Lao PDR Health Governance and Nutrition Development Project...

Aide Memoire-December 2016

1

Lao PDR Health Governance and Nutrition Development Project (HGNDP)

Implementation Support Mission Aide- memoire September 26 to October 11, 2016

I. Key Project Data and Performance Rating

Key Project Data Key Performance Rating

Previous Rating

Current Rating

Board Approval June 23, 2015 Progress towards achievement of Project Development Objectives

Satisfactory Moderately Satisfactory

Effectiveness date

October 12, 2015 Overall Implementation Progress

Satisfactory Moderately Satisfactory

Closing Date December 31, 2020

Disbursed US$7.0 million

US$7.0 million

Total Project Cost (Grant)

SDR 18.8 million (total, of which SDR 9.4 million grant and SDR 9.4 million credit)

% disbursed 53% of Grant; 26% of overall project cost

53% of Grant; 26% of overall project cost

II. Introduction

1. A World Bank (WB) mission met in Vientiane from September 26 to October 11, 2016 with the following objectives: (i) verify the achievement of Disbursement Linked Indicators (DLIs) Year 1 targets, (ii) review the progress on the Health Governance and Nutrition Development Project (HGNDP) implementation and technical assistance (TA) to Civil Registration and Vital Statistics (CRVS); (iii) provide technical assistance to the DLI workshop with project provinces; and (iv) to review and discuss any pending actions from the last mission, particularly the delays in Social Behavior Change Communication (SBCC) implementation, recruitment of KAP survey firm and financial management (FM) specialist; and (v) meet with Ministry of Health (MOH) counterparts and Development Partners (DPs) to identify areas for technical assistance to facilitate transition of financial support from DPs to the Immunization Program; The mission also undertook a field visit to Luangnamtha and Oudomxay provinces to review the implementation of the programs covered under the DLIs and to assess their readiness for rolling out the SBCC activities. 2. The mission was co-led by Somil Nagpal (Senior Health Specialist and Task Team Leader) and Sutayut Osornprasop (Human Development Specialist and Co-Task Team Leader). The Health, Nutrition and Population Global Practice Manager Toomas Palu joined part of the mission. The following core team members traveled to Vientiane to participate in the mission: Emiko Masaki (Senior Health Economist), Nkosinathi Mbuya (Senior Nutrition Specialist), Birte Sørensen (Consultant), Rutu Dave (Energy Specialist), Samuel Mills (Senior Health Specialist), Pamornrat Tansanguanwong (Senior Social Safeguard Specialist), and Frederick Yankey (Hub Leader for Financial Management). The following Vientiane-based team members participated in the mission: Banthida Komphasouk (Health Specialist), Sophavanh Thitsy (Operations Analyst), Jutta Krahn (Consultant), Peter Crawford (Environmental Specialist), Siriphone Vanitsaveth

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized


2

(Senior Financial Management Specialist), Khamphet Chanvongnaraz (Procurement Specialist), Viengsamay Vongkhamsao (Senior Water and Sanitation Specialist), Khamkong Liemphrachanh (Consultant) and Boualamphan Phouthavisouk (Team Assistant). 3. During the mission, the team also consulted with Government of Lao PDR (GoL) counterparts from Ministry of Health (MOH), Ministry of Home Affairs (MOHA), Ministry of Justice (MOJ), Ministry of Agriculture and Forestry (MAF), Ministry of Finance (MOF), Ministry of Planning and Investment (MPI), and DPs from the Asian Development Bank (ADB), the European Union, UNICEF, UNFPA, WHO, Swiss Red Cross (SRC), Lux Development, JICA, Populations Services International (PSI) and the Clinton Health Access Initiative (CHAI). The team visited the provinces of Oudomxay and Louang Namtha and met with provincial, district and health center staff as well as community members. Please see list of people met in Annex 1. This Aide Memoire summarizes key findings, recommendations and agreed actions of the mission; a draft Aide Memoire was shared with MOH, MOHA and the National Program Coordination Office (NPCO) of HGNDP for their comments. As part of the World Bank’s Access to Information Policy, and in agreement with MOH and MOHA, the Aide-Memoire will be publicly disclosed.

III. Health Policy and Reform Context

4. HGNDP directly supports the government’s intensified effort for health sector reform implementation in line with the 8th Health Sector Development Plan (2016-2020) and Sector Reform Framework to 2025 to ensure the achievement of sector outcomes toward Universal Health Coverage (UHC) by 2025. The project used innovative results-based financing linked to achievement of specific indicators such as provision of Free MCH and adequate supply of family planning and nutrition commodities, and also invests in strategic behavior change communications to improve nutrition outcomes in Lao PDR. The project has a focus on issues of equity of access, systems strengthening and financial sustainability in the sector, and is accompanied by technical assistance and analytical work to help make progress on these themes. A series of capacity building activities in support of health sector reform for UHC have been undertaken in recent months to enhance capacity on health financing among the technical staff as well as to enhance individual and collective leadership capabilities for reform implementation and delivering results for UHC. Analytical and advisory support to MOH has focused on addressing challenges of declining external financing in the evolving health system context of Lao PDR.

IV. HGNDP Implementation Support

Project Development Objectives

5. The Project Development Objective is to help increase coverage of reproductive, maternal and child health, and nutrition services in target areas in Lao PDR. A large part of the project funds are disbursed against DLIs achieved at central and provincial levels. Implementation of DLI is fully aligned with the five priority areas in health sector reform framework toward universal health coverage. Summary of the Project Status

Component 1: Health Sector Governance Reform


3

6. This Component has been progressing well. A contract to support operation and maintenance of the Health Management Information Systems (HMIS) server is currently under review by the National Internet Center; during this waiting period services are provided free of charge by them. Training of additional staff in District Health Information System 2 (DHIS2) at provincial level (including health centers) is ongoing; a small video to be used as a job aid is currently being finalized. It is the intention to develop a mobile application out of this at a later stage. All DLIs can now be monitored through the DHIS2. WHO continues to provide valued technical support to DHIS2 development and incorporation of additional vertical databases (malaria, tuberculosis, HIV). Incorporation of Expanded Program for Immunization (EPI) and FM information is planned for the near future. NPCO continues to monitor data accuracy through field visits; findings during the field visit indicate that accuracy of reporting has improved over the past six months. Wi-Fi connections are being set up in all districts with shared support from NPCO and Global Fund for Aids, TB and Malaria (GFATM). Department of Planning and International Coordination (DPIC) in collaboration with NPCO has completed and shared the National Health Statistics Report at national level. Reports are currently being printed in Lao and English. 7. Part of the causes for data quality issues is that some provinces and districts still use the old maternal and child health (MCH) form for reporting, leading to inaccuracies in reporting and double work for the field staff and double supervision from provincial and central level. Likewise, health center staff report separately and province and district supervise separately- EPI performance while also reporting the same EPI information through the DHIS2. The mission strongly recommends that the project team work closely with Maternal and Child Center to encourage the use new MCH forms and integrate EPI reporting into DHIS2. Component 2: Service Delivery

8. Considering that this is the first year of DLI implementation and that time was very short (less than six months) for achievement of the DLIs for Year 1, overall achievement of DLIs has been very good. The details of status and issues arising from review of Year 1 DLI achievement are described in Annex 2. The weekly meetings between NPCO and the central departments and centers are proving very effective in information sharing and coordination of activities, and invitation to WB to join these meetings as observers has been very useful. Similar monthly meetings between province and districts have also been introduced. A number of monitoring visits by the NPCO, a few times with WB participation, with on-the job-training and problem solving have also taken place. The Dashboard function in DHIS2 has enabled departments and provinces to closely monitor performance. 9. The Independent Academic Institution (IAI) undertook the first round of independent verification from June-August 2016. For a few DLIs, the information provided by the IAI was not adequate or lacked clarity to determine the DLI achievement. It was agreed during the mission that henceforth, the March missions of the WB team would include a meeting with the NPCO and the IAI to review the methodology and tools proposed, and to clarify any doubts well before data collection commences. Likewise, the September missions would provide an opportunity for mutual feedback on improving the process. In terms of logistical constraints, the rainy season has presented a challenge for travels and only villages and health centers near good roads could be reached. Since data entry is an ongoing process, it was agreed that data verification can take place during the year and the field visits be scheduled for the dry season (April-May).


4

10. The first quarterly DLI workshop, with representation of all departments and provinces concerned, took place during the mission on September 29-30 in Vientiane. The workshop had high level GoL participation and discussed achievement of Year 1 targets, challenges faced, and modalities for better coordination between different departments and between departments and provinces as well as suggestions for improved utilization of the DLI funds to achieve Year 2 DLIs. 11. Below are a number of observations regarding DLI achievement including observations from the field visits:

• Project was able to ensure equity of access to essential services delivery, particularly access to Health Equity Funds (HEF) and Free MCH. While it was understood during project preparation that the provinces would receive additional annual allocations from the ADB budget support tranche and that such additional funds would cover HEF and Free MCH, this has not been the case. Provinces report that once they have exhausted other sources of funds for free MCH they were instructed only to provide free services to families listed as poor in the list prepared by the Leading Committee for Rural Development and Poverty Eradication and available in the health centers. This may negatively affect achievement of Central DLI 4 for number of women that received Free MCH services and a number of provincial DLIs.

• Regarding provincial DLI 3 there is still some lack of clarity that it is the new, long term family planning users, not all family planning users which are to be recorded.

• Regarding provincial DLI 4, it was apparent in all facilities visited that while children are being weighed and measured for reporting purposes, this does not constitute ‘growth monitoring’ since growth charts are not routinely filled, mothers not informed on the adequacy of their child’s growth and counselling is not being provided based on the individual child’s growth. Furthermore, children (mostly from zone 0 and 1) visiting the fixed sites are weighed bi-monthly while children in zone 2 and 3 villages are at the most weighed and measured four times per year during outreach sessions. There appears to be no special provision for closer follow up of malnourished children or a referral system in place (e.g. sending children with acute malnutrition to the district hospital). It appears that health staff have limited understanding of their roles and responsibilities in monitoring child growth and reducing malnutrition. The equipment for anthropometric measurement was available in most – but not all - facilities visited, but it is bulky and not fit for carrying on a motorcycle for outreach clinics. Facilities visited did not have enough “pink books1” to provide to all mothers. While a number of staff are themselves ethnic minorities, overall service provision would benefit from an increase in ethnic minority representation amongst the facility staff to reduce language barriers.

• During the previous mission it was agreed that the four target provinces for provincial DLI 4 will revise their baseline information to include only children who have: (i) had their growth chart filled in and (ii) whose caretakers have received nutrition counselling based on the growth chart. Only the four target provinces for provincial DLI 4 will be rewarded for their performance while all provinces have been instructed to report. Clear instructions as well as simple job aids for growth monitoring and counselling are urgently required. While awaiting the supply of

1 Book to be kept by the Mother for recording pregnancy, delivery, postnatal care, family planning, weight and hight of a child at birth, child immunization and child development up to 5 years.


5

‘mobile’ anthropometric equipment the health facilities can start with growth monitoring of the children from Zones 0 and 1 who come to the fixed sites.

• Regarding provincial DLI 5 (which supports the health sector reform priority 4) that finances the achievement of 4 rounds of integrated outreach conducted in remote, rural areas (zone 2 and 3 of HC catchment areas); it was found that outreach visits in one province appear to include all five required services2 while in another province EPI outreach is still conducted separately (or in some cases only EPI and family planning but not all five activities). What may therefore be reported from some provinces in DHIS2 is the EPI outreach sessions held rather than integrated outreach. Clear job aids for conducting integrated outreach are required to ensure uniformity of the integrated outreach – both for the (short term) purpose of achieving provincial DLI 5, and for the purpose of efficiency gains and improved and more uniform EPI and MCH coverage.

• Regarding demand side interventions to achieve central DLI 4 and provincial DLIs 1, 2, 3, 4, there is to date little work which addresses this aspect. The team found that the National Communication Task force under EPI was conducting a survey along with Lao Women’s Union and the National Lao Front for Construction on current barriers in access to EPI services; the survey should provide some insights into how best to provide EPI and other preventive services to non-Lao speaking ethnic groups. The findings from this survey may be helpful for enhancing access to other services.

Table1: Agreed next steps for Component 1 and 2

Action Target

Date

Responsible

Disseminate DHIS2 instructional video to project provinces and districts

December 30, 2016

NPCO

Cooperation with Ministry of Telecommunication and Post to obtain the GOL plans for internet connectivity nationwide.

December 30, 2016

NPCO

Official Ministerial Order to terminate old MCH reporting forms including EPI and report only through DHIS2.

December 15, 2016

NPCO/MCHC /DHHP/Cabinet

Ensure that provinces and health facilities have adequate supply of “pink books” based on 2016 census data

December 31, 2016

NPCO/MCH Center/Nutrition Center

Develop locally appropriate tools for measuring weight and height in children from 0-5 years and make them available to all health centers responsible for integrated outreach in zones 2 and 3.

December 31, 2016

NPCO/NNC

Provinces to review stock availability of equipment for growth monitoring of children in all their facilities; assess capacity building needs regarding growth monitoring

January 30, 2017

NPCO/PHO/DHO

Provide clear instructions and job-aids to the health facilities regarding growth monitoring and counselling as well as integrated outreach which are user friendly for non-Lao speaking ethnic groups

February 28, 2017

NPCO/NNC/CIEH

2 Including ANC, PNC, family planning, immunization and growth monitoring


6

Component 3: Nutrition Social and Behavior Change Communication (SBCC)

12. While there has been some progress, Component 3 is moving significantly slower than

expected. Among the activities completed, though with some delay, selection process of all consultants has now been completed including the Project Manager for Component 3. Four provincial coordinators have been selected and started working in their respective provinces. International and national SBCC experts are now also on board. The implementation of village-level interventions commenced in late September, starting with the roll-out of Community-led Total Sanitation (CLTS) training-of-trainers (TOT) to relevant government staff at the provincial and district levels in 12 districts in four provinces to become master trainers. Department of Hygiene and Health Promotion (DHHP) with technical support from UNICEF is in process of finalization of revised Infant and Young Child Feeding (IYCF) package during November 2016. The TOT on IYCF package will commence in December 2016. Village facilitators in all 120 villages have also been identified. Following the TOT, these master trainers will provide training to village facilitators. A list of consolidated village WASH profile and baseline on sanitation was done. The behavior change communication (BCC) package on promoting rural sanitation is ready for printing and use, in parallel with CLTS process. It was agreed that the Center of Information and Education for Health (CIEH) will take the lead on rolling-out implementation of BCC package for sanitation. Development of the national SBCC strategic action plan is well underway. Despite this recent progress on several fronts, the mission is concerned about the delays in finalizing Standard Operating Procedures (SOP), the delay in hiring of the baseline survey firm, and in conducting village-level orientation sessions.3 13. The mission recommends that the MOH leadership discuss with NPCO and the relevant technical departments to accelerate the pace of implementation. It is agreed that NPCO is responsible for the overall coordination of Component 3, while DHHP and its technical centers are responsible for implementation and to provide high quality technical support according to the agreed timeline. 14. A study tour to Vietnam to learn from their SBCC experience, led by Vice Minister of Health, was also successfully completed in August. The MOH team has shown commitment to select and apply relevant practices from Vietnam for implementation in Lao PDR. The study visit has also paved way for potential technical support on SBCC for Lao PDR from the Alive & Thrive expert team, who can help strengthen capacity of the Lao PDR’s team on formative research as well as M&E, among others. 15. The collaboration between MOH (HGNDP) and Ministry of Agriculture and Forestry (MAF) (Strategic Support for Food Security and Nutrition Project – SSFSNP) to support the convergence approach in nutrition at the village level in 12 districts in four provinces has progressed well. Working teams from the two ministries have communicated on a regular basis, contributing to well-coordinated work plans (village selection, phasing) as well as a joint M&E tool (Knowledge, Attitude, and Practice - KAP survey). The partnership has recently been expanded further to include the education sector, as HGNDP and SSFSNP has been drafted and engaged the Early Childhood Education project to identify areas that they could collaborate,

3 A full SOP for provincial health offices, district health offices, and health center staff, and a shortened, simple SOP for village facilitators.


7

strengthening the multi-sectoral approach for improved nutrition outcomes. A Memorandum of Understanding (MOU) between HGNDP and SSFSNP has been drafted and is being finalized. 16. Procurement: 121 height boards and weighing scales (for adults and children) have been purchased and will be placed in 120 villages identified for Year 1 SBCC intervention by November 2016 to support growth monitoring and nutrition counseling at the village level. Pocket-sized portable projectors (“Pico projectors”) have been procured and will be available at health centers in November 2016. NPCO will come up with a plan for pico projector use and maintenance from Year 2 onward. 17. Village Facilitators: While village facilitators in 120 villages have been identified, the mission learned from the field visit that there has not been sufficient briefing provided to the selected village facilitators nor to the responsible health center staff about their roles and responsibilities. The field visit also found that provincial coordinators were not empowered to communicate actively with the health center staff and village facilitators. Hence, it is crucial that orientation sessions to brief village facilitators and the supervising health centers need to take place as soon as possible, and to be completed by December 2016. Village-level orientation for all villagers on the implementation of village-level SBCC also needs to take place by the end of December 2016. 18. Communication and Participation: The mission commends the NPCO and staff on its continuing efforts to strengthen its staff and communication strategy to raise awareness and include all ethnic populations in the project process. Ethnic sensitive Information and Education Communication (IEC) materials are being produced. More nurses and midwives of various ethnic backgrounds have been placed at health centers to deliver services in poor remote areas; ethnic village facilitators are being recruited to assist with outreach and the participation process. Despite these positives, the mission found that there remain several barriers for ethnic groups to participate including limited understanding of Lao-Tai language, distance and transportation costs, and traditional beliefs that are not aligned with medical profession practice. More proactive staff mapping and communication would need to be developed to ensure effective participation of ethnic groups going forward using communication equipment and existing local resources such as the Lao Women’s Union, Lao Front for National Construction, and Lao Youth Union. 19. Gender and Capacity building: The mission found that gender biases are still common in remote areas, as several community leaders appear not to believe that women have the capacity to be trained to be village facilitators (e.g. due to shyness). The mission appreciates the commitment from MOH leadership at the central, provincial, and district levels to address the biases, and ensure that there are at least two women per village to be trained as village facilitators. In addition, as the NPCO is developing a training course for staff and village facilitators, it is important to ensure that training materials are gender- and ethnic-sensitive. The project has consciously reached out to female staff and village facilitators to ensure effective communication for service delivery. The mission encourages the NPCO to include husbands and the respective male and female elderly in awareness-raising meetings and training, as they are considered influential family members and can play an important role in supporting behavior change. Gender-ethnic disaggregated data should be collected especially with regard to staff, village facilitators, and beneficiaries.


8

Table 2: Agreed next steps for Component 3

Action Target date Responsible Sign MOU between HGNDP and SSFSNP on a regular basis, contributing to well-coordinated work plans (village selection, phasing) as well as a joint M&E tool (KAP survey).

November 2016 NPCO

Orientation to all village facilitators and responsible health centers in 120 villages (conducted at the responsible health centers), followed by Village-level orientation for all villagers on the implementation of village-level SBCC in 120 villages

December 2016 DHHP/CIEH/NPCO

TOT of the BCC package to promote rural sanitation December 2016 Nam Saat (WASH Center)/CIEH

TOT of the revised IYCF package for master trainers at the provincial and district levels completed

December 2016 CIEH/Nam Saat/MCHC/NNC

Village facilitators are trained on CLTS follow-up and the use of BCC package to promote rural sanitation,

January 2016

Nam Saat/CIEH

Triggering of CLTS completed in 120 Y1 villages February 2017 DHOs/PHOs

Training of IYCF package for all village facilitators completed

February 2017 CIEH/Nam Saat/MCHC/NNC

Village facilitators deliver IYCF package at the village session and conduct CLTS follow-up and deliver BCC package to promote rural sanitation

March 2017 Village facilitators/ DHO/PHO DHHP/NPCO

Component 4: Project Management, Monitoring and Evaluation 20. There are persisting delays in recruitment of a firm to conduct the KAP baseline survey, which is also affecting the availability of baseline data for some key nutrition-related indicators. Due to potential conflict of interest of the firm initially selected, the MOH has decided to re-evaluate the remaining firms that submitted expression of interests and send the request for proposal (RFP) to the best qualified firm to submit their technical proposal. Upon issuance of RFP, it is expected that the candidate firm will be selected by December 2016. 21. It was found during the field visit that provincial managers are still not completely clear about what they can use DLI funds for. While awaiting the arrival of the Financial Management (FM) firm under the ADB grant to provide FM training to the provinces, instructions have been sent to all provinces clarifying that they can use the earlier ADB FM manual for spending and accounting for DLI funds; the DLI funds can be spent on activities which will contribute to the achievements of DLIs. It may be useful to set a limit under which the provinces can inform the NPCO of expenditures and above which they have to seek approval before incurring expenditures. This would allow them to solve minor problems immediately. The Bank team will also be able to provide technical support to the development of annual operational plan process at the provincial levels.


9

Table 3: Agreed next steps for Component 4

Action Target date Responsible

Contract negotiations finalized for the recruitment of KAP survey firm

December 25, 2016 MOH

Complete selection and contract FM Specialist for overall FM of the project

January 2, 2017 NPCO

Financial Management

22. The overall project FM performance is rated as satisfactory. The project have maintained the records of the project in an acceptable manner, financial reports for the projects have been submitted by the due dates, the first audit report covering the period from effectiveness on October 12, 2015 until the end of September 2016 is due on Much 31, 2017 and the mission raised the need for project management to inform the State Audit Organization (SAO) about their proposed ToRs and seek their confirmation in good time to ensure compliance. 23. Regarding the financial report for DLI Year 1 performance the mission reviewed the MOH financial report to be used to support the DLI submission. The mission was informed that the available financial report of MOH covered up to June 2016. The mission advised that so long as the amount recorded under the Eligible Expenditure Program (EEP) was in excess of the DLI amount for Year 1, it will be sufficient to be used in support of their submission. The mission also advised the MOH to submit its financial report in the same format as that of last year and avoid only submitting the report for Chapter 10. The financial report should be the same as that for MOH with all chapter information. The finance team was advised to take a look at what was submitted last time and follow the same format. 24. Cumulative disbursement is at approximately 53% for the grant (D0730) with no disbursement for the Credit (56760). It has been three months since the last reporting of expenditure paid from advance to the designated account (DA). Therefore, it is now time to report on the use of funds from the DA. The mission strongly recommends that the NPCO prepares and submit a Withdrawal Application to the WB immediately to ensure that the DA remains active (this has since been completed).

Procurement

25. Overall, procurement performance of the project is considered moderately satisfactory. Implementation of procurement packages is progressing. In particular, during this year the NPCO has completed 67% of shopping of goods and 89% of individual consultant contracts. However, it has taken a long time to recruit a firm to implement KAP survey. The NPCO therefore should spend extra efforts to speed up the mentioned selection to avoid further delay. The Bank procurement staff can provide procurement clinic to the project staff if it is needed, if the NPCO required. Annex 6 shows the results of procurement assessment and recommendation. 26. Post review: The mission will conduct post review and the key findings from the post review will be shared with the NPCO through a separate follow-up letter by the WB to the NPCO.


10

27. Updated Procurement Plan: The mission advised the NPCO to update the procurement plan in order to reflect the current implementation status of all procurement packages and to add new packages as necessary. The mission suggest NPCO to submit revised procurement plan to the WB not later than November 30, 2016. Social Safeguards

28. The mission discussed the Ethnic Group Development Plan (EGDP) approved in March 2015, and identified with the NPCO the activities that need to be implemented to ensure that ethnic groups residing in the project areas have the opportunity to participate in and benefit from the project in culturally appropriate ways. Identified activities include: (i) appointing a social safeguards focal point overseeing safeguards related activities; (ii) organizing consultations with key stakeholders in 14 participating provinces and at 120 village health centers in the four provinces under the SBCC component. Summary of these consultations will be submitted to the World Bank; (iii) setting up feedback and resolution mechanisms (FRM) focusing on health and project related issues using existing/traditional mechanisms or appropriate mechanisms of existing projects such as those of the Poverty Reduction Fund project. FRM information will be included in the IEC materials and will be distributed to all relevant units of the project; (iv) ensuring that all IEC and training materials are gender and ethnic sensitive; and (v) providing an update on safeguards in the progress and annual reports (please see more details and agreed next steps in Annex 3). Environmental Safeguards

29. The mission discussed the Environment and Social Management Framework (ESMF) and the environmental monitoring that will be required to ensure compliance. It is important that the NPCO appoint an environmental safeguards focal point to oversee these key activities and ensure that training materials are gender- and ethnic-sensitive.

30. The mission recognizes the NPCO commitment to monitoring Environmental Safeguards and staff on its continuing efforts to strengthen its staff and its communication strategy to raise awareness.

31. Environmental safeguards activities and monitoring should be summarized in the progress and annual reports. Monitoring and Evaluation

32. The Project is using the Project Result Framework agreed at appraisal as a basis for monitoring and evaluation of the Project results, and to assess its progress towards the Project Development Objective, It is importance for Project to monitor the accuracy of the achievement of result indictors and its progress. The mission noted that progress of result indicators related to service delivery are on-track, while indicators related to SBCC interventions are off-track. The mission urged that NPCO accelerate the implementation of the community interventions under to SBCC component. See Annex 7 for the latest Project indictor results.


11

Joint Arrangement with ADB 33. While the ADB was unable to attend the joint mission as planned a video conference was held to take stock of progress of each project and to seek ways to better coordinate and harmonize activities. The following joint suggestions were made: 34. The WB and ADB teams encourage the government to allocate counterpart funds that are equivalent to the ADB policy-based loan proceeds using the allocation mechanisms similar to the NT2 funds. The funds should be channeled to: (i) the provinces for health services improvement and (ii) MOH key departments for the implementation of the health sector reform strategy. 35. The WB and ADB take note that funding (LAK 66 billion) is now available in the National Health Insurance Bureau (NHIB) to finance HEF and free MCH in the provinces. WB and ADB encourage the government to make the funds available to the provinces as soon as possible for scale up those programs in the provinces. ADB, through the ADB TA loan and grant, will provide assistance to MOH and NHIB to: (i) improve targeting, management and monitoring of the funds and (ii) support the development of the national health insurance system. 36. The WB and ADB support that national and international consultants hired under ADB TA loan and grant be utilized to improve the FM mechanisms in the provinces and in the MOH key departments. The WB will provide comments on the ToRs of the international consultant for FM, to be hired under the ADB TA grant. 37. The WB and ADB will use harmonized ToRs for the audit of the two projects. WB will re-send ToRs to ADB for finalization.

V. Technical Support and Capacity Building Activities for Universal Health Coverage,

health systems strengthening and preparedness for donor transition

38. With the appointment of the new Director General (DG) of Department of Finance MOH, the mission team had an opportunity to discuss the WB’s analytical support that has recently commenced, and is being implemented under the HGDNP with funding support from a WB-administered Multi-Donor Trust Fund (MDTF). The relevant ministries were also consulted - including MOF and the Ministry of Planning and Investment (MPI) - on potential areas of technical support from the WB to improve availability, quality, and use of the budget and expenditure data for planning and monitoring of the national health sector plan. As per the request of Department of Finance (DOF), the WB will convene a meeting with key ministries i.e. MOH, Ministry of Foreign Affairs (MOFA), MOF and MPI on improving coordination and harmonization of expenditure reporting from NGOs and DPs to have a more complete picture of overall development assistance for health in Lao PDR. 39. In terms of additional analytical support, initial sectoral diagnostic work including data collection, compilation and preliminary data analysis for a Health Financing System Assessment (HFSA) is underway, with a special focus on transition support for immunization financing. The assessment will help to identify key priority issues, mapping of key stakeholders, and information gaps for the immunization service delivery and priority areas of technical support and capacity building to be supported by the WB. A draft of the rapid assessment will be available by the end of November 2016 and will be used as a key input to the next Gavi mission on transition planning


12

expected in December 2016. The team has been closely engaged with the EPI unit, Gavi and technical agencies supporting the EPI program in the country transition process. In parallel, the assessment will also serve to draft a case study on Lao PDR as part of the UNICO (Universal Coverage) case study series of the WB, which will be shared with the Government for validation and review before its finalization. 40. The WB team has been engaged closely with the key government offices including Cabinet Office, MOH, MOF, Ministry of Labor and Social Welfare (MLSW), and MPI in facilitating a national policy dialogue on Universal Health Coverage (UHC). Following the International UHC Symposium which was co-organized with the government from June 12-13, 2016, the team has been closely working with MOH and organized follow-up technical meetings and a field visit involving key stakeholders to develop a common understanding of key challenges related to expansion of SHI coverage for the poor and non-poor informal sector and created a platform for policy discussions across ministries. Several key government officials from MOH, MPI, Cabinet Office, and MOF including Vice Minister of Health, and Director of NHIB participated in workshops in Manila in May and thereafter in Kuala Lumpur in August 2016 under the aegis of the Leadership for UHC program in Asia. The workshops facilitated development of key priority focus areas and concrete action plans to accelerate national efforts for UHC. The WB team has been supporting MOH, together with other DPs, in conducting a series of in-country UHC workshops to enhance capacity of government officials in financing, service delivery and governance as well as to facilitate the policy dialogue on UHC. The first in-country workshop was conducted on October 18-19, 2016 focusing on the concept and principles of UHC and health service delivery. The second workshop is scheduled for November 24-25, 2016, focusing on financing for UHC in transition countries. The workshops are targeted at government officials both at central and provincial level and are co-organized by the WB, the government and other DPs. 41. For the technical support to increase efficiency of the EPI program, HFSA Immunization module has been used for diagnostics in dialogue with the EPI center. The assessment has identified the following areas where mainstreaming of EPI activities would increase efficiencies as well as reduce cost of program implementation. First, the DHIS2 is increasingly proving robust data from targeted provinces. EPI data is already included in the DHIS2 while the EPI program continues to use their separate recording system. This causes double work at the facility level. Full integration of the EPI data and discontinuation of the separate recording would decrease the workload in the field and provide quality data for program management. Second, the EPI program has developed a supervisory guide for MCH and EPI which is administered separately from the supervisory checklist administered quarterly and monitored through the DLIs; merging the two and administering them together would both increase efficiency and save cost. Third, the EPI program has until recently provided separate outreach services every quarter; it has recently been decided to merge EPI and MCH services to form integrated outreach. During field visits it was found that a number of facilities continue to provide separate EPI outreach sessions and that some merge only with FP services. Effectively implementing integrated outreach services has the potential to substantially increase availability of EPI as well as MCH services, especially to ethnic minority and other remote populations, but clear guidelines, job aids, appropriate equipment, staff and means and funds for transport would need to be available in every health facility. A first step would be TA to assist with stock taking and needs assessment for targeted facilities to provide quality outreach services. Action on these areas will also serve to facilitate the achievement of DLIs.


13

42. Future possible areas for efficiency gains include: (i) studies on immunization and other basic service demand side constraints; and (ii) mainstreaming supply chain management, including supply of vaccines and commodities into one system using which uses IT for commodity forecasting and management at least down to the district level. Priority areas for immediate WB technical assistance support would be discussed with the EPI Unit, Gavi and other partners who support the immunization transition planning during the up-coming December mission.

VI. Technical Support to Civil Registration and Vital Statistics (CRVS)

43. Under the HGNDP Component 1 to improve the CRVS system, the WB teamalso provided technical support to MOHA to: (i) finalize draft CRVS strategic plan; (ii) review the existing CRVS and identity management system (IDMS) related laws and regulatory instruments to make recommendations for improvement or development of a new Law on Citizen Management; (iii) develop a costed civil management information system (CMIS); and (iv) streamline and standardize birth and death notification, registration and certification through redefining the processes. With support from World Bank-Korea, MOHA organized a Stakeholders Consultative Workshop during March 28-April 1, 2016 to: (i) present the draft CRVS strategy and the review of existing legislation relating to CRVS; (ii) share international lessons on CRVS and civil management information system; and (iii) collect feedback and agree on the roadmap for development of the CRVS system with provincial and central secretariat to the Civil Management Coordinating Committee (CMCC). 44. MOHA has requested financial support with an estimated cost of 17.2 billion LAK (US$2.2 million equivalent) for establishing the CMIS, and of this, 8 billion LAK (US$ 1m equivalent) has been allocated for the period 2015-2017. The mission pointed out that the actual cost to fully establish the CMIS may be more. Additionally, the estimated cost for the implementation of the CRVS strategic plan 2016-2020 including amending the legislation is estimated in the draft plan as 341 billion LAK (US$43 million equivalent). MOHA has requested for financial support from the World Bank Group for the implementation of the CRVS strategic plan, CMIS and legislation, as well as support its interoperability and linkages with the DHIS2 platform of the MOH. The mission informed MOHA that a formal request should be submitted through MPI which is overseeing the development of the new Country Partnership Framework (CPF). MOHA will have the opportunity to provide inputs during consultations on the CPF in the last week of October 2016. The CPF will be finalized in December 2016.

List of Annexes:

Annex 1: People met

Annex 2: Status of Achievement of DLI Year 1 (Component 2)

Annex 3. Social Safeguard Review

Annex 4: Financial Management Performance

Annex 5: Civil Registration and Vital Statistics

Annex 6: Procurement Assessment

Annex 7: Result Framework and Monitoring


14

Annex 1: People met

Name Position Organization

Government

H.E. Prof. Dr. Bounkong Sihavong Minister of Health MOH

H.E. Dr. Phouthone Muangpark Vice Minister MOH

H.E. Mr. Syphouk Vongphakdy Vice Minister MOHA

Dr. Prasongsidh Boupha Director General, DPIC MOH

Dr. Somphone Phangmanixay Director General, DOF MOH

Dr. Kotsaythoune Phimmasone Deputy Director, DOF MOH

Dr. Founkham Rattanavong Deputy Director General, DPIC MOH

Dr. Chandavone Phoxay Deputy Director General, DHHP MOH

Dr. Khamseng Philavong Deputy Director, NNC MOH

Dr. Somchanh Saysida Acting Director General, DTR MOH

Dr. Sivong Sengaloundeth Deputy Director General, FDD MOH

Mr. Oulaysith Panyavong Technical Staff, FDD MOH

Dr. Pamon Saymongkhoune Deputy Administrative, CMC MOH

Dr. Kopkeo Souphanthong Deputy Director, MCHC MOH

Dr. Naly Thammavong Deputy Director, FMC MOH

Dr. Latsada Phamuang Deputy Head of Division, DHHP MOH

Dr. Nakhonsay Phimmachanh Deputy Chief of Division, DOP MOH

Mr. Phouvanh Tanthaly Technical Officer, DHHP MOH

Dr. Khampasong Theppanya Head of Division, DHP, DOP MOH

Dr. Souphasay Khamphonthong Technical Staff, NNC MOH

Dr. Bounthasay Nolakham Technical Staff, DOP MOH

Dr. Latsadavanh M/E Staff, DPCI MOH

Dr. Sengmany Khambounheuang

Head of Division, FDD MOH

Dr. Bounsatiene Phimmasene Chief, External Finance Division MOH

Dr. Viengxay Viravong Deputy Chief of HFP Division, DOF MOH

Mr. Bounmy Sibounheung Deputy Budget Division, DOF MOH

Mr. Khamphai Vilayphone Technical Staff, Budget Division, DOF

MOH

Ms. Sengmontha Oupengvong Technical Staff, FPD, DOF MOH

Dr. Phanthong Bouasawanh Technical Officer, NHIB MOH

Mr. Bountim Technical Staff, DOF MOH

Mr. Phommaxay Technical Staff, Inspection Division MOH

Mr. Khamsen Southisack DLIs Assistant, NPCO MOH

Dr. Chansaly Phommavong Deputy Director, HGNDP MOH

Dr. Southanou Nanthanontry Deputy Director, HGNDP MOH

Dr. Sounthone Nanthavongdouangsy

Project Manager, NPCO MOH

Ms. Choulaphone Saysasene Project Manager, HGNDP-Comp 3 MOH

Dr. Amphone Keooudom SBCC Consultant,, CIEH MOH

Mr. Phanthanou Luangxay Procurement, HGNDP MOH

Mr. Phouthasone Phengsackda DLI Support, HGNDP MOH


15

Khamseng Phommachanh Advisor Coordinator, NPCO MOH

Dr. Khamvieng Vilaphanh Project Coordinator, HGNDP MOH

Mr. Alain Noel CTA, HGNDP MOH

Mr. Vilaysack Financial, HGNDP MOH

Ms. Olayvanh Chanthavong Office Administrator, HGNDP MOH

Ms. Phouthalaty Sihapanya Chief of Admin. HGNDP MOH

Mr. Viengthong Chongwaxiong IT, HGNDP MOH

Mr. Somphone Chanthavong NPCO

Mr. Bounmy Phantavong Technical officer, Personnel Department

MOH

Mr. Khamthan Khamdeng Head of Division MOPS

Ms. Kommaly Vilaphanh Director, DCM MOHA

Mr. Khansith Luangxay Director, VSD, DCM MOHA

Ms. Vanhpheng Vilaythong Technical Staff, DCM MOHA Oudomxay Province

Dr. Sounthone Luangxaysy Deputy Director of PHO PHO

Dr. Sysoumang Soukaphone Deputy of PHO Admininistrative PHO

Dr. Sithivone Hongsakhone Deputy Head of MCH PHO

Mr. Khamxay Inthasone Technical Staff, EPI, MCH PHO

Mr. Sayphone Soukasuem Deputy of Planning and Finance Statistic Section

PHO

Mr. Somphanh Xaythany Provincial Consultant/facilitator PHO

Dr. Khamla Soulideth Deputy Head of DHO Lar PHO

Mr. Bounsong Vongvilay Deputy Head of Administrative Lar PHO

Mr. khampasong Phongphachith MCH Lar PHO

Mr. Somxay Phanthavongsa Head of Health Center Kokmaiyay HC

Mr. Kheam Head of Village Heuysang village

Ms. Khin VHV Heuysang village

Mr. Hak VHV Heuysang village

Dr. Somphanh Phoumixay Head of DHO Namor DHO

Ms. Chansone Sipaseuth Head of MCH Namor DHO

Mr. Bounpheung MakAloun Deputy Head of DHO Namor DHO

Mr. Unti Tousoulideth Head of DHO Administrative Namor DHO

Ms. Kham Phonsavanh MCH Namor DHO

Mr. Pier Boua Planning and Finance: Statistic Namor DHO Mr. Khamnat Sivilay Health of Center Hueypord HC

Mr. Heamphan Head of Village Hueysang village

Mr. Loun (VHV) Hueysang village

Mr. Pherb (VHV) Hueysang village

Ms. Chai (VHV) Hueysang village Luangnamtha Province

Dr. Ounheuane Phoutsavanh Deputy Head of PHO PHO

Dr. Bounmy Sysouphanh Head of Administrative PHO

Ms. Bouavan Phanthavong Head of Statistic Section (DLI member)

Luangnamtha Province

Mr. Thavikhoune Xaybounthip Finance Project Provincial Luangnamtha Province

Ms. Khampheng Finance Assistant Luangnamtha Province


16

Mr. Viladeth Acting Head of Planning and Cooperation (DLI member)


Mr. Bounkhong Technical Staff Planning (DLI member) Luangnamtha Province

Dr. Bouany Inchay Head of Hygiene and Health Care Unit (DLI member)


Mr. Phet Technical Statistic (DLI member) Luangnamtha Province

Ms. Lamphay Deputy Head of Hygiene and Health Care Unit (DLI member)


Ms. Chanthy Thammakhan Head of Food and Drug unit (DLI member)


Dr. Amphone Vikelou Head of HC Luangnamtha Province

Ms. Chidaphone Technical Staff, MCH (DLI member) Luangnamtha Province

Mr. Sengvongsa Data collection expert (DLI member) Luangnamtha Province

Mr. Sengphet Technical Staff, HD Luangnamtha Province

Ms. Chan Finance Technical of District Luangnamtha Province

Ms. Bouahan Head of Namsing HC Luangnamtha Province

Ms. Payia Namsing HC Luangnamtha Province

Ms. Daovone Technical Staff, Namsing HC Luangnamtha Province

Mr. Sysone Technical Staff, Namsing HC Luangnamtha Province

Mr. Thongvanh Acting Head of Donemay HC Luangnamtha Province

Ms. Phiewsouloune Technical Staff, Donemay HC Luangnamtha Province

Mr. Thonsouk Technical Staff, Donemay HC Luangnamtha Province

Development Partnership

Chu Hong Anh HIS Officer, Health Systems WHO

Jil Haentges UNV WHO

Jean-Marc Thome CC SRC

Monica Fong Coordinator WHO

Garrett Young Director CHAI

Eric Seastedt Country Director PSI

Frank Haegeman Technical Advisor Lux-Dev


17

Annex 2: Status of Achievement of DLI Y1 (Component 2)

General comments on the DLIs.

45. C DLI 1: Average percentage of HMIS reports from all target provinces provided on

time and fully completed – increase 10% over baseline. On average there has been an increase

in both indicators and the DLI has been achieved. 2 provinces have not improved on timeliness

and completeness by 10%.

46. C DLI2- Details of stock availability of essential family planning and nutrition

commodities in all target provinces recorded by MOH. Reports have been received from all

provinces. The IAI report notes that in two provinces there were variations between stock registers

at HC/DHO and PHO. The DLI target has been achieved. The data shows that in no provincial

stores have Zinc tablets; Vitamin A is not available in eight provinces; Iron and Folic Acid is not

available in six provinces; implants are not available in eight provinces. The Committee for

monitoring and forecasting will now be planning for adequate supply for the coming year and look

into having improved supply management systems in place.

47. C DLI 3- Number of target provinces in which the number of health centers without

a community midwife has been reduced by 10% over baseline. Most of the target provinces (except for two) have reduced the number of health centers without a community midwife by 20%; the overall DLI has been achieved. IAI reported that the DHO list was considered in accordance with the HC midwife posting in all provinces except for one.

48. C DLI 44 – Baseline for number of women who receive free ANC, free Delivery and

free PNC established for all provinces. The indicator for Year 1 is to establish a baseline for the

number of women receiving free maternal health care services in the 14 target provinces. Since

the DHIS2 does not at present have individual patient records, three separate lists for ANC,

Delivery and PNC are maintained. All three would have increased and the DLI has been achieved.

Provincial level DLIs

49. P DLI 1: Number of women who deliver with the assistance of a SBA increased by

10% over baseline. Target for this DLI was met in 12 provinces; while this was partially achieved

two provinces have only met 60% of the target. The IAI reports confirms this finding but found

that one additional province did not have reliable data. All these 3 provinces have achieved 60%.

50. P DLI 2: Number of pregnant women who receive 4 ANCs increased by 10%.

3 provinces have not achieved the 10% increase; in addition, IAI found that the data could not be

verified for 2 provinces. All these 5 provinces have achieved 60% of the target.

4 The money for this DLI will likely be exhausted in year 1 and additional funds need to be

identified for disbursement against this DLI in year 2.


18

51. P DLI 3: Number of new women age 15 – 49 years adopting long term family planning

increased by 10%. NPCO reported that 4 provinces had not achieved the target; these 4 had

achieve 60% of the target; the IAI report reported an additional 4 provinces where data was not

found to be reliable. In the 6 of the eight provinces which have not fully achieving the target, 60%

of the target had been achieved. Field visits showed that there remains some lack of clarity about

the difference between (all) long term FP users and new long term FP users.

52. P DLI 4: 4 Target provinces report baseline value for number of children under 5

years who received nutrition counselling and an updated growth chart5 in accordance with

MOH guidelines. NPCO reported that baseline had been re-submitted after the criteria had been

communicated to the provinces. IAI did not find reliable data on growth monitoring and

counselling as per agreed definition. This finding was confirmed during field visits in April, June

and October (total 7 provinces). It is suggested that the NPCO once more instructs the provinces

to report baseline data as per agreed definition (separate reporting on 1). Adequately filled growth

chart with the mother and; 2) counselling provided based on the growth chart. The definition of

filled in includes measurement every two months. For example, a child of 18 months of age shall

have at least 9 entries, a child of 6 months of age at least 3 entries (which include height and weight

at birth). Final decision on DLI achievement will be made once the revised data is received.

53. P DLI 5: Number of villages in zones 2 & 3 in which integrated outreach is conducted

at least four times during the year increased by 10% over baseline. It has become clear that

the baseline recorded represents EPI visits and not integrated6 outreach; four provinces have

reported 0 because they are not doing integrated outreach in zones 2 and 3 villages. All provinces

should be informed that they have to revise their baseline as well as revise their reporting for the

past year and that only ‘stamp’ villages – not EPI villages should be included. To undertake true

field level growth monitoring the health centers will need additional transportation (MCs); ‘baby

pants’ for weighing; and a different instrument for measuring the height of the child – since they

cannot carry the bulky equipment on their MC. The IAI reports confirm that the reported data

on integrated outreach is inconsistent in all provinces. Final decision on DLI achievement

will be made once the revised data is received.

54. P DLI 6: Training of 2 health facility staff in each district in use of the standard

supervisory checklist; Standard supervisory checklist scores for all health centers and

district hospitals in each target province for 2 quarters completed. (Due to the limited time

available for implementing the activities it was agreed between the NPCO and the WB that one

round of supervisions to all district hospitals and a few health centers in each province would

satisfy the DLI requirement). Training had taken place in all provinces; NPCO reported that

supervisory checklist had been filled for each district hospital and most health centers. IAI

confirms training completed; IAI records that there is inconsistent recording in some provinces

and that scores could not be obtained in some provinces. The IAI will seek further information.

5 The definition of filled in growth chart includes measurement every two months. For example, a child of 18

months of age shall have at least 9 entries, a child of 6 months of age at least 3 entries (which include height and weight at birth). 6 Integrated outreach includes EPI, ANC, PNC, FP, growth monitoring and nutrition counselling


19

Final decision on DLI achievement will be made once IAI provides additional information.

P DLI 7: Percentage of provincial non-salary health recurrent expenditure allocated to the

district level – increased by 5% over baseline. NPCO has provided an overview showing that

district budgets (non-staff recurrent) has increased by 5% in all provinces. IAI has compared

provincial allocation to district receipt for two sample districts in each province – but has not

commented on the overall provincial increase in allocation to districts over baseline. The IAI will

seek further information. Final decision on DLI achievement will be made once IAI provides

additional information.


20

Annex 3. Detailed status of Social Safeguards

55. Mission and NPCO discussed the Ethnic Group Development Plan (EGDP) which provides planned activities that address the challenges faced by ethnic groups and ensure that they benefit from the project in culturally appropriate ways. The EGDP complies with policies of the Lao People’s Democratic Republic concerning ethnic groups, as well as the World Bank’s Operational Policy 4.10 on Indigenous People. Identified social safeguards activities are listed below. 56. Institutional setting/staff: It was agreed that the NPCO will appoint staff(s) who would be responsible for overall safeguards related activities. Safeguards focal point(s) would develop a work plan and work closely with the provincial health coordinators to ensure that all activities are budgeted and implemented as planned.

57. Public Consultations: According to the EGDP, a series of public consultations (free, prior and informed consultation - FPIC) will be organized to provide affected populations, especially ethnic groups, the opportunity to learn about the project, voice their perspectives and concerns, and ensure their broad community support for the project. It was agreed that the NPCO will develop a plan to conduct public consultations in the 14 participating provinces and in all 120 of the village health centers in four provinces under the SBCC component. The NPCO safeguards focal point(s) will work closely with the World Bank safeguards specialist on the consultative process following the framework of consultations with ethnic groups (EGDP section 3.5). Report on the consultations would be submitted to the WB.

58. Feedback and Resolution Mechanism (FRM): In accordance with the article 13 of the GoL, Decree 192/PM, all investment projects would need to establish an effective mechanism for grievance resolution. It was agreed that the purpose of the FRM is to ensure that the project has a system to receive feedback and issues raised from citizens, and that these feedbacks are addressed appropriately and on a timely basis. The FRM aims to also help the project increase its management effectiveness by responding to its beneficiary communities. It was agreed that the NPCO would review the existing traditional feedback and resolution mechanisms in the project areas as well as experiences of other projects such as the Poverty Reduction Fund. The NPCO would discuss with the WB prior to the setting up of the FRM to ensure that the project could properly address these feedback/complaints/recommendations at the village, district and provincial levels. Information on the FRM would be included in all the IEC materials in both oral and printed forms. Progress and annual report would include an update on the FRM mechanisms.

59. Citizen Engagement/Beneficiary survey: At the end of each fiscal year, it would be a useful occasion for the NPCO to organize meetings to provide an overview of the project’s progress to all key stakeholders in 14 provinces and at the village health centers. Basic beneficiary survey should be developed to gather feedback from beneficiaries for further project improvement. It was agreed that the NPCO will use the existing monthly meetings to provide updates to stakeholders, and will review whether the KAP survey under component 3 would suffice for this purpose.

60. Reporting: Social safeguards activities and gender-ethnic disaggregated data will be included in the progress and annual reports.


21

Agreed Actions:

Items Agreed actions Timeframe

Institutional setting/staff

-NPCO to appoint a social safeguards focal point(s) overseeing all social safeguards related activities. -NPCO to inform all provincial coordinators to work closely with the safeguards focal point(s) for all activities implemented within the province.

By October 31, 2016

Free, Prior, and Informed Consultation

-A consultation plan for 14 provinces and all the village health centers (120) in the four provinces of the SBCC component will be developed. -Consultations will be conducted by the NPCO. -Consultation report will be submitted to the World Bank.

By October 31, 2016 During November – December 2016 By January 31, 2017

Feedback and Resolution Mechanism

-NPCO will review and design an appropriate FRM, and will discuss with the World Bank. -FRM information and contacts will be included in all IEC materials and will be distributed to all participating villages, and will be displayed in the public areas at the provincial, district and village levels. -Information on how the project manages grievances will be included in the project reports.

By November 15, 2016 By January 31, 2017 Ongoing.

Citizen engagement

-NPCO will use the existing monthly meetings of the project at the end of the fiscal year to provide an update on the project to stakeholders, especially at the village level. Simple beneficiary survey will be developed to gather input for future development of the program. NPCO will review whether the KAP survey would cover this aspect for the project.

At the end of fiscal year. By January 31, 2017


22

Annex: 4: Financial Management Performance

61. Overall project FM performance is rated as satisfactory. The project have maintained the records of the project in an acceptable manner, financial reports for the projects have been submitted on the due dates, the first audit report is still not due and the mission raised the need for project management to inform the SAO in good time to ensure compliance. 62. Staffing: At the head office, an FM consultant has been engaged by the project to help maintain financial records and support project work. There is still delay in the recruitment of the FM specialist. The mission team noted there had been some discussion in relations to this position and the team of financial consultants to be hired by the ADB. This mission team recommends to urgently continue the discussion on recruitment of this position as it is critical to ensure financial performance of the project. 63. Financial Manual: It was expected that there will be a revised comprehensive manual to be used by both ADB and WB for the implementation of their support for MOH. The mission was informed that this has also been delayed due to the delay in recruiting the firm for the assignment, however the ministry was using the financial manuals of the previous WB and ADB financed projects for the current projects. These manual are adequate for the time being and they will be revised when the consulting firm is on board. 64. Financial reporting: The project has submitted the IFRs for the project as required and in line with agreed format, but without ADB project information. It had been agreed previously by both ADB and WB that one comprehensive financial report would be used and submitted to both institutions; however, in practice the project have submitted separate financial reports relating to their individual project activities. The mission raised this and requests the MOH to advise if this consolidated report will be considered or would prefer to continue to issue two separate reports for ADB and WB activities. 65. Audit: It was agreed that the audit for both ADB and WB financed projects will be conducted by the SAO and that a draft TOR jointly cleared by WB and ADB will be shared with the SAO. The mission urges the MOH to discuss the TOR with the SAO and agree firmly the program for the audit. The first audit of the Bank financed project will be from the effectiveness date to September 30, 2016. The audit report is due to be submitted to the WB by March 31, 2017. MOH is advised to ensure that they take all required actions including informing SAO, preparing their financial statements in good time for the audit to meet this compliance deadline. 66. Change of government financial year: The mission discussed the implication of the change of government’s financial year from October to September to January to December to project reporting. The mission provided options to the project to ensure that there is no gap, but yet follow the same fiscal year reporting of government. The guidance and options are as follows:

• The current period ending September will end as such and the semi-annual IFRs will be submitted for the period ended September 2016. This will also apply to the audit for the period ended September 30, 2016;

• The project can then provide the next IFR to cover 9 months from October 2016 to June 2017 and then continue to report the following 6 months to December 2017;


23

• The other option is to prepare 6 months period from October to March 2017 and then prepare a 9 month period from April to December 2017;

• In respect of the audit, it is straight forward, the next audit will be a period of 15 months from October 2016 to December 2017;

67. Financial report for DLI year 1 performance; the mission reviewed the MOH financial report to be used to support the DLI submission. The mission was informed that the available financial report of the ministry was up to June 2016. The mission advised that so long as the amount recorded under the EEP was in excess of the DLI amount for year 1, it will be sufficient to be used in support of their submission. The mission also advised the ministry to submit its financial report in the same format as that of last year and avoid only submitting the report for chapter 10. The financial report should be the same as that for MOH with all chapter information. The finance team was advised to take a look at what was submitted last time and follow the same format. 68. Disbursement; Cumulative disbursement is at approximately 53% for the grant (D0730) and no disbursement for the Credit (56760). It has been three months since the last reporting of expenditure paid from advance to the designated account (DA). Therefore, it is now time to report on the use of funds from the DA. The mission strongly recommends that the NPCO prepares and submit a Withdrawal Application to the Bank by October 21, 2016 to ensure DA remains active.


24

Annex 5: Civil Registration and Vital Statistics

69. During a WB mission in the November 2015, MOHA requested technical assistance on the following: (i) finalize draft CRVS strategic plan; (ii) review the existing CRVS and identity management system (IDMS) related laws and regulatory instruments to make recommendations for improvement or development of a new Law on Citizen Management; (iii) develop a costed civil management information system (CMIS); and d) streamline and standardize birth and death notification, registration and certification through redefining the processes. 70. With support from World Bank-Korea, MOHA organized a Stakeholders Consultative Workshop during March 28-April 1, 2016 to: i) present the draft CRVS strategy and the review of existing legislation relating to CRVS; ii) share international lessons on CRVS and civil management information system; iii) collect feedback and agree on the roadmap for development CRVS system with provincial and central secretariat to the Civil Management Coordinating Committee (CMCC). H.E. Mr. Syphouk Vongphakdy, Vice Minister of Home Affairs chaired the workshop which was attended by the Secretariat to Lao PDR CMCC (comprising MOHA, Ministry of Health (MOH), Ministry of Justice (MOJ), Ministry of Public Security (MPS), Ministry of Education and Sports (MOES), Ministry of Planning and Investment (MPI), Ministry of Foreign Affairs (MOFA), and Ministry of Labor and Social Welfare) at national and provincial levels, development Partners (WHO, UNICEF, Plan International, ADB, Korea Exim Bank), and officials and technical staff from Department of Citizen Management. Summary of key discussions

71. CRVS strategic plan – Following the workshop, the Secretariat to the CMCC has updated the draft CRVS strategic plan with support from a local consultant and World Bank-Korea experts. This draft was submitted in October, 2016 to the CMCC for review and clearance. Comments from the CMCC meeting will then be incorporated and put on the agenda for the Cabinet meeting and endorsement by the Prime Minister’s office. Further, as suggested during the workshop, MOHA is establishing a program management office with dedicated staff within the MOHA Department of Citizen Management to ensure effective implementation of the strategic plan and the CMIS. Coordination among the line ministries of the CMCC was hitherto a major challenge but the March 2016 workshop made it clear that strengthening CRVS is a collective effort and thus has facilitated the engagement of other line ministries. The Prime Minister’s Office is supportive of a joint effort to improve CRVS in Lao PDR

Follow-on actions

• MOHA to follow up and facilitate the clearance of the CRVS strategic plan by the CMCC and its being tabled for endorsement at a Cabinet meeting by December 2016.

• MOHA to establish a program management office with dedicated staff within the MOHA Department of Citizen Management and also identify personnel at the Provincial and district levels.

72. CRVS legislation – The 2009 Family Registration Law and related laws have been reviewed and a report was prepared with support from a local consultant and World Bank-Korea experts. The report which includes a comparative analysis of CRVS Legislation in Lao PDR, Vietnam, and Korea, provided three options for the modernization of the CRVS legislation in Lao


25

PDR: i) Making no change to the existing legislation; ii) Amending the existing legislation; and iii) Enacting new legislation plus amending the current legislation. Subsequently, in consultation with the National Assembly a decision has been made to amend the 2009 Family Registration Law with the following timeline; a CRVS Law Drafting Committee to begin reviewing the existing laws and start preparing a draft from October 2016; public consultations to begin March 2017 to solicit feedback; draft amended law to be submitted to MOJ November 2017; MOJ to submit the drat amended legislation to the Law Committee of the National Assembly in January 2018; and submission to National Assembly for adoption in April 2018. A CRVS Law Drafting Committee, led by the Vice Minister, has been appointed with representatives from MOHA, MOJ, MPS and MOFA. While MOH is not part of the Law Drafting Committee, the mission encouraged MOHA to obtain inputs from MOH regarding birth and death registration and its potential linkages with the MOH information system. The mission suggested to MOHA to appoint a dedicated full-time technical staff to the committee to lead the drafting of the law. 73. Given that Vietnam recently enacted CRVS Legislation which went into effect January 2016, the mission suggested to MOHA to consider inviting 1-2 officials from the Government of Vietnam to visit Lao PDR to share recent experiences with the drafting of the CRVS legislation. Prior to the visit, MOHA will develop a detailed costed work plan based on the timeline noted above with assigned roles and responsibilities. After the visit, the work plan will be updated. Follow-on actions

• MOHA to prepare a costed work plan for amending the legislation.

• MOHA to appoint a dedicated staff within the MOHA Department of Citizen Management to lead the drafting of the law

• MOHA to invite 1-2 officials from the Government of Vietnam. WBG to cater to the travel related costs, if necessary

74. Civil management information system – Following the workshop, MOHA considered several options with increasing levels of complexity and cost, prepared by a local ICT consultancy firm (recruited by MOHA). MOHA has decided on an intermediate option. The team is preparing a TOR for consultancy to develop technical specifications and detailed cost breakdown. This work will in turn feed into finalization of design options and a bidding document for recruiting the firm to help establish a CMIS for Lao PDR, which will be interoperable with information systems and databases of other line ministries such as Ministry of Public Security and the MOH. Given that the existing laws lack provisions on data protection and privacy, the proposed amendment of the CRVS laws, as noted above, will take this into consideration in order to ensure smooth implementation of the CMIS.

Follow-on actions

• MOHA, with assistance form WBG-Korean experts, to prepare a TOR for consultancy to develop technical specifications and detailed cost breakdown.

• Detailed cost estimates to be prepared by December 2016 75. Standard operating procedure on registration processes – The mission informed MOHA to consider developing standard operating procedures (SOP) on notification, registration and certification of birth and deaths at health facilities and at home; marriage and divorces registration; change of name; and registration of migration, through redefining the processes. As a


26

first step, the mission suggested hiring a local consultant to work closely with MOHA, MOH, and MPS to delineating the existing processes and make recommendations to the Secretariat of the CMCC. This will inform the updating of existing SOPs (i.e. MOHA Agreement No. 770 and No.633) with inputs from relevant stakeholders at the national, provincial and district levels and villages. The SOP will inform the amendment of the 2009 Family Registration Law as well as establishment of the CMIS. Follow-on actions

• MOHA, with assistance form WBG-Korean experts, to prepare a TOR for consultancy for delineating the existing processes and make recommendations

• MOHA to update MOHA Agreement No. 770 and No.633 76. MOHA request for financial support – MOHA informed that the estimated cost was 17.2 billion LAK (equivalent to US$2.2 million) for establishing the CMIS, and of this, 8 billion kip ($ 1m) has been allocated for the period 2015-2017. The mission pointed out that the actual cost to fully establish the CMIS may be more. Additionally, the estimated cost for the implementation of the CRVS strategic plan 2016-2020 including amending the legislation is estimated in the draft plan as 341 billion LAK (equivalent to US$43 million). MOHA requested for financial support from the World Bank Group for the implementation of the CRVS strategic plan, CMIS and legislation. The mission informed MOHA to put in a formal request through Ministry of Planning and Investment (MPI) which is overseeing the development of the new Country Partnership Framework (CPF). MOHA will have the opportunity to provide inputs during consultations on the CPF in the last week of October 2016. The CPF will be finalized in December 2016. Follow-on actions

• MOHA to provide inputs into the CFP regarding CRVS support.


27

Annex 6: Procurement Assessment

77. Prior review contracts: The information in the table below are summary of number of request sent for the Bank’s review, percentage of cleared and returned without clearance by the Bank during the period from January 2014 to February 2015.

78. Recommendations

No. Action Responsibility

1 RFQ of MOF should be used, C1, DDF

2 Technical Specifications should be prepared properly, C1, DDF

3 Financial capacity for suppliers should not be the same as for contractors,

C1, DDF

4 Bid evaluation report format of MOF should be used, C1, DDF

5 Arithmetical correction should be done properly and attached in the evaluation report,

C1, DDF

6 EOI evaluation report should be done properly C3

7 Evaluation criteria should be consistent with TOR C3

Jan Feb Mar AprMa

yJun Jul Aug Sep Oct Nov Dec Jan Feb

Tot

al/A

vg

Number of Requests 7 5 3 6 6 9 9 1 2 0 3 6 6 6 57

% Cleared by the Bank 71 80 67 100 50 89 89 100 100 0 67 83 33 33 74

% Returned Without

Clearance29 20 33 0 50 11 11 0 0 0 33 17 67 67 26

0

20

40

60

80

100

120


28

8 Supporting document should be provided by consultant during contract negotiation

C3

9 Remuneration adjustment should be based on CPI All

10 New Individual Consultant contract format shall be used All

11 All information about consultant’s rates shall be maintained in estimated cost table

All

12 To avoid the Bank’s return without clearance, before sending for the Bank’s review; please check and ensure that all requests are prepared properly and with reasonable information.

All


29

Annex 7: Results Framework and Monitoring

LAO PEOPLE’S DEMOCRATIC REPUBLIC

Health Governance and Nutrition Development Project

.

Project Development Objectives .

PDO Statement

The Project development objective is to help increase coverage of reproductive, maternal and child health, and nutrition services in target areas in Lao PDR.

These results are at Project Level .

Cumulative Target Values

Indicator Name

Unit of

Measure

Core/Custom

Indicator Baseline

YR1

(Jun 2015

to May

2016)

YR2

(Jun-Sep

2016)

YR3 YR4

YR5

End Target

Women who deliver

with a skilled birth

attendant at home or at

a health facility (DLI

P1)

Number 63,380 72,889 22,986 30% over

baseline

40% over

baseline

50% over

baseline 50% over

baseline


30

Pregnant women who

receive 4 Antenatal

Care Contacts (DLI

P2)

Number 59,960 71,724 22,216 30% over

baseline

40% over

baseline

50% over

baseline 50% over

baseline

Number of new

women aged 15-49

years adopting long

term methods of family

planning (DLI P3)

Number 54,569 59,833 14,054 30% over

baseline

40% over

baseline

50% over

baseline 50% over

baseline

Children age 0-6

months in target high

priority nutrition

districts exclusively

breastfed

Percent

Waiting

for KAP

survey

results

N/A N/A

Direct Project

Beneficiaries Number Core 0 242,8707 108,501 1.4 million

o/w female Percent Core 0 93.35 65.41 80 .

Intermediate Results Indicators

Cumulative Target Values

Indicator Name

Unit of

Measure

Baseline YR1 YR2 YR3 YR4

YR5

End Target

7 Core ANC4+Delievery at Facility + Skilled births at Home+PNC+4 types of long term FP+ Children receiving growth monitoring


31

Component 1:

New born children

provided with birth

Notification in target

provinces

Percentage 0 N/A 25% 20% over

baseline

30% over

baseline

40% over

baseline 40% over

baseline

Component 2:

Villages in Zones 2

and 3 in the areas of

the health centers

where integrated

outreach sessions are

conducted at least four

times during the year

(DLI P5)

Number 0 2,900 N/A 30% over

baseline

40% over

baseline

50% over

baseline 50% over

baseline

Component 2:

Women in Target

Provinces who receive

free maternity health

care services (DLI C4)

Number 0 327,827 114,641 30% over

baseline

40% over

baseline

40% over

baseline 40% over

baseline

Component 2:

Health centers and

district hospitals which

score more than 50%

on the Standard

Supervisory Checklist

for every quarter of the

Year (DLI P6)

Percentage 0 69% 30% over

baseline

50% over

baseline

70% over

baseline

80% over

baseline 80% or more

Component 3:

Female village

facilitators trained in

Number 0 0 0 1200 1600 1600 1,600


32

SBCC in target

districts

Component 3:

Children under 5 years

who receive nutrition

counselling and an

updated growth chart

in accordance with

MOH guidelines (DLI

P4)

Percentage 0 16,142 37,524 30% over

baseline

40% over

baseline 50% over baseline

50% over

baseline

Component 3:

Villages declared open

defecation free in

target districts

Number 0 0 0 240 360 400 400

Component 3

Beneficiaries reporting

satisfaction with social

and behavior change

communications

activities taking place

in their communities

Percentage 0

Baseline to

be

determined

N/A

10%

increase

over

baseline

25% incre 25% increase

over baseline

.

Lao PDR Health Governance and Nutrition Development Project...

Documents

Transcript of Lao PDR Health Governance and Nutrition Development Project...