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Document of

The World Bank

FOR OFFICIAL USE ONLY Report No: PAD3423

INTERNATIONAL DEVELOPMENT ASSOCIATION

PROJECT PAPER

ON A

PROPOSED ADDITIONAL GRANT

IN THE AMOUNT OF SDR 7.3 MILLION (US$10 MILLION EQUIVALENT)

TO THE

REPUBLIC OF TAJIKISTAN

FOR THE

TAJIKISTAN HEALTH SERVICES IMPROVEMENT PROJECT

NOVEMBER 25, 2019

Health, Nutrition & Population Global Practice Europe And Central Asia 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

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CURRENCY EQUIVALENTS

(Exchange Rate Effective October 2019)

Currency Unit = Tajik Somoni (TJS)

TJS 9.69 = US$1

US$1.38 = SDR 1

FISCAL YEAR

January 1 - December 31

Regional Vice President: Cyril E Muller

Practice Group Vice President: Annette Dixon

Country Director: Lilia Burunciuc

Practice Manager: Tania Dmytraczenko

Task Team Leader(s): Kate Mandeville, Baktybek Zhumadil

ABBREVIATIONS AND ACRONYMS

AF1 First round of Additional Financing AF2 Second round of Additional Financing CPF Country Partnership Framework (W CQI Collaborative Quality Improvement CSCs Citizen scorecards DHS Demographic and Health Survey DRS Districts of Republican Subordination ECD Early childhood development Gavi The GAVI Alliance GBAO Gorno-Badakhshan Autonomous Oblast GRS Grievance Redress Service HH Health houses HRITF Health Results Innovation Trust Fund HSIP Health Services Improvement Project IE Impact evaluation IR Intermediate results MCH Maternal and child health MOHSP Ministry of Health and Social Protection NCDs Non-communicable diseases PBF Performance-Based Financing PCF Per capita financing PCG Project Coordination Group PDO Project Development Objective PHC Primary health care POM Project Operations Manual PPSD Project Procurement Strategy for Development RHCs Rural health centers SSSHSPA State Surveillance Service on Health and Social Protection Activities TWG Technical Working Group

Tajikistan

Second Additional Financing to the Tajikistan Health Services Improvement Project

TABLE OF CONTENTS

I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ........................................ 7

II. DESCRIPTION OF ADDITIONAL FINANCING .................................................................... 16

III. KEY RISKS ..................................................................................................................... 24

IV. APPRAISAL SUMMARY .................................................................................................. 26

V. WORLD BANK GRIEVANCE REDRESS .............................................................................. 30

VI SUMMARY TABLE OF CHANGES ..................................................................................... 31

VII DETAILED CHANGE(S) .................................................................................................... 31

VIII. RESULTS FRAMEWORK AND MONITORING ................................................................... 35

ANNEX 1: SUMMARY OF CHANGES TO THE RESULTS FRAMEWORK ...................................... 49

MAP TAJ 33493

The World Bank Second Additional Financing to the Tajikistan Health Services Improvement Project (P170358)

Apr 18, 2019 Page 1 of 51

BASIC INFORMATION – PARENT (Tajikistan Health Services Improvement Project (HSIP) - P126130)

Country Product Line Team Leader(s)

Tajikistan IBRD/IDA Kate Mandeville

Project ID Financing Instrument Resp CC Req CC Practice Area (Lead)

P126130 Investment Project Financing

HECHN (9318) ECCCA (1608) Health, Nutrition & Population

Implementing Agency: Ministry of Health & Social Protection, Ministry of Health & Social Protection ADD FIN TBL1

Is this a regionally tagged project?

Bank/IFC Collaboration

No

Approval Date Closing Date Expected Guarantee Expiration Date

Original Environmental Assessment Category Current EA Category

30-Jul-2013 30-Sep-2020 Partial Assessment (B) Partial Assessment (B)

Financing & Implementation Modalities Parent

[ ] Multiphase Programmatic Approach [MPA] [ ] Contingent Emergency Response Component (CERC)

[ ] Series of Projects (SOP) [ ] Fragile State(s)

[ ] Disbursement-Linked Indicators (DLIs) [ ] Small State(s)

[ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country

[ ] Project-Based Guarantee [ ] Conflict

[ ] Deferred Drawdown [ ] Responding to Natural or Man-made disaster

[ ] Alternate Procurement Arrangements (APA)


Apr 18, 2019 Page 2 of 51

Development Objective(s) The revised PDO is to contribute to the improvement of the coverage and quality of basic primary health care (PHC) services in selected districts.

Ratings (from Parent ISR) RATING_DRAFT_YES

Implementation

19-May-2017 20-Nov-2017 23-May-2018 05-Dec-2018 06-Jun-2019

Progress towards achievement of PDO

MS

MS

MS

MS

MS

Overall Implementation Progress (IP)

S

S

S

S

S

Overall Safeguards Rating

Overall Risk S

S

S

S

S

BASIC INFORMATION – ADDITIONAL FINANCING (Second Additional Financing to the Tajikistan Health Services Improvement Project - P170358) ADDFIN_TABLE

Project ID Project Name Additional Financing Type Urgent Need or Capacity Constraints

P170358 Second Additional Financing to the Tajikistan Health Services Improvement Project

Restructuring, Scale Up No

Financing instrument Product line Approval Date

Investment Project Financing

IBRD/IDA 18-Dec-2019

Projected Date of Full Disbursement

Bank/IFC Collaboration

30-Jun-2022 No


Apr 18, 2019 Page 3 of 51

Is this a regionally tagged project?

No

Financing & Implementation Modalities Child

[ ] Series of Projects (SOP) [ ] Fragile State(s)

[ ] Disbursement-Linked Indicators (DLIs) [ ] Small State(s)

[ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country

[ ] Project-Based Guarantee [ ] Conflict

[ ] Deferred Drawdown [ ] Responding to Natural or Man-made disaster

[ ] Alternate Procurement Arrangements (APA)

[ ] Contingent Emergency Response Component (CERC)

Disbursement Summary (from Parent ISR)

Source of Funds Net

Commitments Total Disbursed Remaining Balance Disbursed

IBRD

%

IDA 25.00 24.19 0.09

100 %

Grants 4.80 4.71 0.09

98 %

PROJECT FINANCING DATA – ADDITIONAL FINANCING (Second Additional Financing to the Tajikistan Health Services Improvement Project - P170358)

PROJECT FINANCING DATA (US$, Millions)

SUMMARY-NewFi n1

SUMMARY (Total Financing)

Current Financing Proposed Additional Financing

Total Proposed Financing

Total Project Cost 33.00 12.00 45.00

Total Financing 33.00 10.00 43.00

of which IBRD/IDA 25.00 10.00 35.00


Apr 18, 2019 Page 4 of 51

Financing Gap 0.00 2.00 2.00

DETAILSNewFinEnh1- Additional Financing

World Bank Group Financing

International Development Association (IDA) 10.00

IDA Grant 10.00

IDA Resources (in US$, Millions)

Credit Amount Grant Amount Guarantee Amount Total Amount

Tajikistan 0.00 10.00 0.00 10.00

National PBA 0.00 10.00 0.00 10.00

Total 0.00 10.00 0.00 10.00

COMPLIANCE

Policy

Does the project depart from the CPF in content or in other significant respects?

[ ] Yes [ ✔ ] No

Does the project require any other Policy waiver(s)?

[ ] Yes [ ✔ ] No

INSTITUTIONAL DATA

Practice Area (Lead) Health, Nutrition & Population

Contributing Practice Areas

Climate Change and Disaster Screening

This operation has been screened for short and long-term climate change and disaster risks


Apr 18, 2019 Page 5 of 51

Gender Tag Does the project plan to undertake any of the following? a. Analysis to identify Project-relevant gaps between males and females, especially in light of country gaps identified through SCD and CPF Yes b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or men's empowerment Yes c. Include Indicators in results framework to monitor outcomes from actions identified in (b) Yes

PROJECT TEAM

Bank Staff

Name Role Specialization Unit

Kate Mandeville Team Leader (ADM Responsible) Health systems HECHN

Baktybek Zhumadil Team Leader Operations HECHN

Dilshod Karimova Procurement Specialist (ADM Responsible) Procurement EECRU

Niso Bazidova Financial Management Specialist (ADM Responsible) FM EECG1

Hmayak Avagyan Environmental Specialist (ADM Responsible) Environmental Safeguards SCAEN

Suryanarayana Satish Social Specialist (ADM Responsible) Social Safeguards SCASO

Andrianirina Michel Eric Ranjeva Team Member Finance Officer WFACS

Damien B. C. M. de Walque Team Member Impact Evaluation DECHD

Gabriel C. Francis Team Member Program Assistant HECHN

Gil Shapira Team Member Impact Evaluation DECHD

Husniya Dorgabekova Team Member GBAO HECHN

Michael Kent Ranson Team Member Health financing and Gavi HHNGE

Mohammad Tawab Hashemi Team Member Quality Improvement HHNGF


Apr 18, 2019 Page 6 of 51

Mutriba Latypova Team Member Implementation Support and Nutrition HECHN

Ruxandra Costache Counsel Legal LEGLE

Shahlo Norova Team Member Administrative and Client Support ECCTJ

Extended Team

Name Title Organization Location


Page 7 of 51

I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING

1. Introduction. The Project Paper seeks the approval of the Board of Executive Directors to provide an additional IDA grant in the amount of SDR 7.3 million (US$10 million equivalent) to the Tajikistan Health Services Improvement Project (HSIP) (P126130). This second round of additional financing (AF2) would scale-up the activities under the parent project, with a focus on child health services in primary care. This AF2 is to be supplemented by an expected US$2 million of co-financing from the GAVI Alliance (Gavi).

2. Background. The parent project, for an IDA grant amount of SDR 10 million (US$15 million equivalent), with co-financing in the amount of US$4.8 million from the Health Results Innovation Trust Fund (HRITF), was approved by the Board on July 30, 2013 and declared effective on December 11, 2013 with an original closing date of January 31, 2019. A first round of additional financing (AF1) in the amount of SDR 7.3 million (US$10 million equivalent), approved on June 22, 2015, financed the costs associated with: (i) the financing gap arising from construction of rural health centers (RHCs); and (ii) the scaling-up of activities initiated under the original IDA grant to cover additional primary health care (PHC) facilities in four districts. The associated restructuring of the parent project in August 2018 also included: (i) a minor revision of the Project Development Objective (PDO); (ii) adjustments to the project results framework; and (iii) an 11-month extension of the original project closing date, from January 31, 2019 to December 31, 2019. A second restructuring of the parent project was approved on September 12, 2019, to extend the closing date from December 31, 2019, to September 30, 2020, to avoid the closure of the Project before the signing of the AF2.

3. PDO and activities. The objective of the Project is to contribute to the improvement of the coverage and quality of basic primary health care (PHC) services in selected districts. Activities contributing to the PDO to date include (i) implementation of comprehensive PHC financing mechanisms, including a Performance-Based Financing (PBF) pilot at the PHC level in selected districts, and strengthening social accountability through the use of citizen scorecards (CSCs); (ii) improving the capacity of PHC providers to deliver quality services through physical infrastructure improvements, training in family medicine, and development of and training on clinical treatment protocols for maternal and child health (MCH) care and selected non-communicable diseases (NCDs), and introduction of a collaborative quality improvement (CQI) process for managing predominantly acute respiratory illness, child under-nutrition, and high blood pressure (hypertension). The Project has three components: 1) PBF; 2) PHC strengthening, and 3) Project management, coordination, and monitoring and evaluation.

4. Project Performance and Progress. To date, the Project has performed at an overall satisfactory level with respect to the likelihood to achieve the PDO and implementation progress. More specifically, although implementation progress has been rated Satisfactory throughout, the rating of the likelihood to achieve the PDO has been rated Moderately Satisfactory, mainly given the challenges related to measurement of the PDO indicators due to discrepancies in between data sources (Demographic and Health Survey (DHS) and Project administrative data), as described below.


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5. Progress towards the PDO. PDO indicator No.3 (average health facility quality of care score), measured through project data, has demonstrated consistent improvements from an aggregate 73 percent (76 for RHC and 70 for health houses (HH)) in 2017 when the PBF manual was updated to 90 percent (91 for RHC and 89 for HH) in 2019. For the remaining three PDO indicators (No.1, No.2, and No.4), the DHS survey had originally been defined as the source of data and has presented mixed results per project region (Table 1). Given that DHS data reflect an average across all districts in a region rather than specific to project districts, these values may not be reflective of trends in project districts. Data sources that may better reflect specific progress in project districts, namely administrative data and the linked impact evaluation (IE) of the PBF pilot have, therefore, been used to complement the DHS (Table 1). Project data shows consistent improvements across PDO indicators No.1 (percentage of pregnant women receiving antenatal care), No.2 (contraceptive prevalence rate), and No.4 (percentage of children under-five with diarrhea treated with any Oral Rehydration Therapy) in all project regions. The IE shows improvement for PDO No.1 across project districts in Soghd and Khatlon. For PDO No. 4, the IE shows improvement in Soghd, but a decline in performance in Khatlon.

Table 1: Progress towards the PDO by data source and region

PDO indicators

Results by datasource and

region

No.1 (percentage of pregnant women

receiving antenatal care)

No.2 (contraceptive

prevalence rate)

No.4 (percentage of children under-five with diarrhea treated with any

Oral Rehydration Therapy)

DHS* Soghd ↑ ↑ ↓ Khatlon ↑ ↓ ↓ DRS ↓ ↑ ↓ Project data** Soghd ↑ ↑ ↑ Khatlon ↑ ↑ ↑ DRS ↑ ↑ ↑ IE*** Soghd ↑ N/A ↑ Khatlon ↑ N/A ↓ DRS N/A N/A N/A

↑ indicates improvement in indicator; ↓indicates worsening of indicator; DRS = Districts of Republican Subordination; N/A = results for this indicator not available from IE. *2017 DHS survey results compared to 2012 DHS survey baseline; **Project administrative data collected quarterly 2015 - 2019; ***Results from IE endline survey (2018) compared to baseline (2015). 6. Implementation Progress. Eleven out of 12 intermediate results (IR) indicators are on track or have either achieved or exceeded their end-of-project target values. One IR indicator (hypertensive adults receiving anti-hypertensive treatment) has remained roughly the same between baseline and endline surveys of the accompanying IE. Activities under all project components are progressing satisfactorily and on schedule, as detailed below.


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7. Component 1: Performance-based financing. (US$13.96 million, thereof US$12.80 million original grant, US$1.16 million AF1). Project administrative data indicate consistent quarter on quarter increases on utilization (measured through quantity indicators) and quality of key services. Most quantity indicators have reached a coverage of 95 percent or higher. For example, the percentage of fully vaccinated children has reached 99 percent; the percentage of children under 2 years of age who received growth monitoring and counseling has increased to 100 percent, and the share of pregnant women who received four antenatal care visits has risen to 98 percent. Though the overall coverage of contraceptive users is low compared to other indicators, the data shows significant improvement achieved in 2018. For example, the number of new users of contraceptives increased by 40 percent in 2018, compared to 2017. There have also been positive results for key quality indicators. Steady progress has been observed across all indicators and in both RHCs and HH between the 3rd quarter of 2017 and the 3rd quarter of 2018. Overall, during this period, quality scores have risen from 77 percent to 88 percent. The progress in overall quality scores is driven by improvement in a number of sub-areas, including MCH, NCD, and quality of lab services. Specifically, scores for child health have increased from an aggregate 69.5 percent (75 for RHC and 64 for HH) in 2017 to 91 percent (93 for RHC and 89 for HH) in 2019; maternal health scores increased from 79.5 percent in 2017 to 89.5 percent in 2019; NCD scores increased from 66 percent to 81 percent; and, finally, with the supply of new lab equipment and consumables procured by the Project, scores for the quality of lab services increased from 36 percent to 52 percent.

8. Results of the IE. An IE of the PBF component, which compared changes over time in districts with PBF to those in selected control districts1, provided evidence of substantial positive impacts of PBF on many dimensions of quality of care. It indicated that the PBF component increased the availability of equipment and supplies at the PHC facilities. The component also had positive impacts on infrastructure and infection prevention and control standards, such as the availability of containers for sharps and needles in consultation rooms. For example, the availability of refrigerators for cold storage increased in HHs from 23 percent at baseline to 96 percent in the follow-up, compared to 32 percent to 55 percent among the control HHs. There was also evidence that improvements in structural quality and provider knowledge translated into better content of care. For example, providers in the PBF facilities were more likely to perform key examinations, such as measuring the height and weight of children under-five. PBF also had positive impacts on health providers. Their income increased by about two-thirds due to performance bonuses and they reported higher satisfaction, especially concerning the working conditions in the facilities. Community perceptions of health providers were also positively impacted, with individuals living in PBF districts reporting significantly higher perceptions that staff were competent, worked closely with, and listened to, the community. Despite these improvements, there was only a limited impact on the utilization of incentivized health services by the community, with a marked significant increase in timely postnatal care (18 percentage points) and a small increase in blood pressure measurement in adults

1 Ahmed T, Arur A, de Walque D, Shapira G. 2019. Incentivizing Quantity and Quality of Care: Evidence from an Impact Evaluation of Performance-Based Financing in the Health Sector in Tajikistan. Policy Research Working Paper 8951. Washington (DC): World Bank Group


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(3 percentage points). There were no statistically significant impacts on antenatal care, child growth monitoring, or vaccination.

9. Results of a linked qualitative study of PBF. The modest effects on utilization prompted a follow-up qualitative study of residents and primary care staff in PBF districts intended to understand care-seeking decisions2. Findings suggest that community residents had overall positive experiences at primary care facilities, including trusted relationships with staff. Mothers spoke positively about the quality of care they received in primary care facilities. However, limitations in service capacity and provider availability at primary care facilities, as well as referrals to district facilities, had the effect of discouraging residents from accessing primary care facilities more often. Residents tended to associate provider specialization and availability of equipment with higher quality and competency. Additionally, some residents tended to delay care-seeking to facilities due to a lack of recognition of symptoms or preference for home remedies. Poor road conditions and the cost of transport negatively affected care-seeking and health worker household visits.

10. Component 2: PHC strengthening.(US$14.3 million, thereof US$6 million original grant, US$8.3 million AF1). The implementation of CQI also continues to progress satisfactorily. Regular meetings of the staff of RHCs, HHs, and regional quality improvement specialists help the project-supported facilities develop action plans to further improve their performance in serving their populations. Given the expiration of the CQI staff contracts on December 31, 2018, the Project has provided additional support to the health center staff, who have the necessary knowledge and skills to use the CQI tools and databases independently, on organizing the quarterly sessions and maintaining/aggregating the database. At the national level, the CQI tool was officially handed over to the Republican Center for Family Medicine for further usage and scale-up. Under the physical infrastructure improvement sub-component, 35 out of 38 sites (including the construction of 37 health facilities and renovation of the Family Medicine Training Center in Khatlon) have been completed and handed over to respective local authorities. The remaining 3 sites have been nearly completed and should be handed over to local authorities by November 2019. This component has also provided technical assistance for per capita (capitation) financing (PCF) for primary care to correct for regional and district inequities in financing. Under Resolution Number 827 of the Government of the Republic of Tajikistan, a national step-wise rollout of per capita financing was initiated in 2015. In 2018, the model operated in 55 districts and is expected to scale-up to all districts in 2019.

11. Component 3: Project management, coordination, and monitoring and evaluation (US$4.81 million, thereof US$4.2 million original grant, US$0.61 AF1). The Project Coordination Group (PCG) team has been reduced to the core team necessary for effective implementation of the Project within the remaining time and budget.

12. Government commitment. Overall, ownership of the PDOs by the Ministry of Health and Social Protection (MOHSP) has been strong throughout project implementation, with coordination and roles of

2 Singh N et al. Impact Evaluation of a Performance Based Financing Pilot for Rural Health Systems in Tajikistan. Endline Qualitative Study Report. World Bank Group, forthcoming


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key staff responsible for project implementation, including those in the PCG, defined in a satisfactory manner, including decision-making processes related to project activities.

13. Compliance with key legal covenants and conditions. Environmental and social safeguards have been implemented satisfactorily. The financial management arrangements at the PCG, including planning and budgeting, accounting, financial reporting, funds flow, internal control, external audits, and staffing are satisfactory and continue to be acceptable to the World Bank. The interim financial reports have been submitted on time and are satisfactory to the World Bank. The project audit reports are unqualified and received on time. Procurement, financial management, project management, counterpart funding, and monitoring and evaluation are all rated satisfactory.

14. Disbursement and commitment. As of October 2019, combined total disbursements from both the IDA Grant and the HRITF Grant reached 98 percent of the total financing amount (US$29.8 million equivalent). The IDA grant has disbursed US$23.76 million (97.87 percent); the HRITF grant has disbursed US$4.70 million (97.87 percent). Currently, the equivalent of US$0.31 million of the remaining US$0.62 million is expected to be disbursed by the original closing date of December 31, 2019. The remainder will be used to support PCG salaries and operational costs until AF2 effectiveness. The average disbursement amount per year has been US$4.70 million equivalent.

15. Rationale for AF2. The rationale for this AF2 is based on the opportunity to increase the development effectiveness of project activities to address the persistent challenges in primary care and transition to government ownership, supported by consistent satisfactory performance of the parent project. The HSIP is eligible for a second AF due to the strong project performance, as described above. Enduring challenges in PHC justify scaling up of activities under AF2. By incorporating learning from AF1, the PBF IE and linked qualitative study, the development effectiveness of activities under AF2 will be improved. This includes supporting the sustainability of PBF through the transition to government ownership after four years of PBF implementation as a pilot under the parent project. The timing of the AF2 also enables crowding in of an expected additional US$2 million of external funding from Gavi, which must be disbursed before December 2020. In addition to direct financing of the proposed Project, this may lead to further collaboration and joint financing with Gavi or other partners, particularly around health systems strengthening. Finally, the AF2 provides a bridge to the Early Childhood Development (ECD) Project (P169168). This US$40 million project is a cornerstone of the new Country Partnership Framework (CPF), which was approved in April 2019. The AF2 also diminishes future risks to implementation of the ECD Project by retaining experienced PCG staff who have consistently delivered strong performing health projects over the past 20 years.

16. While Tajikistan has made substantial progress in reducing child mortality in recent years, challenges with child health remain (Table 2), with stunting rates being the highest in the Europe and Central Asia region. Deaths of children under-five years old have declined over the last 5 years, from 43 deaths per 1,000 live births in 2012 to 33 in 2017 (DHS 2017). However, this average conceals large geographical variation, from 11 deaths per 1,000 live births in Dushanbe to 40 deaths per 1,000 live births in Khatlon (Table 2). While indicators of undernutrition have also improved, these remain at high levels. Stunting affects nearly 1 in 5 children (18 percent), with no difference in prevalence between rural and


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urban areas. The prevalence of stunting is highest in Gorno-Badakhshan Autonomous Oblast (GBAO), where almost one-third (32 percent) of children are too short for their age. Micronutrient deficiencies are highly prevalent, with over 40 percent of children suffering from anemia (low iron levels). Furthermore, vaccination coverage varies across the country, and recent outbreaks of vaccine-preventable diseases (including a 2017 measles outbreak in Dushanbe) indicate that the national immunization program requires further strengthening.

Table 2: Child health and poverty indicators vary across the country

17. Tajikistan’s PHC system, which the World Bank has been supporting the government to develop over the last 20 years, is a critical platform to improve child health. Tajikistan’s health system is making a slow transition from the hospital-dominated, input-based model common to ex-Soviet countries to one that is more responsive to population health needs. Out of pocket spending remains the predominant source of funding for the health sector (65 percent of current health spending, 2015 data3), with spending on medicines and informal payments by households to health providers making up the largest share4. As the source of health care closest to families, the PHC system provides many entry points to improve child health: from following up on families after a new birth (postnatal consultations), to regular monitoring of child growth and development, to providing all routine vaccinations. Bypassing these facilities for higher-level services is common, however, due to persistent under-investment in PHC, with around one-third of government health spending going to primary care since 20105 and only 3 family medicine doctors for every 10,000 people, compared to 21 specialists in 20176. Since 2000, the World Bank has been supporting the Government of Tajikistan in transforming PHC through three consecutive health sector projects. The projects have supported the re-training of specialists as family medicine doctors and nurses, the rehabilitation and construction of PHC infrastructure, and initiatives to improve the quality of PHC, such as the recent pilot of PBF. 18. While the quality of care delivered to families who attend primary health facilities has improved, this has not yet converted into a higher demand for child health services. From the IE of PBF under HSIP (paragraph 8), it appears that supply-side incentives are not always sufficient to change health- 3 WHO Global Health Expenditure Database 4 Schwarz et al. BMC Health Services Research 2013, 13:103 5 National Health Accounts, Tajikistan 6 Republican Centre for Medical Statistics and Information

Weighted average

Dushanbe Sughd DRS Khatlon GBAO

Infant deaths per 1,000 live births 27 9 26 25 33 26 Under-5 deaths per 1,000 live births 33 11 33 30 40 30 Stunted children under 5 years ( %) 18 18 16 15 19 32 Children that are exclusively breast fed ( %) 34 - - - - - Children (aged 6-23 months) fed according to the three IYCF* practices, (%) 9 7 13 5 10 8

Children aged 24-35 months who received all basic vaccinations (%) 82 71 92 69 86 70

Children whose births are registered (%) 96 98 99 91 96 97 Sources: DHS (2017)


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seeking behavior among families. No significant impacts on vaccination rates were observed, but baseline coverage was already relatively high. Looking ahead, the focus needs to be on “last mile service delivery”, i.e.,. additional effort to identify hard-to-reach unvaccinated groups. With respect to growth monitoring, there was no measured impact despite low levels at baseline. These mixed results on quality and quality of services are consistent with other PBF schemes evaluated under the HRITF. When examined alongside the qualitative findings (paragraph 9), this lack of consistent impact on service utilization despite recognized increases in quality of care may indicate that: (i) more time may be needed for cultural change following quality improvements associated with PBF; (ii) demand-side interventions are needed to promote the use of primary care services; and (iii) budget constraints, including transport costs and informal payments, are dampening demand for primary care services.

19. Demand-side interventions may be needed to promote the use of essential child health services. Using both demand- and supply-side interventions might, therefore, increase the impact on the utilization of priority child health services. Drawing on the results from the qualitative study (paragraph 9), this could include primary care nurses and community health volunteers working with households (including mothers, partners, and household elders) to strengthen awareness and knowledge on (i) prevention and management of childhood disease and illness, including the importance of optimal nutrition and vaccination; and (ii) the effectiveness and range of services available at primary care facilities. This type of household engagement was used successfully under the recent Tajikistan Japan Social Development Fund Nutrition Grant Scale-Up Project (P146109), which aimed to improve health and nutrition status among children under-five in the 14 districts of Khatlon oblast. Implemented between January 2015 and May 2018, this project reached a total of 535,437 beneficiaries and made an important contribution to improving child health and nutrition status.

20. Beyond demand creation, the scale-up and sustainability of PBF is a priority concern and is influenced by political, financial, and institutional factors. As many PBF pilots funded by the HRITF draw to an end, the scale-up and sustainability of PBF at a national level is becoming an important topic. Although there is currently little evidence of the optimal approach, research examining scaling up of this and other health policies suggest that key determinants include: (i) political commitment, including government ownership and a transition plan; ii) availability and sustainability of financial support, including incorporation into macro-level funding mechanisms and established budgetary processes; and (iii) institutional capacity, data availability, and evidence of effectiveness7. In Tajikistan, the government has not yet committed to scaling up the PBF pilot. Public financial management regulations and domestic verification capacity may present barriers to government management of performance-based payments. Cultural change of both providers (focus on results rather than inputs) and service users (recognition of and trust in higher quality services) is likely to also need support. Lack of accurate population and demographic data hampers the ability to plan and deliver health services, as well as to ensure equitable distribution of resources. Finally, most primary care facilities still currently use paper-based records, with District Health Information System 2 only implemented at the regional level.

7 Gergen J, Falcao J, Rajkotia Y. Stunted scale-up of a performance-based financing program on HIV and maternal-child health services in Mozambique - a policy analysis. African Journal of AIDS Research : AJAR. 2018;17(4):353-61


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21. Fiscal space for health remains constrained, however the Government of Tajikistan is improving the strategic purchasing of health services with support from international partners. The Government of Tajikistan has been trying to maintain macro-fiscal stability in the face of medium-term commitments to financing large infrastructure projects. Tajikistan’s health care system is tax-financed, with the government as the primary purchaser of health services, and little to no risk pooling. Government spending on health as a share of general government spending is low (at 5.9 percent, 20178) compared to other countries at similar levels of gross national income per capita, with little prospect of expanded domestic funding in the short-term. However, patterns of public health spending – with the bulk of spending on salaries and on inpatient care – suggest that there is considerable scope for improvements in the efficiency of spending. Recent pilots transforming the purchasing of health services include the PBF pilot and PCF rollout, as well as a State Guaranteed Package of Health Services, supported by the World Health Organization, to define the scope of health services purchased, and a new pilot case-based payment model for inpatient care, to be supported by the Asian Development Bank.

22. Support for the nationwide rollout of primary care capitation under the parent project offers an opportunity to strengthen primary care financing. Prior to the transition to per capita financing for PHC, budgets for primary care facilities were historical, input-based, and strikingly unequal, with up to 8-10 fold differences between different types of facilities (urban health center, district health center, RHC, and HH). Each year, the MOHSP calculates normative per capita rates that each type of facility should receive as a baseline. Factors in the formation of normative base rates include the facility’s catchment population, a summary of services provided, the salaries of existing staff, and an adjustment for harsh conditions/high altitude (a coefficient range for altitudes beginning at 1,200 meters). While the MOHSP determines these standards, the funds are predominantly raised through local taxes and paid through district administration budgets. These per capita payments pay for most service provision, salaries, and other costs of a health facility. An evaluation of the implementation of PCF, conducted by an international consultant under the current project, has identified several bottlenecks that have muted its impact on the equity of PHC financing across facilities, including the exclusion of financing for vertical health programs and lack of flexibility in the budget line for salaries. One improvement that is clearly required is improved data on the population information that is available for each facility, as this provides the basic information for making PCF payments and these data are currently not available in a reliable nor digitized database.

23. Activities under the AF2 will build on the parent Project to address the above challenges. This AF2 is focused on scaling up and ensuring sustainability of investments under the original project and AF1 through (i) continuing PBF in pilot districts, yet with fewer indicators and mainly orientated to child health; (ii) extending PBF to additional areas with poor health indicators to improve quality of care; (iii) adding household engagement activities in PBF districts to create demand for PHC services; (iv) supporting transition of PBF to government ownership and stronger primary care financing in general; (v) providing equipment and training to primary care staff to deliver quality services; (vi) strengthening primary care information systems in project districts; and (vii) undertaking minor improvements to selected primary

8 Global Health Expenditure Database, World Health Organization


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care facilities in project districts for quality health services, including solar panel installation for RHCs constructed under the original project that do not have dependable electricity supplies.

24. The AF2 meets the eligibility criteria under World Bank Policy on Investment Project Financing: (i) the Implementation Status and Results Report ratings for progress towards the PDO and implementation progress have been consistently rated Moderately Satisfactory or better over the most recent 12 months; (ii) the available data for the PDO-level indicators (based on project administrative data) indicates that progress against targets is on track; (iii) there has been substantial compliance with key legal covenants, including audit and financial management reporting requirements; (iv) activities under the AF2 are not expected to change environmental safeguards category nor trigger new safeguard policies9; (v) the fiduciary ratings have been Satisfactory or Moderately Satisfactory for the last 12 months; and (vi) the AF2 activities are consistent with the original PDO and strategically aligned with the objectives of the forthcoming CPF for fiscal years 2019-23, namely investing in human capital, particularly reduction of under-five mortality rates and ECD.

25. This AF2 is the best mechanism for development impact and results. Overall, this AF2, which has the support of Gavi and the commitment of the Government of Tajikistan, is a more appropriate and efficient mechanism to maximize development impact and results in the Tajikistan health sector than a completely new operation or non-lending instruments for the following reasons: (i) the AF2 will use the well-performing HSIP implementation and institutional arrangements as an instrument to maximize outcomes and synergies between HSIP and AF2; (ii) the scope of the proposed scale-up and additional activities can be easily accommodated in the context of the ongoing HSIP, relying on existing MOHSP implementation capacity; and (iii) the AF2 focuses on child health interventions delivered at PHC level that have been found to be highly cost-effective in other settings, and that proved to be impactful under the HSIP, to date.

26. The proposed Project has been screened for short- and long-term climate change and disaster risks and the overall risk rating is Moderate. The main associated climate risks include rising temperatures, drought conditions with decreased precipitation, a decrease in snow cover, as well as potential mudflows and floods countrywide. The mean annual temperature in the project location is projected to increase by 1℃ by 2050, with a similar projected rate of warming for all seasons. A temperature rise of 1℃ is projected to increase the number of heatwaves by between 100 and 180 percent, while the number of cold surges would decrease by between 20 to 40 percent. The substantial increase is expected in the frequency of days and nights that are considered “hot” under the current climate and a decrease in the number of days and nights considered “cold” under the current climate. These changes in extreme temperatures are expected to have a significant health impact, including mortality and injuries related to heat stress among the Project’s target population. In addition, the

9 Environmental Assessment OP/BP 4.01 was triggered under the original project and this did not change under AF1. The AF1 project paper indicated in error that this policy was not triggered, rather than there being no change in safeguard policies triggered. This AF project paper rectifies this error, however this is noted in the datasheet as a change in safeguard policies triggered, whereas in fact it is simply a continuation of Environmental Assessment OP/BP 4.01


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projected increase in inter-annual rainfall variability is likely to exacerbate drought risk in the future. Projected increases in seasonal rainfall, total runoff, and the proportion of scale-up in heavy events will have profound implications for flooding. These increases in rainfall and flooding may increase the risk of severe injury and negative health effects, including through the likely increased growth and survival of various vectors with a commensurate increase in the prevalence of dengue or other diseases among the Project’s target audience.

DESCRIPTION OF ADDITIONAL FINANCING 27. The AF2 will scale-up the coverage of PBF and quality improvement activities in underserved areas, as well as strengthen demand for primary care services through community outreach. The overall project design remains unchanged10, but the AF2 will scale-up activities already under implementation under the parent project as described below by component.

28. Results framework. Both, PDO- and IR-indicators, as well as baseline and target values, have been adjusted to reflect the progress to date and revised activities. In particular, three PDO indicators have been dropped (percentage of pregnant women receiving antenatal care, contraception prevalence rate, percentage of children under-five with diarrhea treated with any Oral Rehydration Therapy) because these activities will no longer be incentivized under AF2 as well as the measurement challenges (referred to in paragraph 4), and replaced with indicators that better reflect activities under AF2 (percentage of mothers receiving timely postnatal counselling, number of mothers receiving counselling on nutrition). One PDO indicator has been retained (average facility quality of care score). The changes to the results framework are summarized in Annex 1.

29. Gavi co-financing. In addition to the IDA resources, US$2 million of Recipient Executed Trust Fund resources have been committed by Gavi to support Component 1 and 2.2 of the AF2. This funding is subject to the approval of an amendment of the Administrative Agreement of the Integrating Donor-Financed Health Programs Multi-Donor Trust Fund. Activities that will be supported by this expected co-financing are indicated in Table 4.

30. Consistency with current CPF. The AF2 is included in the CPF (135875‐TJ) approved in April 2019, and is consistent with the objectives of Pillar 1 (Human Capital and Resilience) of improving nutrition, hygiene, and reducing the still high under-five mortality rates. It directly contributes to the second objective of the CPF, Enhancing Health Services, and two of the CPF’s indicators under this objective: (i) percentage of children aged 12–24 months in project districts who receive all basic vaccinations; and (ii) children under five years in project districts with height and weight measured in previous six months.

10 Changes to some project activities under AF2 may affect the Project description under the original Project and AF1


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COMPONENT 1: PBF (US$5.875 million, thereof IDA US$4.37 million and expected Gavi co-financing US$1.505m)

31. Continued implementation of a streamlined PBF scheme for PHC services. This will be done by providing quarterly performance-based payments to Eligible PHC Facilities in districts identified in the PBF Manual, based on their performance on a set of criteria agreed upon in writing by the MOHSP and the PHCs and specified in the PBF Manual acceptable to the Association.

a. During the first year of the AF2, PBF will continue to be implemented in the 10 pilot PBF districts, however with fewer indicators and smaller incentive payments to encourage sustainability after the project's lifetime. While the quality of primary care will continue to be incentivized according to a quality scorecard, there will be fewer indicators for the quantity payments focused on selected MCH and NCD services as tracers of integrated primary care. These include child health services of vaccination, postnatal counseling, growth monitoring, and treatment of malnutrition. Indicators on hypertension diagnosis and treatment in the original project will be retained, due to a recent World Bank study11 that found 10 percent or less of adults with hypertension are diagnosed and registered in a health facility in Khatlon and Sogd regions, with the probability of blood pressure control in the entire hypertensive population less than 2 percent. Incentive payments associated with each of these six indicators will be reduced to be more sustainable under any future government funding. A seventh indicator will incentivize health workers to visit each household in their catchment area for patient engagement activities, described below. The PBF manual will be revised by the PCG ahead of disbursement. Quarterly internal verification by the State Surveillance Service on Health and Social Protection Activities (SSSHSPA) will be conducted as per the original project.

b. Scaling-up of PBF to underserved areas to improve quality of care. During the first year of implementation of the AF2, new project districts will be prepared for the implementation of streamlined PBF. Districts have been selected based on a multi-dimensional index of need (including vaccination coverage and poverty rates) in discussion with the government. Districts selected will not be part of the ECD Project under preparation to avoid duplication. Preparation for PBF will involve: (i) a facility mapping exercise undertaken by the Capital Construction Department and verified by an independent international consultant; and (ii) training of health workers and district management teams in PBF principles and computer literacy, using the revised PBF manual. PBF will commence in these new districts during the second year of implementation.

32. Support for the internal and external verification of PBF Scheme through:

a. Internal verification. Quarterly internal verification will be conducted, as per the original project. Capacity building for SSSHSPA,s will be undertaken at the national and subnational level, including

11 Chukwuma, A. et al. 2019. Strengthening Service Delivery for Hypertension in Tajikistan. Washington, DC: World Bank Group


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training and office equipment, to strengthen service capacity in preparation for national scale-up and transition to government ownership.

b. External verification of PBF. External verification of PBF during 2020 will be conducted by UNICEF and is expected to be directly paid for by Gavi (i.e. this expenditure is not part of the expected co-financing). External verification of PBF after January 1, 2021, will be conducted by UNICEF and paid for by AF2. An amended or new Memorandum of Understanding will be drawn up to undertake external verification of PBF as under the existing scheme.

33. Support for comprehensive PHC financing reforms through deepening of per capita financing (PCF), integration of PBF payments, and pilot testing of patient registries. Under AF2, an international consultant will advise on changes that can be made to ease identified bottlenecks to more effective PCF; for example, the move to a single budget line for primary care facilities or flexibility in moving funds across budget lines. An international consultant(s) will also advise on how PBF payments can be incorporated into the PCF payments; for example through an existing dormant financial mechanism in local authorities’ budgets. This will be supported by separate funding from the Global Financing Facility in support of Every Women and Every Child to overcome public financial management barriers to more efficient health financing. Training on PCF, PBF, and patient registry principles in primary care will be provided to regional and district managers to improve knowledge.

34. Transition to government ownership and sustainability of PBF through the development by the MOHSP, through its technical working group, of an action plan for primary care financing, including scaling up of performance-based payments in primary care, their integration with the nationwide PCF scheme, and the deepening of PCF. In both new and existing PBF districts, payments supported by the Project will be discontinued after four quarters of implementation. District and facility managers will be officially informed of this transition by June 2020 to enable the development of sustainability plans in each district, with phased out support from the PCG for the original PBF districts in the second year of implementation. A Technical Working Group (TWG) on Health Financing has already been established and will develop an action plan for scaling up PBF in primary care, their integration with the nationwide PCF scheme, and the deepening of PCF. Table 3 lays out enablers for national scale-up and sustainability for PBF and how these are supported under AF2 activities.


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Table 3: Enablers for national scale-up and sustainability of PBF

Enabler for scale-up and sustainability of PBF

AF2 activities

Government ownership Support to the MOHSP TWG to develop an action plan and implement a national scale-up of integrated PCF/PBF in primary care. Stronger integration of project’s PCF capacity into MOHSP

Sustainable financing Modification of PBF scheme to be cognizant of fiscal constraints TA and support for deepening of per capita financing (PCF), including the integration of PBF payments (including work on public financial management barriers under separate funding), and pilot testing of patient registries

Information on PBF process and results

Rollout of appropriate software in PBF districts

Verification of PBF results Capacity building for SSHSPA

Service user behavior change Household engagement visits and citizen scorecards

Provider behavior change Primary care management training

35. Support to improve PHC service delivery through:

a. Citizen scorecards. To support community engagement and enhance the accountability of health managers and providers, the AF2 will continue to support the CSC mechanism included under the original project. This mechanism will be strengthened according to revised guidelines drawing on best practice in the region and learning under the Project, and this strengthened mechanism will be expanded to the new project districts. The participants of the CSC process on the community side will include patients, mahalla (neighborhood) committees, active citizens, women’s councils, youth, and religious leaders. The CSC process will involve four steps: citizens/users of health services will form focus groups to discuss issues and carry out a scoring exercise around a number of (core and specific) performance and behavior indicators; PHC staff (health managers, nurses, doctors) will carry out a similar self-assessment, which will be followed by a dialogue between community members and PHC staff to discuss results, identify key gaps, issues, and propose solutions. The CSC will then be collated into a jointly-developed action plan for each RHC and attached HHs, formalized through a committee of PHC staff and community representatives for each PHC facility (responsible for establishing target dates for completing actions and follow up), and approved by the district authority. The CSC process will be conducted at least once for each RHC and attached HHs implementing PBF during AF2. Communities will be notified of actions taken through noticeboards in PHC facilities. To ensure that the voice of vulnerable groups is heard, CSCs will be facilitated by trained and certified civil society facilitators with knowledge of the health sector. Extending the improvements seen to date, these arrangements are expected to enhance health workers’ performance, accountability, and responsiveness to patient needs. The CSC process also helps to develop better patient/client responsibility for their own health,


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understanding of the constraints faced by local health providers, and motivation to resolve issues jointly (such as local business investment in new facilities).

b. Household engagement visits to create an understanding of and demand for primary care services to strengthen incentivized services under PBF. This activity will build on currently mandated household visits (Podvorovoy obkhod) where primary care nurses and doctors visit households in their catchment area to assess the health status of family members. Under AF2, these visits will be made more comprehensive through (i) taking a census of household members; (ii) assessing the health needs of household members; (iii) providing information on appropriate services available at the local primary care facility; (iv) creating a follow-up plan for household members for relevant services incentivized under PBF; and (v) providing information on grievance redress mechanisms (see paragraph 45). Training will be provided to health staff in existing and new districts.

c. Patient registries. To better plan, finance, and implement health services in a targeted manner, the Project will pilot the creation of digitized patient registries for PHC facilities in selected project districts. This will involve the development of the appropriate software, data collection through household engagement visits, data entry, and training the responsible personnel. The creation of patient registries in selected project districts will be incentivized through the PBF scheme.

COMPONENT 2: PHC strengthening (US$4.175 million AF2, thereof IDA US$3.68 million and expected Gavi co-financing US$0.495 million).

Sub-component 2.1: Quality improvement (IDA US$1.60 million)

36. Six-month family medicine training for PHC doctors and nurses from new PBF districts. Under the current Project, six months of training in family medicine has been provided to existing nurses and doctors in the PBF districts. Under the AF2, this training will be extended to the staff of the new PBF districts as part of the capacity building plan, which will positively impact the quality of care provided by the facilities. The training will be conducted at the regional MOHSP Family Medicine Clinical and Training Centers for the staff of the new PBF facilities using the existing training material approved by the MOHSP.

37. Primary care management training for all heads of PHC facility networks and directors of RHCs across the country. This course will be delivered to all heads of PHC facility networks across the country, who will be trained at the Postgraduate Medical Institute. A shorter course will be delivered to all directors of RHCs across the country in a train-the-trainer approach, whereby the Postgraduate Medical Institute will train staff at the MOHSP Family Medicine Clinical and Traning Centers. It is estimated that around 1,000 participants nationwide will attend the course, which is feasible as the PCG has previously trained 825 doctors at the regional and central level in management. Primary care management skills such as planning, data analysis for performance, leadership, and community outreach have been noted to be bottlenecks to improved performance under the PBF scheme in the original project. This training will include sessions on climate-related health issues and resiliency measures.


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38. Support to graduate doctors for family medicine specialty training during transition to national funding. It was noted in the qualitative study that mothers tend to associate provider competence with specialization (paragraph 9). To improve the status of family medicine as a specialty, as well as the quality of primary care, the Swiss Development Cooperation has been supporting the development and implementation of a national two-year post university specialty training in family medicine (known as the PUST program). However, this support is now being phased out, with a plan for a transition to state funding over five years. In this transition period to state funding, around 60 graduates from the Tajik State Medical University will be supported over a two-year period. These graduates will be selected from the new project districts in the hope that they will return to their home districts to work after graduation from specialty training.

39. Support for the development, installation, testing of and training on specialized software to improve the quality and coverage of PHC services. In PBF districts, specialized software to improve the quality and coverage of PHC services will be developed, installed and tested; in addition, training for PHC staff will be provided. Implementation is likely to be easier in these districts as the staff is already trained in computer literacy, and facilities have the necessary electronic infrastructure. This will include incorporation of the PBF system as a module in appropriate software, which can then be scaled up nationally. This software will support the monitoring and mitigation of climate-sensitive diseases, particularly when it monitors immunization and uses a messaging function. Continuation of the PBF scheme will also require an upgrade of the PCG server, as well as new software for data protection as required by the Government of Tajikistan.

Sub-component 2.2: Physical infrastructure improvements (US$2.575 million, thereof IDA US$2.08 million and expected Gavi co-financing US$0.495 million)

40. Technical assistance for independent verification of the facility site survey of primary care facilities in districts participating in the PBF scheme to establish physical infrastructure needs (rehabilitation works and basic medical equipment). The facility mapping exercise will be undertaken by the Capital Construction Department of the Republic of Tajikistan. The results will be verified by an independent international consultant and approved by the World Bank. This will determine which facilities require minor refurbishment (with an upper threshold of funding), provision of internet, and the purchase of computers and medical equipment necessary to support the PBF interventions.

41. Basic medical equipment bags for primary care doctors and nurses. These bags will contain basic medical equipment (stethoscope, blood pressure monitor, a thermometer to check the temperature is not raised before vaccination, otoscope, tape measure for growth monitoring, etc.). These will be distributed to: (i) family doctors and nurses in GBAO where the level of equipment is poor; and (ii) newly trained primary care nurses and doctors in the new project districts following the six month family medicine training. By ensuring staff has the basic equipment to provide essential primary care services, this will directly strengthen the quality of front-line service delivery for child health.

42. Minor rehabilitation, equipment, and solar panels for selected primary care facilities, based on the approved site survey of primary care facilities in districts participating in the PBF scheme to establish


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physical infrastructure needs. Selected primary care facilities will be provided with minor rehabilitation, solar panels and basic medical equipment to ensure basic functionality, vaccine effectiveness, and capacity to fulfill PBF requirements.

COMPONENT 3: Project management, coordination and monitoring and evaluation (US$1.95 million, thereof IDA US$1.95 million and expected Gavi co-financing US$0.0)

43. Support for (i) Project implementation and management at the central, regional and district levels, including provision for Training and Incremental Operating Costs, (ii) monitoring and evaluation, and (iii) Project audits. There are no changes to the scope of this component under the AF2. This component will finance: incremental operating costs, including internal verification costs; office, vehicle, and equipment maintenance; services; limited workshops and training for the project implementation staff at central, regional and district levels; monitoring and evaluation; and project audits.

Table 4: Activities expected to be co-financed by Gavi by component

Component 1: Performance-based Financing GAVI (US$)

Performance-based payments to RHC staff in existing and additional districts 960,000

Internet costs - PBF facilities in existing and additional districts 45,000 Household engagement visits in project districts 500,000

Subtotal 1,505,000

Component 2: Primary Health Care Strengthening Sub-Component 1.1: Quality Improvement 0 Sub-Component 2.2: Physical infrastructure improvements Computer Equipment - PBF facilities in additional districts 250,000

Solar panels for rural health centers 245,000

Subtotal 495,000 Component 3: Project Management, Coordination, and Monitoring & Evaluation 0

Total expected Gavi contribution 2,000,000 44. Financial Management and disbursement arrangements. There will be no major change in financial management and disbursement arrangements for the AF2, the only change relates to the Designated Account, which will be opened in a financial institution acceptable to the World Bank. Delays encountered in processing currency conversion and payment transactions through the Ministry of Finance Treasury system under the parent project and the AF1, and the foreign exchange losses that have occurred due to delays in processing transactions from the Treasury side justifies the use of a financial institution acceptable to the World Bank. The financial management responsibilities for the AF2 would remain with the MOHSP’s PCG, which was established in November 2012 to implement the World Bank’s funded projects (namely the HSIP, AF1, and the Japan Social Development Fund Grant). The MOHSP’s PCG has gained the required capacity in implementing partner-funded projects, it is adequately staffed, and appropriate controls and procedures have been instituted. The financial management assessment has


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confirmed that there are overall adequate financial management arrangements in place at the MOHSP for the implementation of the AF2.

45. Grievance redress mechanism. Under AF2, a dedicated grievance redress hotline and email-based service will be developed at the central SSHSPA office. To raise population awareness of and facilitate the use of this mechanism, information boards with contact information at central and regional levels and “complaints and suggestion boxes” will be placed at visible places at each project-supported PHC facility. Project beneficiaries and citizens at large will be encouraged, including through the household engagement visits, to communicate their complaints and suggestions for service delivery improvements and complaints will be considered at CSC sessions to inform the action planning by respective PHC facilities. Necessary technical assistance and capacity building will be provided to SSHSPA and project dedicated staff to improve the effectiveness of PHC action planning and the complaints handling mechanism.

46. Institutional and implementation arrangements remain the same. Activities to be undertaken will be executed under the direction of the MOHSP PCG. The PCG consists of MOHSP technical, fiduciary, administrative staff, and local Project implementation support staff at the central level who manage the implementation of project activities, including monitoring and evaluation. Similar arrangements to those already in place in Khatlon and Sogd Oblast health departments will continue under AF2, and will be established at GBAO health department. Implementation of the citizen engagement activities will be done by the MOHSP public relations team in collaboration with consultant facilitators. The implementing agency capacity and technical expertise have improved over the six years of the Project, and it is therefore well positioned to utilize additional resources, as well as implement activities in the proposed new districts. The full details on operation procedures that guide project implementation are outlined in the Project Operations Manual (POM), adopted by Order #671 of the MOHSP on November 18, 2013, which is being updated to include the AF2 activities. Updating and amending of the POM (as well as a separate specific manual guiding PBF activities) by the Recipient in a manner acceptable to the World Bank will be a condition for AF2 effectiveness. The PCG shall carry out (i) a PHC facility site survey in districts participating in the PBF scheme to establish physical infrastructure needs (rehabilitation works and basic medical equipment), and (ii) an independent verification of the results of the said survey, all in accordance with the provisions of the POM.

47. Extension of the closing date and financing sources. The parent project was restructured in September 2019 to extend the closing date of the IDA Grant D-0700 from December 31, 2019, to September 30, 2020, to avoid closure of the project before signing of the AF2. The AF2 will have a closing date of June 30, 2022. This timeline was deemed sufficient to complete both the original HSIP activities financed under IDA Grant D-0700 as well as the expanded scope proposed under the AF2. All other financing sources, except for the IDA Grant D-0700-TJ, will be closed by the original closing date of December 31, 2019.

48. Citizen Engagement. AF2 will include best practices in citizen engagement through CSC under Component 1 in PHC facilities implementing PBF in existing and new project districts. The Project will track the number of CSC exercises undertaken as per the original project and the percentage of project-


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supported facilities that act on recommendations from the joint action plans. These will be tracked semi-annually to ensure continuous reporting on community engagement results.

49. Gender. The poor access to and quality of MCH services in Tajikistan noted in the sectoral context creates a gender gap. As in the original project, women (especially rural women) will continue to be a direct beneficiary group under AF2 as will children and infants, and postnatal and nutrition counselling to mothers are now PDO indicators. The CPF also notes that women in Tajikistan encounter deep-rooted barriers to voice and empowerment. According to the DHS, women are considered to participate in household decisions if they make decisions alone or jointly with their husband in all three of the following areas: (i) their own health care; (ii) major household purchases; (iii) visits their family or relatives. The 2017 DHS estimated that almost half (49 percent) of currently married women do not participate in any of the 3 decisions. The qualitative study linked to the PBF IE (paragraph 9) also found that young mothers had limited independent decision-making power and were expected to follow the directions of husbands and family elders, particularly the most senior women in the household12. Care-seeking decision-making was thus a collective process within the household. Under AF2, the additional activity of household engagement activities will seek to empower young mothers and shift household decision-making norms around engagement with health services. This will be supported by the CSC process, given that under AF1 women raising children but with a limited voice in their households especially appreciated the opportunity to actively engage in community life.

50. Climate vulnerability and co-benefits. The AF2 seeks to address the climate vulnerability identified in the country context. The main contribution of the AF2 is to contribute to improved access to climate-resilient PHC, particularly in rural areas that are highly vulnerable to climate impacts on health. Component 1 address climate vulnerability by strengthening the provision of PHC, promoting vaccination, and enhancing early case detection and treatment through PBF. Component 2 incorporates climate change considerations by (i) scaling-up use of solar panels in RHCs constructed under the parent project; (ii) developing information systems that will improve datasets available for surveillance of climate-sensitive diseases; and (iii) district managers and chief doctors of primary care facilities will receive management training as part of project activities. This training will include sessions on climate-related health issues and resiliency measures.

III. KEY RISKS 51. The overall risk of the parent project and the AF2 is rated as Substantial due to substantial macroeconomic, political and governance, technical design, and fiduciary risks.

52. Macroeconomic risk is Substantial given Tajikistan’s high vulnerability to external and domestic shocks, low policy buffers, and weak macroeconomic and fiscal frameworks. These risks may impact the timely implementation of the Project due to their direct or indirect impacts on the overall fiscal situation of the country which may lead to further cuts or restraints in public spending. The macroeconomic risk

12 Singh N et al. Impact Evaluation of a Performance Based Financing Pilot for Rural Health Systems in Tajikistan. Endline Qualitative Study Report. World Bank Group, forthcoming


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would be partially mitigated through the improved overall macroeconomic condition driven by the sustained high rate of economic growth and slight improvements in the monetary and exchange rate policy which may lead to the predictability of inflationary expectations and reduce the large current account deficit which in turn may reduce the downward pressure on local currency. The economic growth, which has accelerated since 2016, remains high at above 7 percent annually. The government is taking steps to curb the fiscal deficit and avoid incurring non-concessional public debt to restore the country’s debt sustainability.

53. Political and governance risk is also Substantial. Key governance challenges include the centralization of budgetary power, lack of continuity of civil servants, and a need to develop civil society. To address governance risks in the use of public resources, the project design builds on the work under the World Bank’s governance and anti-corruption strategy by incorporating a combination of internal controls, oversight mechanisms, capacity building for local institutions, and social accountability processes.

54. Technical design risk is rated Substantial. With a relatively short implementation period under AF2 and the expansion of PBF to new districts, as well as the introduction of household engagement activities and the support for the transition of PBF to government ownership, the technical design of the project has been assessed as substantial. However, this risk is mitigated through an adequately staffed PCG with extensive experience in World Bank-funded projects, including the introduction of PBF as a pilot and community training under a previous grant. Adequate capacity building measures (i.e. technical assistance and training) will continue to be provided through the AF2.

55. The fiduciary risk has also been rated as Substantial. Indicators of fraud and collusion have been noted by the World Bank under previous operations and the World Bank has worked with the client to enhance and enforce relevant systems, particularly in relation to fiduciary controls. Lessons learned from previous operations were built into the parent project and are carried through to the proposed AF2. The fiduciary risk under AF1 was rated as substantial, however the auditor has issued an unmodified (clean) opinion on all the project financial statements, indicating that controls appear to be working effectively. To further protect AF2, and to shorten processing times, the Designated Account will be moved to a commercial bank. In addition, financial management capacity building actions, aimed at ensuring smooth implementation of the proposed AF2, will include an update of the financial management section of the POM to detail the funds flow arrangements through the new Designated Account, as well as other controls under the proposed AF2 prior to its implementation. The Preventive Focal Point of the Banks’ Integrity Vice Presidency has been consulted and has offered to remain available to the team should further advice or support be required.

56. Sector strategies and policies, institutional capacity for implementation and sustainability, environmental and social risk, and risk of stakeholders from the PDO remains Moderate. Although a national health strategy is under development, there has been no substantial progress in achieving the objectives of the current health strategy. The MOHSP and PCG have a long track record of successful implementation of World Bank-funded projects, however there remains a risk of change in key counterparts and lack of commitment to government ownership of PBF. With no civil works (except minor


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rehabilitation and installation of solar panels in selected primary care facilities) to be undertaken under the AF2, the environmental and social risk has been maintained as Moderate. The risk of stakeholders from the PDO remains Moderate.

APPRAISAL SUMMARY

A. Economic and Financial Analysis 57. The AF2 will further improve project allocative efficiency by focusing the PBF intervention on the most cost-effective child health interventions. Child health interventions are consistently shown to be cost-effective, with immunization and nutrition interventions among the most cost-effective13. The Copenhagen Consensus (2012) assessed 40 investment proposals to address 10 challenges across sectors (including armed conflict, biodiversity destruction, climate change, natural disasters, and health) and found nutritional interventions (bundled micronutrient interventions to fight hunger and improve education) and expanded childhood immunization coverage to rank first and third, respectively14. Expanding childhood immunization coverage was estimated to have a cost-benefit ratio of approximately 20 and the potential to avert 1 million child deaths or 20 million disability-adjusted life years, per year. Another assessment of the costs and benefits of interventions for maternal and newborn health found postnatal counseling (community-based newborn care to support breastfeeding mothers and care of low birthweight babies) to be the most cost-effective intervention15. The child health interventions to be incentivized under the AF2 have an impact that extends beyond health outcomes. Vaccination, for example, lowers care costs for health systems and families, reduces the time parents spend caring for sick children, and increases the cognitive functioning and productivity of those vaccinated16.

58. Project activities will focus on improvements in technical efficiency, including through improvements to the PBF intervention and broader improvements to the quality of care. The IE under the original project found significant and positive impacts of PBF on quality of care but only moderate effects on utilization. The evidence of substantial impacts of PBF on quality of care justifies its expansion to additional districts, while the continuation of selected quantity incentives takes into account that that behavioral change might take time to materialize. Moreover, it is important to note that for some of the indicators the overall coverage was already high at baseline. For example, close to 90 percent of women received any antenatal care and the same proportion of children aged 12-23 months received all basic vaccinations. The relatively high baseline coverage rates may have limited the scope of the PBF incentives to impact utilization. Another possible explanation for the limited impact of PBF on utilization is that demand-side barriers might constrain uptakes in service utilization. Under the AF2, PBF in some of the new districts will be implemented alongside demand creation activities. As under the original project,

13 Global Investment Framework for Women’s and Children’s Health, 2014; The Lancet Nutrition Interventions Review Group, and the Maternal and Child Nutrition Study Group, 2013 14 Disease Control Priorities Project III, 2012 15 Adam T, Lim SS, Mehta S, Bhutta ZA, Fogstad H, Mathai M, et al. Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. BMJ. 2005;331(7525):1107. 16 See https://www.gavi.org/library/audio-visual/presentations/economic-benefits-of-vaccines


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improved monitoring, evaluation and verification will continue as a complementary strategy to mitigate the problem of information asymmetry. Quality improvement activities under Sub-component 2.1 will be continued through the development of stronger information systems for key child health services and the provision of management training to primary care staff.

59. The AF2 is designed with an emphasis on maximizing the financial sustainability of investments under the original project and the AF1. The AF2 will shift the focus away from investments in physical infrastructure and towards Component 1 and a focus on efficiency (as per previous paragraphs), building financial management processes and capacities. Incentive payments will transition to local authorities to avoid sudden discontinuation of PBF with the end of external financing. The possibility of incentive payments being continued from local authority funding through a dormant financial mechanism will be explored through the provision of technical assistance during the first year of implementation of the AF2. Prior to discontinuation of project-financed PBF in the original PBF districts, district and facility managers will be officially informed to enable the development of sustainability plans, with step-down support from the PCG for the original PBF districts. Similar steps will be taken to inform district and facility managers and to develop sustainability plans in the new PBF districts, prior to the end of the Project. Approximately 60 percent of proposed costs under the AF2, or US$3 million per year, are recurrent costs that would need to be absorbed in public health budgets to continue activities beyond the lifetime of the Project. The majority are PBF payments to providers. This represents only 1.9 percent of public health spending (US$155 million, 2016 data17).

B. Technical 60. The technical design of AF2 has been strengthened by incorporating learning from the original project and AF1, as well as the sustainability of activities after project closing. The comparative advantage of the HSIP rests on the administrative capacity already in place, based on the technical and professional capacity of its implementation unit developed over the last six years and institutional and implementation arrangements already in place to ensure the rapid execution of the proposed activities. The AF2 will build on what has been already accomplished, but ensure maximum value from the investments to date in PHC. Activities to support the transition of the PBF pilot to local ownership addresses local and international concerns of sustainability after the end of externally-financed PBF pilots. The streamlining of the PBF scheme and the addition of demand creation activities incorporate learning from the PBF pilot to strengthen these mechanisms to improve the quality of PHC.

C. Financial Management 61. The financial management arrangements for the Project are assessed as Satisfactory. These arrangements include accounting and reporting, internal control procedures, planning and budgeting, external audits, funds flow, organization, and staffing. The MOHSP has acceptable budgeting and planning capacity in place for the implementation of the AF2. A cash basis will be applied for project accounting,

17 Global Health Expenditure Database


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and International Public Sector Accounting Standards18 will be used for the project financial reporting. The internal control system for projects at the MOHSP continues to be overall acceptable to the World Bank. The MOHSP approves all project expenditures and signs the payment orders along with its Chief Accountant.

62. The MOHSP submits quarterly Interim Financial Reports on time and they are satisfactory to the World Bank. The project audit report for the calendar year 2018 under the AF1 (IDA Grant H8790 and TF014871; IDA D0700 and IDA 56660) was received on time and has been found to be satisfactory to the World Bank. The auditor has issued an unmodified (clean) opinion on the project financial statements. Project management-oriented Interim Unaudited Financial Reports will be used for monitoring and supervision of the AF2. The existing formats of the Unaudited Financial Reports will be used and the MOHSP will produce separate sets of Unaudited Financial Reports for the AF2 on a quarterly basis and submit to the World Bank not later than 45 days after the end of a calendar quarter-end. The first set of Interim Financial Reports will be submitted to the World Bank after the end of the first full quarter following the initial disbursement.

63. Audit arrangements similar to those of the parent project will be adopted for the AF2. The MOHSP will submit the annual audited project financial statements within six months of the end of each fiscal year, and at project closing. The cost of the audit will be financed from the project funds. Following the World Bank’s formal receipt of the audited financial statements from the MOHSP, the World Bank will make them available to the public through its website in accordance with the World Bank’s Access to Information Policy. In addition, the MOHSP will publish the audit reports on its website in a manner satisfactory to the World Bank.

64. In the environment of project implementation, adequate mitigation measures have been established to mitigate the consequences of corruption and will be closely monitored to ensure that the residual project risk remains acceptable. These mitigation measures include: (i) formal internal control framework as described in the POM; (ii) flow of funds mechanism via a financial institution acceptable to the World Bank; (iv) project financial statements to be audited by independent auditors and on terms of reference acceptable to the World Bank; and (v) regular financial management implementation support and supervision will be conducted to monitor and assess the corruption risk.

65. Disbursements from the grant account will follow the transaction-based method, i.e., traditional World Bank procedures. These include advances to the Designated Account, direct payments, Special Commitments and reimbursement (with full documentation and against statements of expenses). The details for disbursement arrangements will be provided in the Disbursement and Financial Information Letter. There are three disbursement conditions: (i) amendment of the PBF Manual, acceptable to the World Bank, to reflect the expanded scope of the Project; (ii) submission of evidence acceptable to the World Bank that activities of an estimated performance-based payments to the PHCs have been verified by the PBF Verification Teams in accordance with and in compliance with the provisions

18 “Financial Reporting Under The Cash Basis of Accounting” issued by the International Public Sector Accounting Standards Board of the International Federation of Accountants


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of the PHC Performance Agreements and in accordance with the procedures set forth in the PBF Manual and the Financing Agreement; and (iii) submission for each selected district (rayon) participating in the PBF scheme, a workplan acceptable to the World Bank carried out in accordance with the PHC facilities site survey and verified in accordance with the procedures outlined in the approved POM.

D. Procurement 66. Procurement activities and packages envisaged under the Project are of standard nature and of small value. They mainly include technical assistance, provision of equipment and training to primary care staff to deliver quality services, rehabilitation of PBF facilities, and other procurement activities. The activities are expected to be similar to those in the parent project in terms of complexity, the participation of the private sector, and procurement methods. The procurement approach, procurement risks, arrangements and procurement plan for the project duration recommended by the Borrower will be presented in the Project Procurement Strategy for Development (PPSD). The PPSD, including a procurement plan for the duration of the project, has been developed with support from the World Bank’s team. Procurement under the AF2 will be governed by the World Bank’s Procurement Regulations for Investment Project Financing Borrowers (July 2016, revised November 2017 and August 2018) (Procurement Regulations), and will also be subject to the World Bank’s Anti-Corruption Guidelines (dated July 2016).

67. The overall procurement risk under the Project is currently assessed as Substantial. The key issues and risks concerning procurement identified at this stage include: (i) procurement and implementation delays due to lack of knowledge and experience of MOHSP/PCG with the World Bank’s Procurement Regulations; (ii) lack of efficient contract monitoring and management skills and tools; (iii) overall high public procurement risk environment. Procurement risks along with the proposed mitigation measures are presented in detail in the PPSD.

E. Social Safeguards 68. The AF2 plans to do ‘more of the same,’ and hence do not envisage any changes relative to the existing project. No major civil works will be financed under the Project. Some small scale rehabilitation of existing buildings and installation of solar panels are planned in some selected primary care facilities. Hence, there is no requirement of ‘lands’ for the Project and OP 4.12 on Involuntary Resettlement continues to be not relevant.

69. A project-specific grievance redress mechanism has been included through the support of the dedicated grievance redress hotline and email-based service at the central SSHSPA office.

F. Environment 70. The environmental category, given to the Project in accordance with OP 4.01 Environmental Assessment, remains Category B, and no additional safeguard policies are triggered. Physical works to be supported by the proposed AF will be limited to the installation of photovoltaic solar panels at selected RHCs within the existing footprint of these facilities and minor rehabilitation of selected primary care


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facilities in new project districts. Hence, the environmental category, given to the Project in accordance with OP 4.01 Environmental Assessment, remains Category B, and no additional safeguard policies are triggered19. The Borrower has shown a satisfactory track record in environmental and social performance throughout the life of the Project. The Environmental Management Framework, prepared for the purposes of the first AF, has been updated to reflect the proposed AF components and was disclosed at the country and World Bank’s website on October 10, 2019. The updated Environmental and Social Management Framework will be applied to address minor environmental impacts associated with the noise, dust and construction waste, along with some occupational health and safety risks. The Environmental and Social Management Framework provides guidelines for designing site-specific Environmental and Social Management Plans, including necessary mitigation and monitoring measures and organizational and implementation arrangements. All proposed physical works will require development of Environmental and Social Management Plans, excluding small scale refurbishing activities inside the facility premises (e.g. wall painting, tiling, installation of cable ducts, new water-pipes, repair/replacement of doors, pipe insulation, installation of solar panels for water heating, and the need to improve access for people with disabilities will be taken into consideration).

WORLD BANK GRIEVANCE REDRESS 71. Communities and individuals who believe that they are adversely affected by a World Bank-supported project may submit complaints to existing project-level grievance redress mechanisms or the World Bank’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. project affected communities and individuals may submit their complaint to the World Bank’s independent Inspection Panel which determines whether harm occurred or could occur, as a result of the World Bank's non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/Projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org

19 Environmental Assessment OP/BP 4.01 was triggered under the original project and this did not change under AF1. The AF1 project paper indicated in error that this policy was not triggered, rather than there being no change in safeguard policies triggered. This AF project paper rectifies this error, however this is noted in the datasheet as a change in safeguard policies triggered, whereas in fact it is simply a continuation of Environmental Assessment OP/BP 4.01

http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service

http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service

http://www.inspectionpanel.org/


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VI SUMMARY TABLE OF CHANGES

Changed Not Changed

Results Framework ✔

Components and Cost ✔

Disbursements Arrangements ✔

Safeguard Policies Triggered ✔

Implementing Agency ✔

Project's Development Objectives ✔

Loan Closing Date(s) ✔

Cancellations Proposed ✔

Reallocation between Disbursement Categories ✔

EA category ✔

Legal Covenants ✔

Institutional Arrangements ✔

Financial Management ✔

Procurement ✔

Other Change(s) ✔

VII DETAILED CHANGE(S)

COMPONENTS

Current Component Name Current Cost (US$, millions)

Action Proposed Component Name

Proposed Cost (US$, millions)

Component 1: Performance Based Financing

13.96 Revised Component 1: Performance-Based Financing

19.83

Component 2: Primary Health Care Strengthening

14.30 Revised Component 2: Primary Health Care Strengthening

18.48


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Component 3: Project Management, Coordination, and Monitoring & Evaluation

4.81 Revised Component 3: Project Management, Coordination, and Monitoring & Evaluation

6.76

TOTAL 33.07 45.07

DISBURSEMENT ARRANGEMENTS Change in Disbursement Arrangements Yes

Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative

2014 1,350,000.00 1,350,000.00

2015 2,573,514.15 3,923,514.15

2016 4,136,661.54 8,060,175.69

2017 4,784,218.19 12,844,393.88

2018 5,874,279.55 18,718,673.43

2019 7,189,546.89 25,908,220.32

2020 3,173,063.63 29,081,283.95

2021 6,359,358.02 35,440,641.97

2022 6,359,358.03 41,800,000.00

2023 0.00 41,800,000.00

SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT)

Risk Category Latest ISR Rating Current Rating Political and Governance Substantial Substantial Macroeconomic Substantial Substantial Sector Strategies and Policies Moderate Moderate Technical Design of Project or Program Moderate Substantial Institutional Capacity for Implementation and Moderate Moderate


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Sustainability Fiduciary Substantial Substantial Environment and Social Moderate Moderate Stakeholders Moderate Moderate Other Overall Substantial Substantial

Safguard_Table COMPLIANCE

Change in Safeguard Policies Triggered

Yes

Safeguard Policies Triggered Current Proposed

Environmental Assessment OP/BP 4.01

No Yes

Performance Standards for Private Sector Activities OP/BP 4.03

No No

Natural Habitats OP/BP 4.04

No No

Forests OP/BP 4.36

No No

Pest Management OP 4.09

No No

Physical Cultural Resources OP/BP 4.11

No No

Indigenous Peoples OP/BP 4.10

No No

Involuntary Resettlement OP/BP 4.12

No No

Safety of Dams OP/BP 4.37

No No

Projects on International Waterways OP/BP 7.50

No No

Projects in Disputed Areas OP/BP 7.60

No No


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LEGAL COVENANTS2

LEGAL COVENANTS – Second Additional Financing to the Tajikistan Health Services Improvement Project (P170358) Sections and Description For purposes of implementing Sub-component 2.2 of the Project, the Recipient shall employ a construction coordinator, and an environmental consultant (when appropriate), who, under the oversight of the head of Construction Department of the MoHSP, will be responsible for: (a) quality assurance of the site environmental control measures and their effectiveness; and (b) coordination and reporting of the same to MoHSP and the Association. For purposes of implementing the activities under Sub-component 2.2 (ii) and (iii) of the Project, the Recipient shall carry out (i) a PHC facility site survey in districts (rayons) participating in the PBF scheme to establish physical infrastructure needs (rehabilitation works and equipment), and (ii) an independent verification of the results of the said survey, all in accordance with the provisions of the POM.

Conditions Type Description Effectiveness Recipient has updated and amended the Project Operational Manual in a

manner acceptable to the Association. Type Description Disbursement Recipient has amended the PBF Manual to reflect the expanded scope of the

Project in a manner acceptable to the Association. Type Description Disbursement Submission of evidence acceptable to the World Bank that activities of and

estimated performance-based payments to the PHCs have been verified by the PBF Verification Teams in accordance with and in compliance with the provisions of the PHC Performance Agreements and in accordance with the procedures set forth in the PBF Manual and the financing agreement

Type Description Disbursement Submission for each selected district (rayon) participating in the PBF scheme, a

workplan acceptable to the World Bank carried out in accordance with the PHC facilities site survey and verified in accordance with the POM.


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VIII. RESULTS FRAMEWORK AND MONITORING

Results Framework COUNTRY: Tajikistan

Second Additional Financing to the Tajikistan Health Services Improvement Project RESULT NO PDO Project Development Objective(s)

The revised PDO is to contribute to the improvement of the coverage and quality of basic primary health care (PHC) services in selected districts.

Project Development Objective Indicators by Objectives/ Outcomes

RESULT_FRAME_T BL_ PD O

Indicator Name DLI Baseline Intermediate Targets End Target

1 2

Coverage of basic Primary Health Care (PHC) services in selected districts

Percentage of pregnant women receiving antenatal care four or more times from a skilled health provider (Text)

Sogd: 79.2%; Khatlon: 39.2%, 78.7% RRS Sogd: 85%; Khatlon: 45%, 82% RRS

Action: This indicator has been Marked for Deletion

Rationale: Activities measured by this indicator will no longer be supported under AF2.

Mothers receiving timely postnatal counselling in existing districts (Percentage)

90.00 91.00 92.00 93.00

Action: This indicator is New

Mothers receiving timely postnatal counselling in new districts (Percentage)

60.00 63.00 65.00


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1 2

Action: This indicator is New Rationale: New districts have different baseline and target to existing districts, therefore a supplementary indicator is warranted.

Contraceptive Prevalence Rate (Text) Sogd: 30.7%; Khatlon: 22.9%, RRS 22.3% Sogd: 35%; Khatlon: 27%, RRS: 27%


Rationale: Activities measured by this indicator will no longer be supported under AF2.

Number of mothers counselled on nutrition (Number) 182,452.00 195,000.00 210,000.00 230,000.00


Rationale: Upgraded from intermediate results indicator as reflects well activities under AF2. Alternative outcome indicator considered was percentage of children with malnutrition who are successfully treated, however this indicator has not been measured accurately under PBF to date.

Quality of basic Primary Health Care (PHC) services in selected districts

Average Health Facility Quality of Care Score in existing project districts (Text)

60% (average among 10 participating districts, RHCs) 50.6% (average among 10 participating districts, HHs)

65% (average among 10 participating districts, RHCs), 55% (average among 10 participating districts, HHs)



Action: This indicator has been Revised

Average Health Facility Quality of Care Score in new project districts (Text)

Rural health center 55 percent Health House 50 percent




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1 2

Action: This indicator is New Rationale: Yearly

Percentage of children under-five with diarrhea treated with any Oral Rehydration Therapy (Text)

Sogd: 79.2%; Khatlon: 68.2%, RRS 82.2% Sogd: 85%; Khatlon: 74%, RRS 85%


Rationale: This is indicator is dropped because quality of care is measured by the Average Quality of Care Score indicator.

PDO Table SPACE

Intermediate Results Indicators by Components

RESULT_FRAME_T BL_ IO


1 2

Component 1: Performance Based Financing (Action: This Component has been Revised)

Number of eligible health facilities in which PBF is initiated (Number) 449.00 650.00 700.00


Percentage of Primary Health Care facilities eligible for PBF payments who received timely PBF payments in the preceding quarter (Percentage)

100.00 100.00


Number of independent verification visits completed per schedule (Number) 10.00 12.00 14.00


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1 2


Percentage of hypertensive adults who are currently receiving anti-hypertensive treatment (Text)

n/a 30.00


Rationale: Hypertension treatment will no longer be incentivized under AF2 scope.

Percentage of hypertension patient charts with treatment according to protocol in existing districts (Text)

80%

82% 84% 85%


Percentage of hypertension patient charts with treatment according to protocol in new districts (Text)

20% 25% 30%


Number of mothers counselled on nutrition (Number) 0.00 3,000.00


Rationale: Upgraded to PDO indicator as better reflects AF2 activities.

Number of citizen scorecard exercises/sessions conducted in the project districts. (Number)

288.00 350.00 400.00 450.00


Average proportion of women attending citizen scorecard exercises 0.00 10.00 20.00 25.00


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1 2 (Percentage)

Action: This indicator is New Rationale: New supplemental indicator added to monitor change in women's agency as part of household engagement visits

Percentage of PHC facilities that act on community action plans (Percentage) 0.00 5.00 15.00 20.00

Action: This indicator has been Revised Rationale: Revised indicator to strengthen citizen engagement

People who have received essential health, nutrition, and population (HNP) services (CRI, Number)

1,250,831.00 1,350,831.00


People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) (CRI, Number)

1,166,908.00 1,216,908.00


Number of children immunized (CRI, Number) 163,699.00 180,000.00


Number of women and children who have received basic nutrition services (CRI, Number)

939,107.00 1,000,000.00


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1 2 Action: This indicator has been Revised

Number of deliveries attended by skilled health personnel (CRI, Number) 0.00 100,000.00


Rationale: No incentives envisaged for antenatal care under the revised PBF scheme.

Percentage of PBF facilities completing household engagement exercise (Percentage)

0.00 30.00 50.00 70.00


Component 2: Primary Health Care Strengthening

Health personnel receiving training (Number) 10,289.00 10,789.00 11,289.00


Rationale: As this indicator is no longer a Core Sector Indicator, its wording and definition has been refined to better reflect the activities supported under Subcomponent 2.1.

Health facilities rehabilitated and/or equipped (Number) 403.00 450.00 470.00


Rationale: No construction or major renovation is envisaged under AF2, only some rehabilitation and provision of equipment. This indicator also ceased to be a mandatory Core Sector Indicator, hence the revision of defination.

Component 3: Project Management, Coordination, and Monitoring & Evaluation


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1 2 Number of new project districts in which PBF MIS is operational (Number) 0.00 4.00 6.00

Action: This indicator has been Revised Rationale: This indicator reflects expansion of revised PBF scheme to new project districts.

Report on evaluation of pilot experience completed and action plan for the roll-out prepared (Yes/No)

No Yes


Rationale: This was a one-off action that had been achieved under the original project.

IO Table SPACE

Monitoring & Evaluation Plan: PDO Indicators Mapped

Indicator Name Definition/Description Frequency Datasource Methodology for Data Collection

Responsibility for Data Collection

Percentage of pregnant women receiving antenatal care four or more times from a skilled health provider

Numerator: Number of pregnant women in project districts receiving ante natal care four or more times from a skilled provider Denominator: Total number of pregnant women in project districts to be disaggregated by districts for Sogd, Khatlon, & RRS.

DHS: every 5 years. PBF: yearly. Impact Evaluation: baseline and follow-up surveys.

DHS USAID/MOHSP


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Mothers receiving timely postnatal counselling in existing districts

Percentage of mothers in project districts who received first postnatal patronage visit at home within the first three days after discharge from the Maternity House

Every six months

Project Data

Project Data

MOHSP PCG, Oblast and Rayon Health Departments.

Mothers receiving timely postnatal counselling in new districts

Every 6 months

Project data

Project data


Contraceptive Prevalence Rate

Numerator: Number of women in project oblast (DHS)/districts (PBF/IE) aged 15-49 years who are currently married and using a modern method of Family Planning. Denominator: Number of women in project oblast (DHS)/districts (PBF/IE) aged 15-49 years who are currently married (to be disaggregated by districts for Sogd, Khatlon & RRS).


Household Survey Household survey

MoHSP Coordination Group, Oblast and Rayon Health Departments

Number of mothers counselled on nutrition

Number of mothers in project districts who received nutrition counselling. To be expressed also in percentage by calendar year.

Every six months

Verified project data

Verified project data

PCG, Oblast health departments, and rayon authorities.


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Average Health Facility Quality of Care Score in existing project districts

Composite Health Facility Quality Score covering key domains of the quality checklist.

Yearly

PBF verified data.

PBF MIS.

MOHSP Coordination Group, Oblast and Rayon Health Departments

Average Health Facility Quality of Care Score in new project districts

Percentage of children under-five with diarrhea treated with any Oral Rehydration Therapy

Numerator: Number of children under-five with diarrhea in project districts visiting Rural Health Centers or Health Houses treated with any ORT Denominator: Number of children under-five with diarrhea in project districts visiting Rural Health Centers or HealthHouses to be disaggregated for project districts in Sogd, Khatlon, and RRS.


DHS, PBF, Impact Evaluation.

MoH Coordination Group, Oblast and Rayon Health Departments

ME PDO Table SPACE

Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped

Indicator Name Definition/Description Frequency Datasource Methodology for Data Collection

Responsibility for Data Collection

Number of eligible health facilities in which PBF is initiated

Number of Rural Health Centers and Health Houses that have received first PBF payment

Yearly.

Project data (PBF MIS database).



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Percentage of Primary Health Care facilities eligible for PBF payments who received timely PBF payments in the preceding quarter

Numerator: Number of Rural Health Centers and Health Houses in project districts who received quarterly PBF payment within [TBD] days of quarter ending in the most recently completed quarter Denominator: Number of Rural Health Centers and Health Houses in projectdistricts who were eligible for payment based on first verification report (ex-ante verification) To be disaggregated for Sogd, Khatlon & RRS.

Yearly.


MoHSP Coordination Group, Oblast and Rayon Health Departments.

Number of independent verification visits completed per schedule

Number of independent verification reports completed by third party verification agency as scheduled, i.e., one report per rayon every six months.

Yearly.

Independent verification reports

MOHSP Coordination Group, Oblast and Rayon Health Departments.

Percentage of hypertensive adults who are currently receiving anti-hypertensive treatment

Target exceeded based on the endline survey results.

Baseline and endline surveys.

Impact Evaluation Household Survey.

World Bank Impact Evaluation Team.

Percentage of hypertension patient charts with treatment according to protocol in existing districts

Numerator: Number of charts of adult hypertensive patients with treatment according to

Yearly.

PBF Verification Records

MoHSP PCG, Oblast and Rayon Health Departments.


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protocol reviewed during internal verification. Denominator: Total number of charts of adult hypertensive patients screened during internal verification

Percentage of hypertension patient charts with treatment according to protocol in new districts

Numerator: Number of charts of adult hypertensive patients with treatment according to protocol reviewed during internal verification. Denominator: Total number of charts of adult hypertensive patients screened during internal verification

Yearly

PBF verification records


Number of mothers counselled on nutrition

Target exceeded. Data source: PBF MIS.

Yearly.

PBF MIS database, official medical statistics.

MoHSP Coordination Group, Oblast and Rayon Health Departments.

Number of citizen scorecard exercises/sessions conducted in the project districts.

Target exceeded.

Yearly.

MOHSP CG reports

MOHSP Coordination Group, Oblast and Rayon Health Departments.

Average proportion of women attending citizen scorecard exercises

Numerator = number of community members who are women attending

Semi-annual

PCG administrative data

MOHSP PCG


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citizen scorecard exercise. Denominator = number of community members attending citizen scorecard exercise. Averaged across all community scorecard exercises for preceding six months.

Percentage of PHC facilities that act on community action plans

Number of rural health centers (and associated health houses) in project districts that develop and implement an action plan to improve services in response to feedback received during citizen score card discussions.

Yearly.

MOHSP PCG reports


People who have received essential health, nutrition, and population (HNP) services

Semi-annually.

Project data.

Project reports.

MoHSP PCG.

People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement)

Semi-annually.

Project data.

Project reports.

MoHSP Coordination Group.

Number of children immunized Semi-annually.

Project data.

Project reports.

MoHSP Project Coordination Group.

Number of women and children who have received basic nutrition services

Semi-annually.

Project data.

Project reports.

MoHSP Project Coordination Group.

Number of deliveries attended by skilled health personnel Semi-

annually. Project data.

Project reports.

MoHSP Coordination Group.


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Percentage of PBF facilities completing household engagement exercise

Numerator: Number of PBF facilities completing household engagement exercise. Denominator: Number of PBF facilities

Every six months

PBF MIS data

MOHSP PCG, Oblast health departments

Health personnel receiving training

This indicator measures the cumulative number of health personnel receiving training to include (i) PBF principles and computer literacy training; (ii) Training on PCF, PBF and registry principles; (iii) 6-month family medicine training, (iv) primary care management training, (v) family medicine specialty training.

Yearly.

Project data (PBF MIS database), official medical statistics


Health facilities rehabilitated and/or equipped

Cumulative number of primary care facilities (rural health centers and health houses) in project districts rehabilitated or equipped.

Yearly.


MoHSP PCG, Oblast and Rayon Health Departments

Number of new project districts in which PBF MIS is operational

Number of districts where the PBF MIS is used to transmit PBF data in soft copy from districts to MOHSP PCG

Yearly.

Project data (PBF Progress reports).


Report on evaluation of pilot experience completed and action plan for the roll-out

“Yes” response indicates that both evaluation report

Once.

PBF Progress report. MoHSP Coordination

Group, Oblast and Rayon


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prepared and action plan for roll out has been completed

Health Departments.

ME IO Table SPACE


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Annex 1: Summary of changes to the Results Framework Indictor Description New Revised Marked for

deletion No change

Comments

PDO Indicators Percentage of pregnant women receiving antenatal care four or more times from a skilled health provider

Activities measured by this indicator will no longer be supported under AF2.

Mothers receiving timely postnatal counselling in existing districts Mothers receiving timely postnatal counselling in new districts (supplementary)

As new Project districts will have different baselines and targets to existing districts, a supplementary indicator for new districts has been included.

Contraceptive Prevalence Rate Activities measured by this indicator will no longer be supported under AF2.

Number of mothers counselled on nutrition Moved from intermediate results indicator to PDO indicator. Average Health Facility Quality of Care Score in existing Project districts

The baseline and target values have been adjusted.

Average Health Facility Quality of Care Score in new Project districts (supplementary)


Percentage of children under-five with diarrhea treated with any Oral Rehydration Therapy

This is indicator is dropped because quality of care is measured by the Average Quality of Care Score indicator.

Intermediate Results Indicators Number of eligible health facilities in which PBF is initiated


Percentage of Primary Health Care facilities eligible for PBF payments which received timely PBF payments in the preceding quarter


Number of independent verification visits completed per schedule


Percentage of hypertensive adults who are currently receiving anti-hypertensive treatment

Measured through impact evaluation household survey, which will not be used for AF2, therefore this indicator dropped and next indicator measured through Project data retained.

Percentage of hypertension patient charts with treatment according to protocol in existing



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districts Percentage of hypertension patient charts with treatment according to protocol in new districts


Number of mothers counselled on nutrition Moved to PDO indicator Number of citizen scorecard exercises/sessions conducted in the Project districts.

Baseline and target values adjusted accordingly

Percentage of PHC facilities that act on joint action plans

Revised wording, baseline and target values

Percentage of PBF facilities completing household engagement exercise

This is a new indicator to capture new activity of household engagement visits.

People who have received essential health, nutrition, and population (HNP) services

• People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement)

• Number of children immunized • Number of women and children who

have received basic nutrition services • Number of deliveries attended by skilled

health personnel

The Corporate Results Indicators have been maintained with adjusted baseline and target values, except for the deliveries breakdown indicator, which is no longer relevant given the scope of AF2.

Health personnel receiving training

Baseline and target values have been adjusted.

Health facilities rehabilitated and/or equipped

The definition as well as baseline and target values have been adjusted to reflect the scope of AF2.

Number of new Project districts in which PBF MIS is operational

The definition as well as baseline and target values have been adjusted to reflect the scope of AF2.

Report on evaluation of pilot experience completed and action plan for the roll-out prepared

This was a one-off action that had been achieved under the original Project.


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