved to be inaccurate, and would thus need to be updated. In addition, updates are needed in the baseline of a few indicators for the water sector, after the new selected list of municipalities is defined for intervention; (b) modify targets for three of the four Project Development Objective (PDO) indicators to better reflect project s targets and implementation. In this case, two PDO will increase targets, and the last will reflect modifications made in the number of beneficiaries from new selected set of municipalities; and (c) change nine of the seventeen Project Development Intermediate Indicators (PDI). Five PDI would have their goals increased due to early achievement of or considerable progress towards end of Project targets, and one would have its target reduced due to changes in State s health sector goals. Another five indicators would be eliminated, and one new indicator would be incorporated. In addition, the change in water sector implementing agency at the beginning of the Project also made some indicators incompatible with the new agency s role. The revised Results Framework table is included as Annex 1. PDO Indicators Indicator One: Number of people served by simplified water supply systems and basic sanitation in at least 10 selected municipalities prioritized by the Project. Though the Project was initially projected to serve 40,000 people with water systems in 10 selected municipalities, a revised list of the 10 selected municipalities reduced the total number of people who will be served through the Project to 29,000. The baseline was also revised according to the revised list of municipalities. 7

13 - Baseline in PAD: 32,295 beneficiaries in Target in PAD: 72,295 beneficiaries in Baseline revised: 29,326 beneficiaries in Target revised: 58,326 beneficiaries in 2017 Indicator Three: Percentage of the overall Barema indicators improved in the 25 reference hospitals. Target would be increased to reflect progress toward the end target. Baseline would be revised since initial baseline was based on preliminary data. - Baseline in PAD: 0 percent in Target in PAD: 80 percent in Baseline revised: 40 percent in Target revised: 85 percent in 2017 Indicator Four: Number of the 25 hospitals that have achieved at least 80% of the Barema. Target would be increased from 15 to 18 maternity hospitals. The methodology for measuring the Barema for each hospital was agreed during the August 2015 mission (Annex 2). - Baseline in PAD: 0 hospitals in Target in PAD: 15 hospitals in Baseline revised: 0 hospitals in Target revised: 18 hospitals in

14 Intermediate Results Indicators - PDI Component 1: Contribute to Reducing the IMR (neonatal and post-neonatal) in the State of Bahia A. Sub-Component 1A: Contribute to reducing State post-neonatal mortality and morbidity due to infectious intestinal diseases Indicator One: Number of simplified water supply systems constructed and operating in at least 10 selected municipalities. The baseline would be updated according to the number of systems in the Project s revised list of 10 selected municipalities, which changed between signing and effectiveness. An additional 20 systems would be constructed in the areas of influence of the 25 hospitals with the highest number of hospitalizations due to infectious intestinal diseases (IID), resulting in a total of 220 systems built by the Project. The wording of the indicator was revised to include the new target area. Revised Indicator: Number of simplified water supply systems constructed and operating in at least 10 selected municipalities and in areas of influence of the 25 hospitals with the highest number of hospitalizations due to infectious intestinal diseases (IID) in Baseline in PAD: 161 systems in Target in PAD: 361 systems in Baseline revised: 215 systems in Target revised: 435 systems in 2017 Indicator Three: Number of River Basin Plans prepared and approved by the River Basin Committee including studies for classifying water bodies. End target was revised from 8 to 4 River Basin Plans due to delays in implementation and complexity of procurement processes. - Baseline in PAD: 0 River Basin Plans in

15 - Target in PAD: 8 River Basin Plans in Baseline revised: 0 River Basin Plans in Target revised: 4 River Basin Plans in 2017 Indicator Four: Number of Community Voluntary Agents trained and operational. The target would be increased to better reflect the good performance of the State with regards to this indicator. The baseline was revised because the original 43 Water Community Voluntary Agents were part of a program led by INGA, which was discontinued following the institutional change from INGA to INEMA and for which data could not be confirmed by implementing agencies later in the Project implementation. - Baseline in PAD: 43 agents in Target in PAD: 772 agents in Baseline revised: 0 agents in Target revised: 900 agents in 2017 Indicator Five: Percentage of coverage of first and second applied doses of oral vaccine against human rotavirus in children under 5 years of age. Target would be increased to reflect the State s good performance on this indicator. Baseline would be revised since initial baseline was based on preliminary data. - Baseline in PAD: 57 percent in Target in PAD: 70 percent in Baseline revised: 76 percent in Target revised: 82 percent in

16 B. Sub-Component 1B: Contribute to reducing neonatal mortality in 25 selected hospitals Indicator Seven: Efficiency increased in 25 hospitals based on the overall number of deliveries. Revised in wording and target due to overall decline in fecundity and number of births in the State of Bahia. Revised Indicator: Percentage of live births in the 25 selected hospitals in relation to the number of births in the State of Bahia. This indicator would measure the percentage of live births in the selected hospitals in relation to the number of births in the state. The total number was changed to a percentage due to the reduction of fertility in the state and of total deliveries in the 25 hospitals. - Baseline in PAD: 59,432 deliveries in Target in PAD: 65,000 deliveries in Baseline revised: 37 percent in Target revised: 42 percent in 2017 Indicator Eight: Percentage of low-risk deliveries in the high complexity maternity hospitals Roberto Santos and José Maria de Magalhães. This is a new indicator. Since Roberto Santos and José Maria de Magalhães hospitals are prepared to attend to high-risk births, they should limit the proportion of lowrisk deliveries attended by highly trained personnel. As such, the reduction in proportion of low-risk births as compared to total number of births in these hospitals would improve effectiveness and increase cost savings in the network. - Baseline: 51 percent low risk deliveries in Target: 25 percent low risk deliveries in 2017 Indicator Nine: Percentage of hospital neonatal deaths occurring in the selected maternity hospitals, 11

17 which are investigated, analyzed and discussed. The target would be increased, and the indicator would focus only in the investigated neonatal hospital deaths. Target increase reflects new commitment to investigate neonatal deaths from the State Health Secretariat. Revised Indicator: Percentage of hospital neonatal deaths occurring in the selected maternity hospitals, which are investigated. - Baseline in PAD: 0 percent in Target in PAD: 70 percent in Baseline revised: 40 percent in Target revised: 80 percent in 2017 C. Component 2: Technical Assistance for the institutional modernization of health, water, and planning sectors Indicator Ten: Number of public officials certified in management by results in the three secretariats involved. Wording of the indicator would be revised to align with the State s strategic priorities. Revised Indicator: Number of public officials certified in public management in the involved secretariats. Public officials from SEFAZ, SEPLAN, SESAB, INEMA, Bahia State Court of Auditors (TCE), and Bahia Water, Engineering, and Sanitation Company (CERB) are expected to receive training in public management of at least 32 hours. Baseline and target values would remain unchanged. Indicator Thirteen: Studies for restructuring of Riverine Riparian Forests Program elaborated and under implementation. The target would be increased according to the revision of intermediate indicator four, to the effect that there would be one study conducted for each of the River Basins included in the River Basin Plan indicator. 12

18 - Baseline in PAD: 0 studies in Target in PAD: 2 studies in Baseline revised: 0 studies in Target revised: 4 studies in 2017 Former Indicator (dropped): Control Processing System updated and integrated into the other TCE system. Due to delay in Project effectiveness, system was developed with State s resources and personnel. Former Indicator (dropped): Studies consolidating information of operation and maintenance of rural systems elaborated and under implementation. The operation and maintenance functions are no longer responsibility of CERB. A study was prepared at the broader state level but no decision on implementation has been taken yet. Former Indicator (dropped): State Water Resources Plan reviewed. Due to changes in the State s Water entities, the State Water Resources Plan is no longer under the responsibility of INEMA. Former Indicator (dropped): Communication strategy Action Plan elaborated and under implementation. Due to changes in the State s Water institutes, the communication action plan is no longer under the responsibility of INEMA. Former Indicator (dropped): River Basin Committees created and operational. Due to delay in Project effectiveness, the River Basin Committees were created with State resources. Barema Indicator The Barema indicator of quality and efficiency measures the progress of two of the four PDO indicators, 13

19 and is composed of ten individual indicators. One of the ten indicators would be revised from measuring the total number of births in the 25 selected maternity hospitals to measuring the percentage of the total births in the State of Bahia occurring in the 25 selected maternity hospitals, comparably to PDI indicator seven. This change is due to the declining fertility rate and number of births in the state of Bahia, which makes the proportion of births a more appropriate measure for capturing the births in the 25 selected hospital. In addition, the Barema indicator that measured the number of contracts signed with maternity hospitals would be replaced by a new indicator measuring the number of hospitals with health professionals trained in neonatal resuscitation. This change would take into account the state of Bahia s commitment to improve neonatal care, and the contracts with the maternity hospitals would continue to be a part of the variable component of the per-capita for Year III of the Project. The revisions to the Barema indicators are detailed in Annex 2, including the methodology for calculating both the individual and global indicators. Financing Change in Loan Closing Date(s) Explanation: The State of Bahia requested an 18-month extension of the closing date from April 30, 2016 to October 31, 2017 to allow the Borrower enough time to (i) achieve the PDOs; and (ii) complete all planned activities. The extension is largely justified based on the 22-month lag between Board approval (November 2, 2010) and Project effectiveness (August 30, 2012), and on implementation delays. The following factors contributed to the effectiveness delay: (i) submission of Project documentation when the Secretariat of National Treasury (STN) was pursuing an administrative reorganization that included changes in its loan processing procedures, which required revision of Project documentation presented by the State; and (ii) an administrative reform in the Government of Bahia that resulted in the merger of two implementing agencies, specifically INGA (the state s water agency), and Instituto do Meio Ambiente (the state s environmental agency), to create the new Office of Environment and Water Resources (INEMA), requiring modifications in the loan agreement prior to the signature. With regards to implementation, two main factors contributed to delays: (i) the creation of INEMA provoked delays in the implementation of the Water sector activities once the Project became effective due to the need to adjust to the new agency s capacities and priorities, and (ii) there was a learning curve associated with the innovative results-based financing disbursement features of the Project. 14

20 One of the four PDO indicators and two of the 17 original PDI indicators depend on the construction of simplified water systems and sanitary modules. Given initial challenges with the Bank s procurement rules, the construction of the first 100 simplified water systems was only initiated in January As such, the Project extension ensures enough time for all water systems and sanitary modules to be finalized within the duration of the Project. In addition, there were also delays in the procurement process for conducting the River Basin Plan studies. More recently, delays in conducting required technical audits to validate health sector outputs and per capita premia have also been affecting disbursements. Ln/Cr/TF Status Original Closing Date Current Closing Date Proposed Closing Date Previous Closing Date(s) IBRD Effective 31-Dec Apr Oct Dec-2015 Change in Disbursement Arrangements Explanation: Per-capita Disbursement Mechanism The per-capita disbursement mechanism has been modified to define disbursements modalities on project s final year, due to the extension, including performance based indicators for disbursements. Under Subcomponent 1B, there are proposed changes in the performance indicators of the variable component of the per capita disbursement. New performance indicators for Year V (2016) would be included due to the extension of Project s closing date. Per-capita disbursement arrangements are detailed in Annex 4. The total amount of the capita to be disbursed each year is defined by the number of validated pregnant women registered during pregnancy multiplied by the per capita amount of US$150 starting in year II (US$120 in year I). The individual per capita cost is determined by the cost of non-procurable items of obstetric and neonatal health care services provided to each beneficiary, and may be revised annually. Starting in Year II, the disbursement is increasingly determined by the achievement of performance indicators. In 2016 (Year V), the number of pregnant women would correspond to those registered in the program during the previous year or during the Project year with highest number of registered women. 15

21 The variable component in Year V would be determined by performance indicators. Output Disbursement Mechanism The disbursement arrangements have been revised to expand the payment per results mechanism, under the Project s framework, which includes an output based disbursement modality. Nine new Outputs are proposed for the Water sector and four new Outputs for the Health sector, in addition to the ten existing outputs, totaling 23 outputs for the project. The list of Outputs could be further revised at the request of the Borrower. The table in Annex 3 summarizes the changes made to Outputs, which would be included in the revised Operational Manual alongside any additional changes during Project implementation. The Borrower s fiduciary system was evaluated by the WBG and found acceptable to monitor and report current and new outputs. Original third party technical auditor procedures would remain, with SUS Bahia being responsible for technical auditing of the new and original health sector outputs, and municipalities and/or technical units auditing new outputs in the water and sanitation sector. Reallocations Explanation: A reallocation of Loan Proceeds has been done to respond to the above changes in the disbursement arrangements. Despite recent changes to improve per-capita disbursements (Category of Disbursement 4) through the increase in the per-capita premium amount, disbursements in the first two years of the Project were below initial estimates due to difficulties in validating registered beneficiaries and the decline in the fertility rate in Bahia. In order to give Project implementation more flexibility, and taking into account the demonstrated effectiveness of Output-based disbursements, the Category of Disbursement 2 would be revised to incorporate Outputs for the health sector and Per-capita premia under Part 1.B of the Project. Category of Disbursement 4 would be maintained to register loan proceeds disbursed under that category prior to restructuring. Financial reporting has been assessed by the Financial Management Specialist, and Interim Financial Reports (IFR) will continue to present sufficient information on disbursements associated to the Outputs and Capita for the Health Sector under the combined disbursement category. 16

22 The loan s unallocated funds (Category 5) totaling US$2,764,000 would be reallocated to Category 3 (Water Sector Outputs under Part 1.A (ii) of the Project). These funds would be utilized for the construction of 20 additional simplified water systems and 100 sanitary modules in the areas of activity of the 25 hospitals with the highest number of hospitalizations due to IID, and the progress would be measured through the revised PDI Indicator One (Number of simplified water systems built in the areas of activity of the 25 hospitals with the highest number of hospitalizations due to IID). Based on the changes explained, the table of Allocation of Loan Proceeds would be modified as indicated below. Ln/Cr/T F Curren cy Current Category of Expenditure Allocation Disbursement % (Type Total) Current Proposed Current Proposed IBRD USD GO, TRGN, NCS, CS UNDER PART 2 8,500, ,500, HEALTH STR OUTPUTS UNDER PART 1.A 4,000, ,054, WATER STR OUTPUTS UNDER PART 1.A 28,386, ,150, PER-CAPITA PREMIA UNDER PART 1.B 16,200, ,145, UNALLOCATED 2,764, Designated Account FRONT END FEE 150, , Total: 60,000, ,000, Disbursement Estimates Change in Disbursement Estimates 17

23 Explanation: Given the extension of the closing date, the disbursement estimates have been revised to reflect the new action plan and respective procurement plan. Original and revised disbursement estimates are included below. Fiscal Year Current (USD) Proposed (USD) ,999, ,000, ,000, ,150, ,000, ,000, ,500, ,000, ,500, ,000, ,850, Total 59,999, ,000, Components Change to Components and Cost Explanation: The following changes to Project activities are aligned with the Project s PDOs and with the State of Bahia health priorities. There are no changes to component costs. Under Subcomponent 1B, the definition of eligible beneficiaries for the per capita premium would be modified to include pregnant women 35 years of age and older, in addition to the already included pregnant women aged 10 to 19 years old. These two age groups are considered to be high- risk 18

24 pregnancies and have direct influence in Project indicators. Eligible beneficiaries would continue to be verified through the external technical audit, using a randomized representative sample of medical records of any of SUS systems, as proposed by the SESAB through a technical note submitted on April 24, 2015, which received the Bank s approval on May 22, 2015, and/or a mechanism satisfactory to the Bank. Also under Subcomponent 1B, part of the Project s activities to strengthen the maternal and neonatal health care originally funded with the per capita disbursement mechanism would also be funded by the output based disbursement mechanism, with the inclusion of new health Outputs (Annex 3). Under Subcomponent 2C of the Project, the activities would be revised as follows: Activity (i) the development of strategic plans for both entities as well as a communication strategy for INEMA would be excluded along with its respective indicator (Communication strategy Action Plan elaborated and under implementation) due to changes in the responsibilities of the State s Water entities. Activity (iii) the development of a plan for remote operations that includes enhancing efficiency, finding alternatives to transfer knowledge, lowering costs, and creating staff incentives for improved performance would be excluded because CERB has advanced with similar activities with its own resources. Under Subcomponent 2D, the sole activity would be revised from Provision of support to TCE for, inter alia, the updating of the TCE s administrative and processing system to enable TCE to provide timely review and monitoring of the Borrower s investment operations, such as those under the Project to Provision of support to TCE for, inter alia, enabling TCE to provide timely review and monitoring of the Borrower s investment operations, such as those under the Project since the updating of the TCE s Control Processing System was conducted prior to Project effectiveness with State s resources. Similarly to activity 2A, a new activity 2E would be included with the objective to strengthen the capacity of SEFAZ, which would be the new Project coordination unit. Current Component Name Proposed Component Name Current Cost (US$M) Proposed Cost (US$M) Action Contribute to Reducing the IMR (neonatal and post-neonatal) in the No Change 19

25 State of Bahia Technical Assistance for the Institutional Modernization of Health, Water, and Planning Sectors No Change Total:

26 ANNEX 1: Results Framework Project Name: Integrated Health and Water Management Project (SWAP) (P095171) Project Stage: Restructuring Status: DRAFT Team Leader: Fernando Lavadenz Requesting Unit: LCC5C Created by: Marize De Fatima Santos on 16-Mar-2016 Product Line: IBRD/IDA Responsible Unit: GHN04 Modified by: Marize De Fatima Santos on 16-Mar-2016 Country: Brazil Approval FY: 2011 Region: LATIN AMERICA AND CARIBBEAN Lending Instrument: Specific Investment Loan Project Development Objectives Original Project Development Objective: The objectives of the Project are to: (a) increase access to clean water, sanitation and basic health care in at least 10SelectedMunicipalities most affected by infectious intestinal diseases (ID); and (b) improve Neonatal health care in 25 Selected Hospitals using a Barema indicator of quality and efficiency. Results Core sector indicators are considered: Yes Results reporting level: Project Level 21

27 Project Development Objective Indicators Status Indicator Name Core Unit of Measure Baseline Actual(Current) End Target Revised Number of people served by simplified water supply systems, and basic sanitation in at least 10 selected municipalities prioritized by the project Number Value Date 02-Nov Jun Oct-2017 Number of people served by simplified water supply systems, and basic sanitation in at least 10 selected municipalities prioritized by the project Number Value Date 02-Nov Jun Dec-2015 No Change Percentage of annually investigated hospitalizations of children under five, due to intestinal infectious diseases, in 25 hospitals. Percentage Value Date 02-Nov Dec Dec-2015 Revised Percentage of the overall Barema indicators improved in all 25 reference hospitals. Percentage Value Date 02-Nov Jun Oct

28 Percentage of the overall Barema indicators improved in all 25 reference hospitals. Percentage Value Date 02-Nov Jun Dec-2015 Revised Number of the 25 hospitals that have achieved at least 80% of the Barema indicators Number Value Date 02-Nov Jun Oct-2017 Number of the 25 hospitals that have achieved at least 80% of the Barema indicators Number Value Date 02-Nov Jun Dec-2015 Intermediate Results Indicators Status Indicator Name Core Unit of Measure Baseline Actual(Current) End Target Revised Number of simplified water supply systems constructed and operating in at least 10 selected municipalities and in areas of Number Value Date 02-Nov Jun Oct

29 influence of the 25 hospitals with the highest IDD hospitalizations Number of simplified water supply system constructed and operating in at least 10 selected municipalities. Number Value Date 02-Nov Jun Dec-2015 No Change Number of rural sanitary pilot modules built in at least 10 selected municipalities Number Value Date 02-Nov Dec Dec-2015 Revised Number of River Basin Plans prepared and approved by the River Basin Committee including studies for classifying water bodies Number Value Date 02-Nov Jun Oct-2017 Number of River Basin Plans prepared and approved by River Basin Committee bodies and ratified by CONERH including studies for classifying water. Number Value Date 02-Nov Jun Dec-2015 Revised Number of Community Voluntary Agents Number Value

30 Trained and operational Date 02-Nov Mar Oct-2017 Number of Community Voluntary Agents Trained and operational Number Value Date 02-Nov Mar Dec-2015 Revised Percentage of coverage of first and second applied doses of oral vaccine against human rotavirus in children under 5 Percentage Value Date 02-Nov Mar Oct-2017 Annual increase of coverage rate of vaccination against human rotavirus. Percentage Value Date 02-Nov Mar Dec-2015 No Change Population coverage by family health teams in the state of Bahia Percentage Value Date 02-Nov Dec Dec

31 New Percentage of live births in the 25 selected hospitals in relation to the number of births in the State of Bahia Percentage Value Date 02-Nov Dec Oct-2017 New Percentage of low-risk deliveries in the high complexity maternity hospitals Roberto Santos and Jose Maria Magalhaes Percentage Value Date 02-Nov Jun Oct-2017 Revised Percentage of hospital neonatal deaths occurring in the selected maternity hospitals investigated Percentage Value Date 02-Nov Dec Oct-2017 Percentage of neonatal deaths occurring in the selected maternity hospitals investigated, analyzed and discussed Percentage Value Date 02-Nov Dec Dec-2015 Revised Number of public officials certified in public management in the involved secretariats Number Value Date 02-Nov Jun Oct

32 Number of public officials certified in management by results in the three secretariats involved. Number Value Date 02-Nov Jun Dec-2015 Revised Number of strategic agendas in the health sector that prioritize maternal and child health. Number Value Date 02-Nov Dec Oct-2017 Number of strategic agendas in the health sector that prioritize maternal and child health. Number Value Date 02-Nov Dec Dec-2015 Revised Creation of a geographic information system (SIG) unit within CERB Number Value Date 02-Nov Dec Oct-2017 CERB Geographic Information System Unit Number Value

33 established and operational and Bahia state map of infectious intestinal diseases prevalence and water systems updated. Date 02-Nov Dec Dec-2015 Revised Studies for restructuring of Riverine Riparian Forests Program elaborated and under implementation Number Value Date 02-Nov Dec Oct-2017 Studies for restructuring of Riverine Riparian Forests Program elaborated and under implementation Number Value Date 02-Nov Dec Dec-2015 Marked for Deletion Efficiency increased in 25 hospitals based on the overall number of deliveries Number Value Date 02-Nov Dec Dec-2015 Marked for Deletion Control Processing System updated and integrated into the other TCE systems Number Value Date 02-Nov Jun Dec

34 Marked for Deletion Study consolidating information of operation and maintenance of rural systems. Number Value Date 02-Nov Dec Dec-2015 Marked for Deletion State Water Resources Plan Reviewed Number Value Date 02-Nov Dec Dec-2015 Marked for Deletion Communication strategy Action Plan elaborated and under implementation Number Value Date 02-Nov Dec Dec-2015 Marked for Deletion River Basin Committees created and operational Number Value Date 02-Nov Dec Dec-2015 * See Annex 2 for the Barema indicator 29

35 30

36 ANNEX 2: Monitoring of Targets and Results of the Barema Indicator The overall Barema indicator is calculated based on the combined performance of the 25 selected maternity hospitals on each of the ten indicators compared to the target for that indicator. Each of the 10 indicators have equal weights in the calculation of the indicator, for a total of 100 points or percentage. For instance, to calculate Indicator 1 (Mother Kangaroo program implemented in 25 Maternity hospitals selected), the number of hospitals that had the mother kangaroo program implemented is divided by the end target of 15 to obtain each year s value for this indicator. This procedure is repeated for each of the ten indicators described in Table A.2.1, below. Table A.2.1: Overall Barema Indicator INDICATOR BASELINE 2010 TARGET 2016 WEIGHT COMMENTS 1. Mother Kangaroo program implemented in 25 Maternity hospitals selected 2. Efficiency measured through the proportion of births in the 25 selected maternity hospitals in relation to the total number of births in the State of Bahia Original indicator: Number of deliveries in the 25 Maternity Hospitals selected 3. Percentage of hospital neonatal deaths investigated 4. Number of selected hospitals with neonatology services implemented (ITU or ICU) 5. Number of selected hospitals with milk bank implemented 6. Index of IT beds/obstetric beds in the 25 selected maternity hospitals 7. Proportion of ICU beds/obstetric beds in the 25 selected maternity hospitals % 42% 10 59,432 65, Excluded 40.76% 80% /765 = 0,08 149/765 = 0, /765 = 0,10 192//765 = 0,25 Target adjusted from 25 to 15 due to variety of health care units profile, where the implementation of Mother Kangaroo in not required or mandatory Indicator revised due to decrease in fertility rate in the State of Bahia Target increased to 80% in Target for 2014 set to 50%, and 2015 target set to 65%. Target adjusted from 25 to 22 due to varying maternity hospital levels Target adjusted from 25 to 15 due to varying maternity hospital levels 10 Maintained 10 Maintained 8. Number of mother and child joint beds Maintained 9. Percentage of ITU beds referred from the central referral system 10. Number of hospitals with health professionals certified in neonatal resuscitation Original indicator: Signed management contracts with the selected 25 maternity hospitals 0% 50% 10 Maintained Excluded New indicator included for increased impact on attention to neonates

37 INDICATOR BASELINE 2010 TARGET 2016 WEIGHT TOTAL EFFECTIVENESS 40% 80% 100 COMMENTS 32

38 Table A.2.2: Individual Barema Indicator Indicator # Indicators Individual target Mother Kangaroo Proportion of births % investigated neonatal deaths ITU or ICU services Milk bank Proportion of ITU beds Proportion of ICU beds Number of joint beds % UTI beds in referral system * Neonatal resuscitation Total Weight certificate Weight of the 25 maternities will use all 10 Barema indicators to measure individual hospital performance with the 10 indicators, targets and weights above. Individual targets remain the same for each indicator across all maternities. Indicators Proportion of births % investigated neonatal deaths ITU or ICU services Milk bank Proportion of ITU beds Proportion of ICU beds Number of joint beds % UTI beds in referral system Neonatal resuscitation Total Weight certificate Weight of the 25 maternities will use 9 Barema indicators to measure individual hospital performance with the respective weights indicated above Indicators Mother Kangaroo Proportion of births % investigated neonatal deaths ITU or ICU services Proportion of ITU beds Proportion of ICU beds Number of joint beds % UTI beds in referral system Neonatal resuscitation Total Weight certificate Weight of the 25 maternities will use 9 Barema indicators to measure individual hospital performance with the respective weights indicated above Indicators Proportion of births % investigated neonatal deaths ITU or ICU services Proportion of ITU beds Proportion of ICU beds Number of joint beds % UTI beds in referral system Neonatal resuscitation Total Weight certificate Weight of the 25 maternities will use 8 Barema indicators to measure individual hospital performance with the respective weights indicated above Indicators Proportion of births % investigated neonatal deaths Proportion of ITU beds Proportion of ICU beds Number of joint beds % UTI beds in referral system Neonatal resuscitation Total Weight certificate 33

39 Weight of the 25 maternities will use 7 Barema indicators to measure individual hospital performance with the respective weights indicated above Note: Indicators in blue are measured collectively for all 25 hospitals. *The % of investigation of hospital deaths has target of 50% in 2014, 65% in 2015, and 80% in

40 ANNEX 3: Output Disbursement Arrangements # Output Name Unit of measurement Number of Deliverables Unit cost US$ Program budget US$ s Plans for building of simplified water supply systems elaborated Simplified water supply systems built and operational in at least 10 selected municipalities and in the areas of activity of the 25 hospitals with highest number of hospitalizations due to IID in 2014 Supervision of the construction of the simplified water supply systems built WATER SECTOR OUTPUTS Plans elaborated ,740 2,582,800 Increase in the number of deliverables from 200 to 220 according to the new goal of Systems built and operational as certified by the respective municipality (Prefeitura) Final Supervision reports elaborated by CERB ,500 13,090, , ,800 increasing water coverage in the areas of operation of the hospitals with most hospitalizations by IID in 2014 (Indicator 1 - Annex 1). Adjusted Output name accordingly. 4 Rural sanitary pilot modules built and operational Modules built and operational as received by each beneficiary family and certified by the TCE 1,100 2,430 2,673,000 Increase in number from 1,000 to 1, Term of adherence of selected communities for the Community with Healthy Habits Program Number of households certified as households with healthy habits Number of communities certified as a community with healthy habits Signed terms of adherence ,300 Number of certified households ,000 Number of certified communities 220 1, ,100 New outputs created for the implementation of the new Community with Healthy Habits Program 8 River basin plans (Planos de Bacia) prepared and approved by the river basin committees (Comitês de Bacia) including studies for classifying water bodies according to location and predominant use Plans prepared and approved by the river basin committees 4 1,225,000 4,900,000 Number of deliverables revised from 8 to 4 (Indicator 3 - Annex 1) 35

41 # Output Name Unit of measurement Number of Deliverables Unit cost US$ Program budget US$ s 9 Community volunteer agents for social mobilization trained and retained by INEMA Agents trained and retained 900 1,295 1,165,500 Number of deliverables revised from 722 to 900 (Indicator 4 - Annex 1) 10 Report on the quality and quantity of waters in the State of Bahia Report prepared 1 220, , Report on the quality and quantity of the water in the areas of influence of the Project Report prepared 1 180, , Executive project for the integrated network of groundwater and hydrometeorology monitoring in the Project s areas of influence Installation of platforms for data collection on groundwater conditions Project prepared 1 154, ,500 Platforms installed ,000 2,500,000 New outputs created for implementation of new integrated monitoring of groundwater and hydrometeorology conditions activity of INEMA 14 Installation of platforms for data collection on climate conditions Platforms installed 20 50,000 1,000, Installation of platforms for data collection on hydrologic conditions Platforms installed 40 17, ,000 HEALTH SECTOR OUTPUTS Doses of oral vaccine against human rotavirus applied in children under one year of age (first dose) Doses of oral vaccine against human rotavirus applied in children under one year of age (second dose) New family health teams (PSF) in the State appointed and in operations Applied doses 400, ,000 Maintained Applied doses 400, ,000,000 Maintained PSF teams created ,000 2,000,000 Maintained 36