SRI LANKA: Second Health Sector Development Project (CR 52280) Aide-Memoire. Implementation Support Mission May 5-15, 2015

Transcription

1 SRI LANKA: Second Health Sector Development Project (CR 52280) Implementation Support Mission May 5-15, 2015 Aide-Memoire Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized 0

2 Table of Contents A. Introduction... 3 B. Key Project Data... 3 C. Project Development Objective... 3 D. Summary: Implementation Progress... 3 E. Detailed Description of Status of Project Components... 3 F. Procurement, Financial Management (FM) and Disbursement... 7 Procurement Component Procurement Component Financial Management Component Financial Management Component Disbursement... 9 G. Safeguards... 9 H. Results Framework and Monitoring & Evaluation I. Communications Related to the Project J. Summary of Discussions Regarding Possible Project Restructuring K. Proposed Next Implementation Support Visit: ANNEXURES Annex 1. Status of Agreed Actions from December 2014 Mission Annex 2. Agreed actions from the current May 2015 mission Annex 3: Cash Flows for Annex 4: Updated Results Framework (Based on April 2015 Results Report) Annex 5: Outcome of discussions to Review and Modify the Results Framework, mission meetings May 7 and 9, 2015 with participation of MOH, MOF, MOPP, Provincial MOHs

3 A. Introduction Sri Lanka: Second Health Sector Development Project (CR 52280) Implementation Support Mission May 5-15, 2015 Aide-Memoire 1. The World Bank conducted its third implementation support mission for the Sri Lanka Second Health Sector Development Project (SHSDP) from May 5 to 15, The objectives of the mission were to review the implementation status of the SHSDP and its progress towards achieving its development objective. 2. The team 1 held discussions with officials of the Ministry of Health and Indigenous Medicine (MoH), the Ministry of Provincial Councils and Regional Development (MPCRD), the Ministry of Finance (MoF), Ministry of Policy Planning, Economic Affairs, Child, Youth and Cultural Affairs (MoPP) including the Departments of External Resources, National Planning, National Budget, Treasury Operations and Project Management and Monitoring, and the 9 Provincial level health authorities. The mission thanks the Government of Sri Lanka (GoSL) for its cooperation and hospitality. 3. This Aide Memoire (AM) summarizes the discussions and agreements reached during the consultations. The team s findings, summarized in this AM were discussed at a wrap-up meeting, chaired by the Dr. D.M.R.B. Dissanayake, Secretary, MoH on May 15, B. Key Project Data Project Data Project Performance Ratings Board Approval (Original): March 27, 2013 Summary Ratings: Last** Now Effectiveness date (Original): September 12, 2013 of PDO: S S Original Closing Date: September 30, 2018 Implementation Progress: S S Original Credit Amount: US $200 million Project Management: S S (SDR million) Procurement: MS MS Amount Disbursed*: US $56.4 million Financial Management: S S (SDR 40.0 million) Safeguards: S S Disbursement % 30.8 percent M&E: S S Deviation from original estimate: 7.7 percent Counterpart Funding: S S *As of May 15, 2015 ** Last ratings from the Implementation Status Report dated December 29, Ratings: HS=Highly Satisfactory; S=Satisfactory; MS=Moderately Satisfactory; U=Unsatisfactory; HU=Highly Unsatisfactory 1 The team consisted of: Kumari Vinodhani Navaratne (TTL, Sr. Health Specialist), Phoebe Folger (Operations Officer), Nkosinathi Mbuya (Sr. Nutrition Specialist), Owen Smith (Sr. Health Economist), Khalid Bin-Anjum (Sr. Procurement Specialist), Jiwanka Wickramasinghe (Sr. Financial Management Specialist), Darshani De Silva (Environmental Specialist), Sandya Salgado (Sr. External Affairs Officer), Dilinika Peiris (Communications Associate), Lashan Jayawardena (Environment Management consultant), Dakshinari Hulugalle (consultant, HRH and Pharmacy), Susrutha Goonaskdera (Social Development consultant) Nalika Gunawardena (Consultant on Planning) and Kerima Thilakasena (Program Assistant). 3

4 C. Project Development Objective 4. The Project Development Objective (PDO) is to support the implementation of the National Health Development Plan (NHDP) to upgrade the standards of performance of the public health system and to enable it to better respond to the challenges of non-communicable diseases and nutrition. Based on implementation progress, disbursement performance, results through the end of 2014, and discussions with GoSL including results management and monitoring teams from the MoPP and MoF the mission is pleased to confirm that the project remains on track and likelihood of achieving the Project Development Objective is high. The Development Objective (DO) rating remains as Satisfactory. D. Summary: Implementation Progress 5. The mission is pleased to note strong overall implementation progress and commends GoSL s commitment to results focused development and accountability at all levels. As agreed in the project, the results and disbursement linked indicator (DLI) report for the calendar year 2014 results was submitted to the Bank in April An independent consulting firm will validate the results for the nine DLIs through field visits. From the results, in consultation with the MoF, MoPP, and MoH, the research team and the World Bank will finalize the actual achievement progress for the year 2014 by June 30, The Implementation Progress (IP) rating remains as Satisfactory. E. Detailed Description of Status of Project Components 6. Component 1 (US$190 million): Support to priority areas under the National Health Development Plan (NHDP). This component supports the implementation and achievement of goals of the NHDP and the project supports 20 results under three thematic areas: (i) maternal and child health, nutrition and communicable diseases; (ii) prevention and control of non-communicable diseases (NCDs); and (iii) health system improvement measures. As indicated above, the progress and results report for calendar year 2014 submitted by the Project Management and Monitoring Department of the MoPP indicates good implementation progress overall under Component 1. Commitment for achievement of the agreed targets by the implementing teams in the MoH and the 9 Provinces is high as indicated by the strong progress against targets for most of the 20 indicators. The 2014 results are presented in Annex 4 in the updated results framework. A summary description of each of the agreed target areas along with the relevant results indicators is given below. 7. Thematic area I: Maternal and Child Health, Nutrition and Communicable Diseases Under thematic area I, the following PDO and intermediate level indicators are monitored. % of pregnant women with anemia after the second trimester (PDO Indicator 2) % of Maternal and Child Health (MCH) clinics with an agreed package of equipment and supplies for the provision of care for pregnant women and children under five years. (DLI 5) 3

5 % of Comprehensive Emergency Obstetric and Neonatal Care (CEMOC) facilities providing 24x7 CEMOC services % of Medical Officer of Health areas with at least three health and nutrition community support groups Case detection rate for Tuberculosis 8. Progress against indicators under thematic area I is mixed. The 2014 targets were exceeded for the percent of CEMOC facilities providing 24x7 CEMOC services and the percent of Medical Officer of Health areas with at least three health and nutrition community support groups. However the targets for Tuberculosis case detection rate and percent of MCH clinics with an agreed package of equipment and supplies for the provision of care for pregnant women and children under five years have not been met. Results for the PDO indicator on Anemia among pregnant women in the second trimester will be monitored and reported through the regular administrative from 2015 onwards. As such, were not available for this indicator for Thematic area II: Prevention and control of non-communicable diseases (NCDs) Under thematic area II, the following PDO and intermediate level indicators are monitored. % of persons (over 40 years) screened for selected NCDs at Healthy Lifestyle Centres (HLCs) (PDO Indicator 1) % of centrally managed health facilities with Emergency Treatment Units (ETUs) for that level of facility based on standard guidelines (PDO Indicator 3) (DLI 1) % of provincially managed health facilities with ETUs for that level of facility based on standard guidelines (PDO Indicator 4) (DLI 2) % of Medical Officer of Health areas with at least two HLCs (DLI 6) % of primary health care institutions having one month s buffer stock for 16 selected NCD drugs No. of provinces with at least one health facility providing rehabilitation services 10. Progress is on track for all indicators for thematic area II. The GoSL s results report noted that while the overall achievement of percent of primary health care institutions having one month s buffer stock for 16 selected NCD drugs was good, at the time of reporting, one of sixteen essential drugs was out of stock at all primary health care institutions in seven districts. The Ministry of Health launched the National Rehabilitation Guidelines for Sri Lanka and is developing tools to monitor the disabled patients who require services. In addition, the MoH is planning, in collaboration with the World Bank, to carry out an assessment on accessibility for disabled persons in health facilities. The planned timeframe for this is from June to December Thematic area III: Health System Development Under thematic area III, the following PDO and intermediate level indicators are monitored. % of MoH managed health facilities sending indoor morbidity through electronic Indoor Morbidity and Mortality Return (e-immr) (DLI 3) 4

6 % of provincially managed health facilities sending indoor morbidity through e- IMMR (DLI 4) % of training institutes managed by the MoH meeting national standards % of laboratories in health facilities (base hospitals and above) participating in external quality assurance program for selected tests conducted by the Medical Research Institute % of hospitals (base hospitals and above) that have obtained Environmental Protection Licenses (EPL) and Scheduled Waste Licenses (HWL) % of fully functioning quality management units (QMUs) in MoH managed base hospitals and above (DLI 7) % of fully functioning quality management units (QMUs) in provincially managed base hospitals and above (DLI 8) % of National Competitive Bidding (NCB) contracts awarded within the first nine months of the previous calendar year from 2014 onwards % of the six monthly cash forecast (for non-salary recurring and capital expenditures) released (DLI 9) 12. The health systems development thematic area includes nine indicators intended to monitor and support the expansion and modernization of the health system. Overall, progress against targets in this thematic area is good however two of the nine indicators in this area either did not report results (the percent of training institutes managed by the MoH meeting national standards) or did not meet their 2014 targets (the percent of base hospitals and above that have obtained Environmental Protection and Scheduled Waste licenses). 13. The MoH finalized a framework for standards of basic training programs (FSBTP) and a tool to evaluate the degree of compliance of training schools to each criteria specified in the framework. Furthermore, the National Training Policy for the Health Workforce (NTPHW) has been drafted and is awaiting the approval of the MoH and other relevant stakeholders. The framework is a core guide for improving the standards of the MoH managed health schools and consists of six core areas: governance; trainee recruitment; trainers; curricula; infrastructure and evaluation mechanisms. Out of the thirty four training schools, the MoH is working with eight schools to enhance their performance and meet the framework standards. 14. Component 2 (US$10 million) Innovation, Results Monitoring and Capacity Building. The objective of this component is to support the implementation of innovations within the NHDP in addition to activities related to operational research, capacity building, results monitoring and technical assistance. A broad five year plan for this fund has been developed. The mission agreed that the MoH will send detailed annual activity plans for each calendar year starting from It was agreed that the annual plan for 2015 will be submitted to the Bank by June 15, One of the major activities to be carried out under Component 2 is the 2015/2016 Demographic and Health Survey (DHS). While implementation progress related to this survey has been slow, the mission noted that a Memorandum of Understanding between the MoH and the Department of Census and Statistics with clear designation of roles for the two parties was signed on March 23, It was agreed that finalizing the consultancy with ICF International (the international technical assistance team) will be given high priority and 5

7 awarded before June 30, The planned national health utilization survey and urban health related tasks originally under the Component 2 will now be carried out under a Trust Fund and Bank grant funding with close collaboration with the GoSL. 16. Capacity development supported by Component 2 includes both local and international training. The MoH, following wide consultation and prioritization, developed a capacity building training plan for international training that was submitted to the World Bank on April 22, 2015 for review and concurrence. The mission reviewed the training plan and recommends inclusion of a few additional training programs relevant to the project development objective. The mission agreed that the letter informing of our concurrence and / or suggestions for improvement of the proposed capacity building plan will be issued by the Bank team to the MoH before May 30, The mission also agreed that more efforts will be taken to send participants to organized training courses rather than study tours. Furthermore, the mission agreed that training participant/s will need to send a report /proposal to the MoH and to the World Bank on the outcomes, applicability and adaptability of the training to Sri Lanka. The required template will be developed by the project support team and submitted to the Bank for concurrence before June 15, Component 2 also intends to create opportunities for innovators and researchers in the health sector at all levels and staff categories (provinces, hospitals, administrators) to carry out pilot projects that would help improve the efficiency and quality of the Sri Lankan health system. The required formats for the call of proposals were developed, cleared and the application call is accessible on the MoH website: While a few proposals have been received by the MoH, the proposals are yet to be sent to World Bank for review and clearance prior to being awarded. The mission discussed ways of simplifying fund release to the researchers and innovators and it was agreed that the revised fund flow mechanism for these grants will be agreed with the Bank before June 15, The mission also agreed that to simplify the selection process, a two page concept note will be introduced for selection of proposals. The relevant template for a concept note will be prepared by the project support team and submitted to the Bank before June 15, Component 2 supports the implementation of Component 1 tasks at the provincial level with the support of a small team of professionals attached to the MPCRD. The mission notes that the team consisting of the Deputy Project Director, a Financial Management Specialist and the support of the Procurement Specialist and the Project Specialist are expected to institutionalize the results monitoring of the health sector as well as support to develop the procurement capacity at the provincial level. The mission urges the MoH and the MPDRD to support the establishment and / or reactivation of the agreed monitoring committees (described in detail in the Project Appraisal Document of the SHSDP) at various levels of implementation for this purpose. The mission also agreed with the MoH and the MPCRD that the implementation guideline for utilizing Component 1 resources at the province level, which was originally issued in 2013, will be reviewed and reissued to the provinces before June 30,

8 19. As during the previous mission in December 2014, the mission expressed continued concern regarding the slow implementation of activities and the corresponding low disbursement under this component. F. Procurement, Financial Management (FM) and Disbursement Procurement Component Ninety-five percent of the project funds (Component 1) go to the General Treasury Account and the eligible expenditure program is defined as non-procurable items under this project (Component 1). The funds support the implementation of the NHDP and national procurement guidelines and systems will be used when procuring to meet the sector results. Therefore, the project proposes a strong procurement capacity building program in order to best utilize the existing Sri Lanka National Procurement Guidelines 2006 and to improve the capacity for efficient contract management to ensure timely service delivery and better utilization of allocated resources. 21. The mission noted that a full time dedicated Procurement Specialist and a Project Specialist are supporting the MoH and MPCRD from December 15, 2014 and April 2015 onwards respectively. During the previous mission in December 2014, development of a procurement capacity building program was discussed in detail with the MoH and the MPCRD. Three key pillars are mutually agreed by the Bank and the counterparts for developing an action plan for conducting the capacity building program. While the team noted that this is not yet complete, it was agreed that the updated procurement training plan will be submitted to the Bank before June 30, The Bank team also discussed the need to carry out a Supply Chain Assessment for the health sector. The assessment will review the complete chain from need identification and planning to health service delivery to the clients. This will involve review of organizational structures; finance; procurement; policies and regulations; logistics storage, inventory, transport, and waste management; information systems and processes. The assessment can also help in identifying a value chain in the health sector for bringing value addition to the current service delivery. The Bank team is working on developing a concept note and a draft plan which will be shared with the Government before July 30, 2015 for review and concurrence. Procurement Component There has been no significant progress of procurement activities since the last mission in December The only contract that had to be awarded to ICF International on a single source basis for supporting the Demographic Health Survey is still in negotiations with the firm and the draft negotiated documents are yet to be reviewed and cleared by the Bank. The procurement plan was again discussed in detail and specific comments were communicated for revision. The procurement of equipment packages have been initiated but are yet to be awarded. It was agreed that the revised procurement plan would be sent to the Bank for clearance before June

9 24. Based on the overall progress made on procurement activities and its impact on project implementation, the procurement rating is Moderately Satisfactory. Financial Management Component Staffing: The mission was pleased to note that MoH has formally assigned one staff member from its finance unit on part time basis and a dedicated FM staff member seconded from Government has been assigned to support the MPCRD s role on FM related activities such as the preparation of the quarter interim financial statements, annual financial statements, coordinating with the external audit and actively support the capacity building initiatives planned under the project. Mission expects that these new arrangements should help avoid future reporting delays. 26. Capacity Building: As a part of sector capacity building, training is being planned to utilize some of the capacity building budget of the health sector (from Component 1) to train 60 accountants working in central Government health institutions in An overseas training institution has been identified and the MoH is awaiting the relevant internal approvals. The balance funds are being utilized to improve the facilities of the FM unit at MoH. 27. Financial Management Information System (FMIS): An in-house developed FMIS is ready for implementation with the primary aim being timely bottom up reporting and commitment accounting. A clear roll out and training plan has not yet been developed. The Chief Accountant is actively involved in operationalizing the system and is working on identifying and developing a team of champions/trainers to train the broader group of users and roll out the system. World Bank team advised that system related procedures and guidelines also need to be developed. Adequate capacity building funds will be allocated for such work in the 2016 budget. It was agreed that the presentation of the FMIS system to the Bank team will be scheduled before July 30, Fund flow: The mission notes with appreciation that funds release by the Treasury against the requested amount by the spending units is 88 percent in the MoH and 93 percent in the Provinces in 2014 (Annex 3 for details). The mission noted that the MoH (where the bulk of the capital health budget lies) utilized approximately 81 percent of the 2014 budget. The mission proposes a joint MOH / WB assessment of process related bottlenecks in capital budget utilization to commence in September Quarterly Financial Management Reports (IFRS): In line with the financial covenants of the project, the MoH and MPCRD have submitted all quarterly reports with the last one being for quarter ending December These have been reviewed by the Bank and found to be in order. Delays have been experienced in compiling these reports however, these delays are not expected to continue going forward with the new staffing arrangements in place. The mission reminded that the IFRs (for both Central and Provincial) for each quarter are due before 45 days of completion of the quarter. 30. Annual Audited Financial Reports: The annual audited financial statements for financial year 2013 were due to the Bank by October 31, 2014 and the 2014 audit report is due at the bank before September The audit reports for 3013 were submitted by MoH and 8

10 MPCRD for the central and provincial health activities by February and March, 2015 respectively. The audit report was reviewed and found to be in order. Several joint meetings were held with the Auditors and the health sector staff to agree on steps to improve the timelines as well as to re-clarify the objective of the audit as: (1) Providing assurance on the accuracy of the IFR as statement that represents the health sector expenditures for a given period: (2) Identifying and reporting significant internal control and process related issues in the health sector that adversely affect its performance and results. Both MoH and MPCRD are in the process of reconciling the IFR for the period ending December 31, 2014 against the final appropriation accounts of 2014 prior to submitting to the external auditors. Financial Management Component Disbursements for Component 2 are much slower than anticipated. A MoH Accountant has been assigned on a part time basis to implement the FM activities under Component 2. The IFRs are up to date and found to be in order. It was agreed during the mission that a separate audit report will be prepared for this component. The audit report for Component 2 is due on September 30, 2015 along with the Component 1 audit reports. Disbursement 32. The project has disbursed US$56.4 million (30.8%) since it became effective in September, The overall strong disbursement performance under Component 1 is matched by equally good implementation progress with many of the results for 2014 achieved or surpassed. However, as indicated above, the mission remains concerned by the very slow disbursement under Component 2. The Bank released the first advance of US$ 2 million in May 2014 yet the reported expenditures amount to approximately US$ 67, G. Safeguards 33. It is encouraging to note that larger numbers of government hospitals across the country have applied for Environmental Protection and Scheduled Waste Licenses over the last six months. While the indicator for this activity is not yet achieved, the mission believes it is on track to achieve the target in Other activities related to the overall implementation of the Environment Management Framework (EMF) for health care waste have been slower. The mission recommended that the Directorate of Environment and Occupational Health and Safety (DEOHS), in collaboration with the Central Environmental Agency (CEA), and with the support of the World Bank team update the implementation plan of action of the Environment Management Framework before July 15, The mission noted that the GoSL is yet to initiate the Annual Environmental Audit and requests the MoH to initiate the related tasks as soon as possible so that the first Annual Environmental Assessment Report (AEAR) for assessing the performance of EMF. According to the Financing Agreement, it is due before February In order to achieve this target, the DEOHS should finalize the terms of reference of this assessment taking the recent discussions and decisions into account and submit the updated ToRs to the Bank for comments and clearance by June 15, A consultant/firm for AEAR should be contracted soon thereafter utilizing the Component 2 resources if required. 9

11 H. Results Framework and Monitoring & Evaluation 35. The mission was highly encouraged by the commitment and progress demonstrated by the GoSL and recommends that the GoSL continue to surpass original targets where possible. The mission raised the possibility of refining some of the indicators and/or targets and increasing the targets where necessary especially for targets that have already been achieved through project restructuring (discussed in greater detail under section J below). This idea was also raised in the DLI and results report 2014 submitted by the Department of Project Management and Monitoring of the MoPP. 36. The mission also commends the Ministry of Health, the 9 Provincial Health Ministries, the Project Management and Monitoring Department, Department of External Resources, and the National Planning Department of the MoPP, the Department of Treasury Operations and the National Budget Department of the MoF for supporting the implementation and monitoring of the health sector results on a regular basis. The mission commends the Department of Project Management and Monitoring for submitting, as agreed in the Financing Agreement, the annual Results and DLI Report for 2014 in the first quarter of The mission also commends the MoH for developing and submitting to the World Bank a detailed Progress Report on sector results for 2014 also by the end of the first quarter of Based on the 2014 Results and DLI report and the Progress report, the Bank is supporting an independent validation survey to validate the DLI results for 2014 reported by the GoSL. The same firm, (Nielson Company (Pvt) Ltd) that was selected to carry out the 2013 results was selected by the Bank to carry out the second year survey as well. The survey is currently ongoing and the process is facilitated extensively by the MoH and the 9 Provincial Ministries of Health. Approximately 200 health facilities are visited by the research team to validate the reported results. The results of the survey are expected by June 15, 2015 and following discussions the corresponding funds for the achievement of the DLI targets of 2014 will be released to the GoSL in the 3 rd quarter of According to the Financing Agreement, the GoSL commits to have a team of qualified staff in adequate numbers to support the Senior Assistant Secretary, Medical Services of the MoH as the focal person for the project. The mission notes that most essential categories of staff are now in place to support the implementation and supervision of the project s components. The mission urges this team to regularly review implementation of Component 1 and 2 of the project taking into account the agreed actions attached in Annex 2 of the AM. I. Communications Related to the Project 38. As a well performing project aiming to aiming to enhance the quality of health care in the country, the mission discussed and highlighted the need to share information on the project with the general public and other important stakeholders. The mission discussed the possibility of updating project related information in the Ministry of Health website and welcomed the appointment of a focal person for this task. In addition, the mission recommends that a strategic communications plan be developed and implemented which will help communicate opportunities and challenges that the project would face, going forward. This would create a greater interest and dialogue among the non-health sector groups about 10

12 the changes that would take place in the overall health sector of the country. The mission agreed that the appointment of a focal point by June 15, 2015 who can coordinate between the Bank and the Ministry would be required as a first step to achieving this process. J. Summary of Discussions Regarding Possible Project Restructuring 39. The mission and GoSL agree that the project is an ideal platform to address and tackle more strategic challenges in the health sector and the mission initiated discussions on some of these areas. As part of these discussions, the joint team discussed the possibility of restructuring the project to refine some of the agreed targets and indicators identified in the project. This would also provide opportunities for the GoSL to consider scaling up successful activities and expanding the outcomes including additional objectives that are strategic for the country s overall health system development. Annex 5 presents a table summarizing the proposed revised indicators and/or targets as discussed with the GoSL during the mission. 40. The project is designed to release 95 percent of the funds to the Government s budget cycle which follows the calendar year and the value of five DLIs are linked to results in the provinces while three are linked to the MoH results and one linked to the health sector fund flow. Should the GoSL wish to make any modifications to the values of the Disbursement Linked Indicators under the project, and if those modifications were made at the time of the currently planned midterm review in March 2016, the budget would only see changes in the final year of project fund release (calendar year 2017). 41. The mission also highlights that the restructuring could help simplify the processes related to innovation projects and would be able to establish a mechanism to allow provinces to have access to the Component 2 funds. 42. Therefore, the mission recommends that the GoSL review the proposed results indicators and other required amendments and make recommendations to the Bank if any changes are required in the project design and in the results indicators preferably before July 30, J. Proposed Next Implementation Support Visit and Next Steps: 43. The next implementation support mission can coincide with the planned mid-term review of the project, currently tentatively planned for around March Furthermore, it is envisaged that the agreed actions identified as next steps in this AM (attached as Annex 2) will be reviewed and monitored regularly to meet the agreed timelines. 11

13 Annex 1. Status of Agreed Actions from December 2014 Mission No. Action Due Date Status 1. MLGPC to send the IFR for quarter ending September December 31, 2014 Completed Send final audit reports. December 31, 2014 Completed 3. Updated Procurement Plan for Component 2 sent to the Bank for review. December 31, 2014 Partly completed; to be completed by 4. The MOH, MLGPC and the Provinces will institutionalize the monitoring reviews as agreed in the financing agreements 5. Annual Activity Plan for 2015 activities under Component 2 will be shared with the Bank. 6. Action plan based on the 3 pillars for the capacity building of Provincial health and procurement staff to be drafted by the MPCRD Procurement Specialist in coordination with relevant GoSL staff and sent to the Bank for comments. 7. Information about the WB online procurement learning portal widely disseminated across provinces and MOH. January 2015 on January 15, 2015 January 15, 2015 January 15, 2015 June 15, 2015 Initiated but needs improvements; to be institutionalized by July 30, Not completed, in progress. To be sent by June 15, Not completed and now in progress and will be submitted by June 30, 2015 Completed 8. Complete national capacity building plan January 30, 2015 Completed 9. Hold workshops in January 2015 on results-based planning and monitoring prior to finalizing the annual plans of the MOH and the provinces for January 30, 2015 required. 10. MoH will organize a presentation of the FMIS system under development for the Bank team. 11. Finalize ToR of the Annual Environment Assessment Review (AEAR) and submit to the Bank for comments. Contract a consultant/firm for AEAR 12. Strengthen support team for the SAS Medical Services to expedite implementation of Component 2 and increase monitoring of activities under Component 1 including technical support provided to the 9 Provinces. 13. Develop capacity building program for better commitment planning and management of awarded contracts 14. The Environment and Occupational Health unit to develop a template to prepare integrated province wise health care waste management activity plans and share with larger hospitals and the provinces to develop their 2015/2016 plans January 30, 2015 January 31, 2015 March 31, 2015 February 15, 2015 Dropped by the MoH as not Not completed. Will be carried out before July 30, Not completed, task to be carried out before June 15, staffing improved. March 31, 2015 Initiated and in progress. March 31, 2015 Completed. 15. Submit Results and DLI report for calendar year March 31, 2015 Completed. 16. December 2014 IFR reconciled with the appropriations April 10, 2015 Completed. accounts to be submitted to the Auditor General. 12

14 Annex 2. Agreed actions from the current May 2015 mission No. Action Due Date 1 Annual Plan for 2015 under Component 2 submitted to June 15, 2015 Bank. 2 Capacity Building approval / clearance letter to be May 30, 2015 issued by the Bank. 3 Templates required to report back on International June 15, 2015 training developed. 4 The fund flow mechanism for innovations grants to be June 15, 2015 finalized. 5 A template of a draft concept note to be used intended research groups / innovators developed. June 15, Implementation Guideline for Component 1 June 30, 2015 implementation at the Province level will be reviewed and reissued to the provinces. 7 ICF International Consultancy to be awarded June 30, 2015 Revised Procurement Plan submitted to the Bank. June 15, Procurement Capacity Building Program submitted to June 30, 2015 the bank for review. 9 The TOR for the Environmental audit to be submitted to June 15, 2015 the Bank. 10 Update the implementation plan of activities of the July 15, 2015 Environment Management framework. 11 A focal point should be appointed for Communication June 15, 2015 related to the project. 12 GoSL should inform/ provide recommendations to the July 30, Bank on the need for restructuring. 13 A joint MOH / WB assessment of process related bottle Before September 30, 2015 necks in capital budget utilization study to commence 14 The Bank team to draft a concept note and a plan to July 30, 2015 carry out a health sector Supply Chain Assessment developed and shared with the MOH. 15 Presentation of the FMIS system to the Bank team will be scheduled. Before July 30, The Audit reports for Component 1 - one for Central September 30, 2015 Government Health expenditures and the other for Provincial Government health expenditures - for year ending December 31, 2014 submitted to the Bank. 17 The audit report for component 2 submitted to the Bank September 30,

15 Annex 3: Cash Flows for 2014 LKR 'Mn Province (upto PDHS Level) Imprest Requested Imprest Received % North Western 5,151 4,939 96% Eastern 4,272 3,575 84% North Central 3,148 2,749 87% North 3,692 3, % Central 5,415 5,349 99% Uva 4,007 3,361 84% Southern 5,136 4,544 88% Sabaragamuwa 3,818 3,619 95% Western 10,467 9,912 95% Total Provinces 45,106 41,740 93% Ministry of Health 35,950 31,754 88% Grand Total 81,056 73,494 91% 14

16 Core ANNEX 4: Updated Results Framework (Based on April 2015 Results Report) Project Development Objective (PDO): To upgrade the standards of performance of the public health system and enable it to better respond to the challenges of malnutrition and non-communicable diseases. Indicators Unit of Measure Baseline (2012/201 3) 2013 Target and achievement Cumulative Target Values** 2014 Target and achievement Freque ncy Data Source / Metho dology Responsibili ty for Data Collection Description (indicator definition etc.) PDO Level Indicators % of persons (over 40 years) screened for selected NCDs at healthy lifestyle centers % 3% Target: 4% : 6.8% Target: 6% : 19.9% 8% 10% 12% annual Admin Dir NCD, PDHS, RDHS No of persons screened for each of the selected NCD (hypertension, diabetes mellitus, Cancer: breast, and oral) at healthy life style centers /Population over 40 years % of pregnant women with anemia after the second trimester % 34% Target: 34% : Not reported, used the same baseline of 34%. Target: 31% (will be reported from 2015) 28% 24% 20% annual Survey FHB No. of pregnant women with anemia (Hb below 11g/dl)/Total No. of pregnant women registered. To be introduced from 2014 onwards. % of centrally managed health facilities with ETUs for that level of facility based on standard guidelines (DLI 1) % (at Primary, Secondary & Tertiary levels) 0 Target achieved and verified as 90%: Developed & finalized the policy & guidelines for Accident & Emergency services, awaiting cabinet Target: 10% : 14.3% (4/28 hospitals) 20% 30% 40% annual Admin Director Medical Services (MS) No. of centrally managed health facilities with ETUs for that level of facility based on standard guidelines/total No. of health facilities (at each level) managed by the MOH 15

17 Core Indicators Unit of Measure Baseline (2012/201 3) 2013 Target and achievement Cumulative Target Values** 2014 Target and achievement Freque ncy Data Source / Metho dology Responsibili ty for Data Collection Description (indicator definition etc.) approval. % of provincially managed health facilities with ETUs for that level of facility based on standard guidelines (DLI 2) % (at Primary, Secondary & Tertiary levels) 0 Target achievement, verified as 90%. Developed finalized and make available the policy and guidelines for Accident and Emergency services, awaiting cabinet approval. Target: 20% : 28.8% (157/545 hospitals) 30% 40% 50% annual Admin Data 9 PDHS and 26 RDHS and Dir MS No. of provincially managed health facilities with ETUs for that level of facility based on standard guidelines/total No of health facilities (at each level) managed by the provinces % of MOH managed health facilities sending indoor morbidity through e-immr (DLI 3) % 2% Target: 10% : 26.5%, verified and has achieved 100% of target. Target: 25% : 49% (23/47 hospitals) 50% 65% 80% annual E- IMMR Medical Statistics Unit No. of central Medical Officer of Health managed health facilities sending indoor morbidity through e-immr/total No. of central Medical Officer of Health managed health facilities % of provincially managed health facilities sending indoor morbidity through e-immr (DLI 4) % 1% Target: 15% : 15% verified and 100% of target achieved Target: 30% : 33% 173/525 hospitals 50% 60% 70% annual E- IMMR Medical Statistics Unit No. of provincial health facilities sending indoor morbidity through e-immr/total no. of provincial health facilities 16

18 Core Indicators Unit of Measure Baseline (2012/201 3) 2013 Target and achievement Cumulative Target Values** 2014 Target and achievement Freque ncy Data Source / Metho dology Responsibili ty for Data Collection Description (indicator definition etc.) INTERMEDIATE RESULTS (Outputs) Intermediate Results Thematic Area 1: Addressing Mother and Child Health and Nutrition % of MCH clinics with an agreed package of equipment and supplies for the provision of care for pregnant women and children under five years. (DLI 5) % 20% Target: 20% : 20%, verified and has achieved 84% of target. Target: 45% : 41.9% (1627/3883 MCH clinics) 60% 80% 95% annual Admin FHB, PDHS, RDHS No. of MCH clinics with a complete set of equipment and supplies (to test Hb, Height, weight and availability of micro nutrients and deworming drugs)/total no of MCH clinics % of Medical Officer of Health areas with at least three health and nutrition community support groups % <10% Target: 10% : 55% Target: 20% : 65.5% (216/330 MOH areas) 40% 60% 90% annual Admin HEB, PDHS, RDHS No. of community health and nutrition support groups (established and functioning) in each Medical Officer of Health area/total no. of Medical Officer of Health areas in a given year % of CEMOC facilities providing 24x7 CEMOC services. % 45% Target: 45% : 70%, Target: 50% : 75.3% 55% 65% 75% annual Admin FHB, PDHS No. of centrally and provincially managed health facilities providing 24x7 Comprehensive Emergency Maternal and Obstetric Care (CEMOC) /70 selected hospitals 17

19 Core Indicators Unit of Measure Baseline (2012/201 3) 2013 Target and achievement Cumulative Target Values** 2014 Target and achievement Freque ncy Data Source / Metho dology Responsibili ty for Data Collection Description (indicator definition etc.) Intermediate Results Thematic Area 2: Improving prevention and control of Non-Communicable Diseases % of Medical Officer of health areas with at least two healthy lifestyle centers (DLI 6) % 10% Target: 10% Reported : 25%, verified and has achieved only 64% of target. Target: 25% : 49.3% 50% 70% 90% annual Admin DDG (MSI), Dir NCD, PDHS, RDHS No of Medical Officer of Health areas with at least two healthy lifestyle centers at primary care institution level /Total No of Medical Officer of Health areas in a given year No. of provinces with at least one health facility providing rehabilitation services No. 1 Target: Develop and finalize guidelines for disability and rehabilitation services. Target: 2 :3 provinces (North, East and Western) annual Admin 9 PDHS and 26 RDHS, Dir YEDD No of provinces providing rehabilitation services in at least one facility (to be defined) in each of the provinces : Standards being developed. % of primary health care institutions having one month s buffer stock for 16 selected NCD drugs % (to be presented by MSD and at province levels) 2% Target: Develop capacities for drug logistics system to be improved. Target: 20% : 43.4% 30% 40% 60% Quarter ly yr 2 onward Admin Director MSD No of primary health care institutions having one month s buffer stock for selected NCD drugs (16 drugs)/total No of primary health care institutions : discussions and actions initiated. 18

20 Core Indicators Unit of Measure Baseline (2012/201 3) 2013 Target and achievement Cumulative Target Values** 2014 Target and achievement Freque ncy Data Source / Metho dology Responsibili ty for Data Collection Description (indicator definition etc.) Intermediate Result Thematic Area 3: Health systems improvement % of training institutes managed by the Ministry of Health meeting national standards % N.A. National standards to be developed for accreditation : National standards under development Target: 10% : The National Standard developed, finalized, 4/32 schools identified 20% 30% 40% Annual Admin DDG ETR No of training institutes meeting national standards/total No of training institutes % of laboratories in health facilities (base hospitals and above) participating in external quality assurance program for selected tests conducted by MRI. % 10% 20% : 46.7% reporting though the frequency is not regular and needs improvement Target: 40% : 94.2% (65/69 eligible hospitals) 60% 70% 80% annual Admini strative DDG LS, PDHS, RDHS Proportion of Hospitals BH-A and above with laboratories which participate in external quality assurance program for selected tests conducted by MRI Tests are defined and protocols developed. A phase out plan developed. Case detection rate for Tuberculosis rate 69% Target: 72% Target: 74% 76% 77% 78% Annual Admin TB Director, The percentage of newly notified tuberculosis cases (including relapses) to estimated incident 19

21 Core Indicators Unit of Measure Baseline (2012/201 3) 2013 Target and achievement Cumulative Target Values** 2014 Target and achievement Freque ncy Data Source / Metho dology Responsibili ty for Data Collection Description (indicator definition etc.) : only 66.9% : 66.1% cases (case detection, all forms). % of hospitals (base hospitals and above) that have obtained EPL and HWL % <5% Target: Review existing situation based on the HCWM guidelines/fra mework Target: 10% 6%: 4/69 base hospital A and above 20% 30% 40% annual Admin Director Env and Occ Health No of hospitals that have met standard waste management practices : Review ongoing % of fully functioning quality management Units (QMUs) in MOH managed base hospitals and above (DLI 7) % 9% Target: Guideline/pr otocols for a fully functioning QMU developed, appropriate training carried out Target: 15% :38.1% 40% 70% 95% Annual Admin Director QA and Safety No of fully functioning ± quality management units (QMUs) in MOH managed secondary and tertiary level (Base hospital and above) hospitals/total no of MOH managed hospitals verified as 100%. % of fully functioning quality management Units (QMUs) in provincially managed base hospitals and above (DLI 8) % 6% Target: National Standards to be developed for accreditation Target: 15% : 43.7% of provincial hospitals 40% 70% 90% Annual Admin Director QA and Safety No of fully functioning ± quality management Units (QMUs) in provincially managed secondary and tertiary level (Base hospital and above) hospitals/total no of province managed hospitals by 20

22 Core Indicators Unit of Measure Baseline (2012/201 3) 2013 Target and achievement Cumulative Target Values** 2014 Target and achievement Freque ncy Data Source / Metho dology Responsibili ty for Data Collection Description (indicator definition etc.) : National standards under development province % of NCB contracts awarded within the first nine months of the previous calendar year from 2014 onwards % (to be presented by province s and the MOH) N.A. Not reported. Target: 40% : 73.6% (denominator total NCB contracts in 2014) 50% 60% 80% annual Admin DDG Logistics and PDHS No of NCB contracts awarded within the first nine months of the previous calendar year /Total No of NCB contracts awarded in the previous year % of the six monthly cash forecast (for non-salary recurring and capital expenditures) released (DLI 9) % 81% Equal to or more than 83% : 100% (verified) Target: Equal to or more than 85% : 100%, more than 99% in all provinces Equal to or more than 88% Equal to or more than 90% Equal to or more than 90% 6 monthl y Admin DDG Finance and Provincial Department Health Accountants Amount of funds released by the treasury every 6 months/total value of forecast amount. The for this indicator are not cumulative. The will be presented by the MOH and by Provinces 21

23 ANNEX 5: Outcome of discussions to Review and Modify the Results Framework, mission meetings May 7 and 9, 2015 with participation of MoH, MoF, MoPP, Provincial MoHs The project development objective (PDO) is to upgrade the standards of performance of the public health system and enable it to better respond to the challenges of malnutrition and non-communicable diseases. NCDs Original indicators Remarks Revised PDO indicators Target Remarks 1. % of persons (over 40 years) screened for selected NCDs at healthy lifestyle centers (PDO) modify % of men and women (40-65 years) screened for selected NCDs for the first time at HLCs and mobile clinics (Diabetes and Hypertension) 12% (old) 25% (percentage points) increase from 2014 baseline (men) 25% (percentage points) increase from 2014 baseline (women 25% (new) TO BE DISCUSSEED The info will come from the HLCs and other mobile and outreach clinics. - Male/female ratio 2. % of centrally managed health facilities with ETUs for that level of facility based on standard guidelines (DLI 1) (PDO) modify % of centrally managed health facilities with accident and emergency services for that level of facility based on standard guidelines (DLI 1) 40% (old) - retain Only the word ETU gets replaced by Accident and Emergency in this indicator. 3. % of provincially managed health facilities with ETUs for that level of facility based on standard guidelines (DLI 2) (PDO) modify % of provincially managed health facilities with accident and emergency services for that level of facility based on standard guidelines (DLI 2) 50% (old) - retain Only the word ETU gets replaced by Accident and Emergency in this indicator. 22