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SRI LANKA: Second Health Sector Development Project (CR 52280)

Implementation Support Mission – May 5-15, 2015

Aide-Memoire

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Table of Contents A. Introduction ...................................................................................................................................... 3

B. Key Project Data .............................................................................................................................. 3

C. Project Development Objective ....................................................................................................... 3

D. Summary: Implementation Progress ................................................................................................ 3

E. Detailed Description of Status of Project Components.................................................................... 3

F. Procurement, Financial Management (FM) and Disbursement ....................................................... 7

Procurement – Component 1 ........................................................................................................... 7

Procurement – Component 2 ........................................................................................................... 7

Financial Management – Component 1 ........................................................................................... 8

Financial Management – Component 2 ........................................................................................... 9

Disbursement ................................................................................................................................... 9

G. Safeguards ........................................................................................................................................ 9

H. Results Framework and Monitoring & Evaluation ........................................................................ 10

I. Communications Related to the Project ......................................................................................... 10

J. Summary of Discussions Regarding Possible Project Restructuring ............................................. 11

K. Proposed Next Implementation Support Visit: .............................................................................. 11

ANNEXURES

Annex 1. Status of Agreed Actions from December 2014 Mission .................................................... 12

Annex 2. Agreed actions from the current May 2015 mission ........................................................... 13

Annex 3: Cash Flows for 2014 ........................................................................................................... 14

Annex 4: Updated Results Framework (Based on April 2015 Results Report) .................................. 15

Annex 5: Outcome of discussions to Review and Modify the Results Framework, mission meetings

May 7 and 9, 2015 with participation of MOH, MOF, MOPP, Provincial MOHs ............................. 22

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Sri Lanka: Second Health Sector Development Project (CR 52280)

Implementation Support Mission

May 5-15, 2015

Aide-Memoire

A. Introduction

1. The World Bank conducted its third implementation support mission for the Sri Lanka

Second Health Sector Development Project (SHSDP) from May 5 to 15, 2015. The

objectives of the mission were to review the implementation status of the SHSDP and its

progress towards achieving its development objective.

2. The team1

held discussions with officials of the Ministry of Health and Indigenous Medicine

(MoH), the Ministry of Provincial Councils and Regional Development (MPCRD), the

Ministry of Finance (MoF), Ministry of Policy Planning, Economic Affairs, Child, Youth and

Cultural Affairs (MoPP) including the Departments of External Resources, National

Planning, National Budget, Treasury Operations and Project Management and Monitoring,

and the 9 Provincial level health authorities. The mission thanks the Government of Sri

Lanka (GoSL) for its cooperation and hospitality.

3. This Aide Memoire (AM) summarizes the discussions and agreements reached during the

consultations. The team’s findings, summarized in this AM were discussed at a wrap-up

meeting, chaired by the Dr. D.M.R.B. Dissanayake, Secretary, MoH on May 15, 2015.

B. Key Project Data

Project Data Project Performance Ratings Board Approval (Original): March 27, 2013

Effectiveness date (Original): September 12, 2013

Original Closing Date: September 30, 2018

Original Credit Amount: US $200 million

(SDR 129.8 million)

Amount Disbursed*: US $56.4 million

(SDR 40.0 million)

Disbursement % 30.8 percent

Deviation from original estimate: 7.7 percent

Summary Ratings: Last** Now

Achievement of PDO: S S

Implementation Progress: S S

Project Management: S S

Procurement: MS MS

Financial Management: S S

Safeguards: S S

M&E: S S

Counterpart Funding: S S

*As of May 15, 2015

** “Last” ratings from the Implementation Status Report dated December 29, 2014.

Ratings: HS=Highly Satisfactory; S=Satisfactory; MS=Moderately Satisfactory; U=Unsatisfactory; HU=Highly

Unsatisfactory

1 The team consisted of: Kumari Vinodhani Navaratne (TTL, Sr. Health Specialist), Phoebe Folger (Operations Officer),

Nkosinathi Mbuya (Sr. Nutrition Specialist), Owen Smith (Sr. Health Economist), Khalid Bin-Anjum (Sr. Procurement

Specialist), Jiwanka Wickramasinghe (Sr. Financial Management Specialist), Darshani De Silva (Environmental Specialist),

Sandya Salgado (Sr. External Affairs Officer), Dilinika Peiris (Communications Associate), Lashan Jayawardena (Environment

Management consultant), Dakshinari Hulugalle (consultant, HRH and Pharmacy), Susrutha Goonaskdera (Social Development

consultant) Nalika Gunawardena (Consultant on Planning) and Kerima Thilakasena (Program Assistant).

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C. Project Development Objective

4. The Project Development Objective (PDO) is to support the implementation of the National

Health Development Plan (NHDP) to upgrade the standards of performance of the public

health system and to enable it to better respond to the challenges of non-communicable

diseases and nutrition. Based on implementation progress, disbursement performance, results

through the end of 2014, and discussions with GoSL including results management and

monitoring teams from the MoPP and MoF the mission is pleased to confirm that the project

remains on track and likelihood of achieving the Project Development Objective is high. The

Development Objective (DO) rating remains as Satisfactory.

D. Summary: Implementation Progress

5. The mission is pleased to note strong overall implementation progress and commends

GoSL’s commitment to results focused development and accountability at all levels. As

agreed in the project, the results and disbursement linked indicator (DLI) report for the

calendar year 2014 results was submitted to the Bank in April 2015. An independent

consulting firm will validate the results for the nine DLIs through field visits. From the

results, in consultation with the MoF, MoPP, and MoH, the research team and the World

Bank will finalize the actual achievement progress for the year 2014 by June 30, 2015. The

Implementation Progress (IP) rating remains as Satisfactory.

E. Detailed Description of Status of Project Components

6. Component 1 (US$190 million): Support to priority areas under the National Health

Development Plan (NHDP). This component supports the implementation and achievement

of goals of the NHDP and the project supports 20 results under three thematic areas: (i)

maternal and child health, nutrition and communicable diseases; (ii) prevention and control

of non-communicable diseases (NCDs); and (iii) health system improvement measures. As

indicated above, the progress and results report for calendar year 2014 submitted by the

Project Management and Monitoring Department of the MoPP indicates good

implementation progress overall under Component 1. Commitment for achievement of the

agreed targets by the implementing teams in the MoH and the 9 Provinces is high as

indicated by the strong progress against targets for most of the 20 indicators. The 2014

results are presented in Annex 4 in the updated results framework. A summary description of

each of the agreed target areas along with the relevant results indicators is given below.

7. Thematic area I: Maternal and Child Health, Nutrition and Communicable Diseases

Under thematic area I, the following PDO and intermediate level indicators are monitored.

% of pregnant women with anemia after the second trimester (PDO Indicator 2)

% of Maternal and Child Health (MCH) clinics with an agreed package of equipment and

supplies for the provision of care for pregnant women and children under five years. (DLI

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% of Comprehensive Emergency Obstetric and Neonatal Care (CEMOC) facilities

providing 24x7 CEMOC services

% of Medical Officer of Health areas with at least three health and nutrition community

support groups

Case detection rate for Tuberculosis

8. Progress against indicators under thematic area I is mixed. The 2014 targets were exceeded

for the percent of CEMOC facilities providing 24x7 CEMOC services and the percent of

Medical Officer of Health areas with at least three health and nutrition community support

groups. However the targets for Tuberculosis case detection rate and percent of MCH clinics

with an agreed package of equipment and supplies for the provision of care for pregnant

women and children under five years have not been met. Results for the PDO indicator on

Anemia among pregnant women in the second trimester will be monitored and reported

through the regular administrative data from 2015 onwards. As such, data were not available

for this indicator for 2014.

9. Thematic area II: Prevention and control of non-communicable diseases (NCDs)

Under thematic area II, the following PDO and intermediate level indicators are monitored.

% of persons (over 40 years) screened for selected NCDs at Healthy Lifestyle Centres

(HLCs) (PDO Indicator 1)

% of centrally managed health facilities with Emergency Treatment Units (ETUs) for that

level of facility based on standard guidelines (PDO Indicator 3) (DLI 1)

% of provincially managed health facilities with ETUs for that level of facility based on

standard guidelines (PDO Indicator 4) (DLI 2)

% of Medical Officer of Health areas with at least two HLCs (DLI 6)

% of primary health care institutions having one month’s buffer stock for 16 selected

NCD drugs

No. of provinces with at least one health facility providing rehabilitation services

10. Progress is on track for all indicators for thematic area II. The GoSL’s results report noted

that while the overall achievement of percent of primary health care institutions having one

month’s buffer stock for 16 selected NCD drugs was good, at the time of reporting, one of

sixteen essential drugs was out of stock at all primary health care institutions in seven

districts. The Ministry of Health launched the National Rehabilitation Guidelines for Sri

Lanka and is developing tools to monitor the disabled patients who require services. In

addition, the MoH is planning, in collaboration with the World Bank, to carry out an

assessment on accessibility for disabled persons in health facilities. The planned timeframe

for this is from June to December 2015.

11. Thematic area III: Health System Development

Under thematic area III, the following PDO and intermediate level indicators are monitored.

% of MoH managed health facilities sending indoor morbidity data through electronic

Indoor Morbidity and Mortality Return (e-IMMR) (DLI 3)

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% of provincially managed health facilities sending indoor morbidity data through e-

IMMR (DLI 4)

% of training institutes managed by the MoH meeting national standards

% of laboratories in health facilities (base hospitals and above) participating in external

quality assurance program for selected tests conducted by the Medical Research Institute

% of hospitals (base hospitals and above) that have obtained Environmental Protection

Licenses (EPL) and Scheduled Waste Licenses (HWL)

% of fully functioning quality management units (QMUs) in MoH managed base

hospitals and above (DLI 7)

% of fully functioning quality management units (QMUs) in provincially managed base

hospitals and above (DLI 8)

% of National Competitive Bidding (NCB) contracts awarded within the first nine

months of the previous calendar year from 2014 onwards

% of the six monthly cash forecast (for non-salary recurring and capital expenditures)

released (DLI 9)

12. The health systems development thematic area includes nine indicators intended to monitor

and support the expansion and modernization of the health system. Overall, progress against

targets in this thematic area is good however two of the nine indicators in this area either did

not report results (the percent of training institutes managed by the MoH meeting national

standards) or did not meet their 2014 targets (the percent of base hospitals and above that

have obtained Environmental Protection and Scheduled Waste licenses).

13. The MoH finalized a framework for standards of basic training programs (FSBTP) and a tool

to evaluate the degree of compliance of training schools to each criteria specified in the

framework. Furthermore, the National Training Policy for the Health Workforce (NTPHW)

has been drafted and is awaiting the approval of the MoH and other relevant stakeholders.

The framework is a core guide for improving the standards of the MoH managed health

schools and consists of six core areas: governance; trainee recruitment; trainers; curricula;

infrastructure and evaluation mechanisms. Out of the thirty four training schools, the MoH is

working with eight schools to enhance their performance and meet the framework standards.

14. Component 2 (US$10 million) Innovation, Results Monitoring and Capacity Building.

The objective of this component is to support the implementation of innovations within the

NHDP in addition to activities related to operational research, capacity building, results

monitoring and technical assistance. A broad five year plan for this fund has been developed.

The mission agreed that the MoH will send detailed annual activity plans for each calendar

year starting from 2015. It was agreed that the annual plan for 2015 will be submitted to the

Bank by June 15, 2015.

15. One of the major activities to be carried out under Component 2 is the 2015/2016

Demographic and Health Survey (DHS). While implementation progress related to this

survey has been slow, the mission noted that a Memorandum of Understanding between the

MoH and the Department of Census and Statistics with clear designation of roles for the two

parties was signed on March 23, 2015. It was agreed that finalizing the consultancy with ICF

International (the international technical assistance team) will be given high priority and

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awarded before June 30, 2015. The planned national health utilization survey and urban

health related tasks originally under the Component 2 will now be carried out under a Trust

Fund and Bank grant funding with close collaboration with the GoSL.

16. Capacity development supported by Component 2 includes both local and international

training. The MoH, following wide consultation and prioritization, developed a capacity

building training plan for international training that was submitted to the World Bank on

April 22, 2015 for review and concurrence. The mission reviewed the training plan and

recommends inclusion of a few additional training programs relevant to the project

development objective. The mission agreed that the letter informing of our concurrence and /

or suggestions for improvement of the proposed capacity building plan will be issued by the

Bank team to the MoH before May 30, 2015. The mission also agreed that more efforts will

be taken to send participants to organized training courses rather than study tours.

Furthermore, the mission agreed that training participant/s will need to send a report

/proposal to the MoH and to the World Bank on the outcomes, applicability and adaptability

of the training to Sri Lanka. The required template will be developed by the project support

team and submitted to the Bank for concurrence before June 15, 2015.

17. Component 2 also intends to create opportunities for innovators and researchers in the health

sector at all levels and staff categories (provinces, hospitals, administrators) to carry out pilot

projects that would help improve the efficiency and quality of the Sri Lankan health system.

The required formats for the call of proposals were developed, cleared and the application

call is accessible on the MoH website: www.health.gov.lk. While a few proposals have been

received by the MoH, the proposals are yet to be sent to World Bank for review and

clearance prior to being awarded. The mission discussed ways of simplifying fund release to

the researchers and innovators and it was agreed that the revised fund flow mechanism for

these grants will be agreed with the Bank before June 15, 2015. The mission also agreed that

to simplify the selection process, a two page concept note will be introduced for selection of

proposals. The relevant template for a concept note will be prepared by the project support

team and submitted to the Bank before June 15, 2015.

18. Component 2 supports the implementation of Component 1 tasks at the provincial level with

the support of a small team of professionals attached to the MPCRD. The mission notes that

the team consisting of the Deputy Project Director, a Financial Management Specialist and

the support of the Procurement Specialist and the Project Specialist are expected to

institutionalize the results monitoring of the health sector as well as support to develop the

procurement capacity at the provincial level. The mission urges the MoH and the MPDRD to

support the establishment and / or reactivation of the agreed monitoring committees

(described in detail in the Project Appraisal Document of the SHSDP) at various levels of

implementation for this purpose. The mission also agreed with the MoH and the MPCRD

that the implementation guideline for utilizing Component 1 resources at the province level,

which was originally issued in 2013, will be reviewed and reissued to the provinces before

June 30, 2015.

http://www.health.gov.lk/

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19. As during the previous mission in December 2014, the mission expressed continued concern

regarding the slow implementation of activities and the corresponding low disbursement

under this component.

F. Procurement, Financial Management (FM) and Disbursement

Procurement – Component 1

20. Ninety-five percent of the project funds (Component 1) go to the General Treasury Account

and the eligible expenditure program is defined as non-procurable items under this project

(Component 1). The funds support the implementation of the NHDP and national

procurement guidelines and systems will be used when procuring to meet the sector results.

Therefore, the project proposes a strong procurement capacity building program in order to

best utilize the existing Sri Lanka National Procurement Guidelines 2006 and to improve the

capacity for efficient contract management to ensure timely service delivery and better

utilization of allocated resources.

21. The mission noted that a full time dedicated Procurement Specialist and a Project Specialist

are supporting the MoH and MPCRD from December 15, 2014 and April 2015 onwards

respectively. During the previous mission in December 2014, development of a procurement

capacity building program was discussed in detail with the MoH and the MPCRD. Three key

pillars are mutually agreed by the Bank and the counterparts for developing an action plan

for conducting the capacity building program. While the team noted that this is not yet

complete, it was agreed that the updated procurement training plan will be submitted to the

Bank before June 30, 2015.

22. The Bank team also discussed the need to carry out a Supply Chain Assessment for the health

sector. The assessment will review the complete chain from need identification and planning

to health service delivery to the clients. This will involve review of organizational structures;

finance; procurement; policies and regulations; logistics – storage, inventory, transport, and

waste management; information systems and processes. The assessment can also help in

identifying a value chain in the health sector for bringing value addition to the current service

delivery. The Bank team is working on developing a concept note and a draft plan which will

be shared with the Government before July 30, 2015 for review and concurrence.

Procurement – Component 2

23. There has been no significant progress of procurement activities since the last mission in

December 2014. The only contract that had to be awarded to ICF International on a single

source basis for supporting the Demographic Health Survey is still in negotiations with the

firm and the draft negotiated documents are yet to be reviewed and cleared by the Bank. The

procurement plan was again discussed in detail and specific comments were communicated

for revision. The procurement of equipment packages have been initiated but are yet to be

awarded. It was agreed that the revised procurement plan would be sent to the Bank for

clearance before June 15 2015.

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24. Based on the overall progress made on procurement activities and its impact on project

implementation, the procurement rating is Moderately Satisfactory.

Financial Management – Component 1

25. Staffing: The mission was pleased to note that MoH has formally assigned one staff member

from its finance unit on part time basis and a dedicated FM staff member seconded from

Government has been assigned to support the MPCRD’s role on FM related activities such as

the preparation of the quarter interim financial statements, annual financial statements,

coordinating with the external audit and actively support the capacity building initiatives

planned under the project. Mission expects that these new arrangements should help avoid

future reporting delays.

26. Capacity Building: As a part of sector capacity building, training is being planned to utilize

some of the capacity building budget of the health sector (from Component 1) to train 60

accountants working in central Government health institutions in 2015. An overseas training

institution has been identified and the MoH is awaiting the relevant internal approvals. The

balance funds are being utilized to improve the facilities of the FM unit at MoH.

27. Financial Management Information System (FMIS): An in-house developed FMIS is ready

for implementation with the primary aim being timely bottom up reporting and commitment

accounting. A clear roll out and training plan has not yet been developed. The Chief

Accountant is actively involved in operationalizing the system and is working on identifying

and developing a team of champions/trainers to train the broader group of users and roll out

the system. World Bank team advised that system related procedures and guidelines also

need to be developed. Adequate capacity building funds will be allocated for such work in

the 2016 budget. It was agreed that the presentation of the FMIS system to the Bank team

will be scheduled before July 30, 2015.

28. Fund flow: The mission notes with appreciation that funds release by the Treasury against

the requested amount by the spending units is 88 percent in the MoH and 93 percent in the

Provinces in 2014 (Annex 3 for details). The mission noted that the MoH (where the bulk of

the capital health budget lies) utilized approximately 81 percent of the 2014 budget. The

mission proposes a joint MOH / WB assessment of process related bottlenecks in capital

budget utilization to commence in September 2015.

29. Quarterly Financial Management Reports (IFRS): In line with the financial covenants of

the project, the MoH and MPCRD have submitted all quarterly reports with the last one

being for quarter ending December 2014. These have been reviewed by the Bank and found

to be in order. Delays have been experienced in compiling these reports however, these

delays are not expected to continue going forward with the new staffing arrangements in

place. The mission reminded that the IFRs (for both Central and Provincial) for each quarter

are due before 45 days of completion of the quarter.

30. Annual Audited Financial Reports: The annual audited financial statements for financial

year 2013 were due to the Bank by October 31, 2014 and the 2014 audit report is due at the

bank before September 30 2015. The audit reports for 3013 were submitted by MoH and

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MPCRD for the central and provincial health activities by February and March, 2015

respectively. The audit report was reviewed and found to be in order. Several joint meetings

were held with the Auditors and the health sector staff to agree on steps to improve the

timelines as well as to re-clarify the objective of the audit as: (1) Providing assurance on the

accuracy of the IFR as statement that represents the health sector expenditures for a given

period: (2) Identifying and reporting significant internal control and process related issues in

the health sector that adversely affect its performance and results. Both MoH and MPCRD

are in the process of reconciling the IFR for the period ending December 31, 2014 against the

final appropriation accounts of 2014 prior to submitting to the external auditors.

Financial Management – Component 2

31. Disbursements for Component 2 are much slower than anticipated. A MoH Accountant has

been assigned on a part time basis to implement the FM activities under Component 2. The

IFRs are up to date and found to be in order. It was agreed during the mission that a separate

audit report will be prepared for this component. The audit report for Component 2 is due on

September 30, 2015 along with the Component 1 audit reports.

Disbursement

32. The project has disbursed US$56.4 million (30.8%) since it became effective in September,

2013. The overall strong disbursement performance under Component 1 is matched by

equally good implementation progress with many of the results for 2014 achieved or

surpassed. However, as indicated above, the mission remains concerned by the very slow

disbursement under Component 2. The Bank released the first advance of US$ 2 million in

May 2014 yet the reported expenditures amount to approximately US$ 67,000.00.

G. Safeguards

33. It is encouraging to note that larger numbers of government hospitals across the country have

applied for Environmental Protection and Scheduled Waste Licenses over the last six months.

While the indicator for this activity is not yet achieved, the mission believes it is on track to

achieve the target in 2015. Other activities related to the overall implementation of the

Environment Management Framework (EMF) for health care waste have been slower. The

mission recommended that the Directorate of Environment and Occupational Health and

Safety (DEOHS), in collaboration with the Central Environmental Agency (CEA), and with

the support of the World Bank team update the implementation plan of action of the

Environment Management Framework before July 15, 2015.

34. The mission noted that the GoSL is yet to initiate the Annual Environmental Audit and

requests the MoH to initiate the related tasks as soon as possible so that the first Annual

Environmental Assessment Report (AEAR) for assessing the performance of EMF.

According to the Financing Agreement, it is due before February 2016. In order to achieve

this target, the DEOHS should finalize the terms of reference of this assessment taking the

recent discussions and decisions into account and submit the updated ToRs to the Bank for

comments and clearance by June 15, 2015. A consultant/firm for AEAR should be contracted

soon thereafter utilizing the Component 2 resources if required.

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H. Results Framework and Monitoring & Evaluation

35. The mission was highly encouraged by the commitment and progress demonstrated by the

GoSL and recommends that the GoSL continue to surpass original targets where possible.

The mission raised the possibility of refining some of the indicators and/or targets and

increasing the targets where necessary especially for targets that have already been achieved

through project ‘restructuring’ (discussed in greater detail under section J below). This idea

was also raised in the DLI and results report 2014 submitted by the Department of Project

Management and Monitoring of the MoPP.

36. The mission also commends the Ministry of Health, the 9 Provincial Health Ministries, the

Project Management and Monitoring Department, Department of External Resources, and the

National Planning Department of the MoPP, the Department of Treasury Operations and the

National Budget Department of the MoF for supporting the implementation and monitoring

of the health sector results on a regular basis. The mission commends the Department of

Project Management and Monitoring for submitting, as agreed in the Financing Agreement,

the annual Results and DLI Report for 2014 in the first quarter of 2015. The mission also

commends the MoH for developing and submitting to the World Bank a detailed Progress

Report on sector results for 2014 also by the end of the first quarter of 2015. Based on the

2014 Results and DLI report and the Progress report, the Bank is supporting an independent

validation survey to validate the DLI results for 2014 reported by the GoSL. The same firm,

(Nielson Company (Pvt) Ltd) that was selected to carry out the 2013 results was selected by

the Bank to carry out the second year survey as well. The survey is currently ongoing and the

process is facilitated extensively by the MoH and the 9 Provincial Ministries of Health.

Approximately 200 health facilities are visited by the research team to validate the reported

results. The results of the survey are expected by June 15, 2015 and following discussions the

corresponding funds for the achievement of the DLI targets of 2014 will be released to the

GoSL in the 3rd

quarter of 2015.

37. According to the Financing Agreement, the GoSL commits to have a team of qualified staff

in adequate numbers to support the Senior Assistant Secretary, Medical Services of the MoH

as the focal person for the project. The mission notes that most essential categories of staff

are now in place to support the implementation and supervision of the project’s components.

The mission urges this team to regularly review implementation of Component 1 and 2 of the

project taking into account the agreed actions attached in Annex 2 of the AM.

I. Communications Related to the Project

38. As a well performing project aiming to aiming to enhance the quality of health care in the

country, the mission discussed and highlighted the need to share information on the project

with the general public and other important stakeholders. The mission discussed the

possibility of updating project related information in the Ministry of Health website and

welcomed the appointment of a focal person for this task. In addition, the mission

recommends that a strategic communications plan be developed and implemented which will

help communicate opportunities and challenges that the project would face, going forward.

This would create a greater interest and dialogue among the non-health sector groups about

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the changes that would take place in the overall health sector of the country. The mission

agreed that the appointment of a focal point by June 15, 2015 who can coordinate between

the Bank and the Ministry would be required as a first step to achieving this process.

J. Summary of Discussions Regarding Possible Project Restructuring

39. The mission and GoSL agree that the project is an ideal platform to address and tackle more

strategic challenges in the health sector and the mission initiated discussions on some of

these areas. As part of these discussions, the joint team discussed the possibility of

‘restructuring’ the project to refine some of the agreed targets and indicators identified in the

project. This would also provide opportunities for the GoSL to consider scaling up successful

activities and expanding the outcomes including additional objectives that are strategic for

the country’s overall health system development. Annex 5 presents a table summarizing the

proposed revised indicators and/or targets as discussed with the GoSL during the mission.

40. The project is designed to release 95 percent of the funds to the Government’s budget cycle

which follows the calendar year and the value of five DLIs are linked to results in the

provinces while three are linked to the MoH results and one linked to the health sector fund

flow. Should the GoSL wish to make any modifications to the values of the Disbursement

Linked Indicators under the project, and if those modifications were made at the time of the

currently planned midterm review in March 2016, the budget would only see changes in the

final year of project fund release (calendar year 2017).

41. The mission also highlights that the restructuring could help simplify the processes related to

innovation projects and would be able to establish a mechanism to allow provinces to have

access to the Component 2 funds.

42. Therefore, the mission recommends that the GoSL review the proposed results indicators and

other required amendments and make recommendations to the Bank if any changes are

required in the project design and in the results indicators preferably before July 30, 2015.

J. Proposed Next Implementation Support Visit and Next Steps:

43. The next implementation support mission can coincide with the planned mid-term review of

the project, currently tentatively planned for around March 2016. Furthermore, it is

envisaged that the agreed actions identified as next steps in this AM (attached as Annex 2)

will be reviewed and monitored regularly to meet the agreed timelines.

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Annex 1. Status of Agreed Actions from December 2014 Mission

No. Action Due Date Status

1. MLGPC to send the IFR for quarter ending September

2014.

December 31, 2014 Completed

2. Send final audit reports. December 31, 2014 Completed

3. Updated Procurement Plan for Component 2 sent to the

Bank for review.

December 31, 2014 Partly completed; to

be completed by

June 15, 2015

4. The MOH, MLGPC and the Provinces will

institutionalize the monitoring reviews as agreed in the

financing agreements

January 2015 on Initiated but needs

improvements; to be

institutionalized by

July 30, 2015.

5. Annual Activity Plan for 2015 activities under

Component 2 will be shared with the Bank.

January 15, 2015 Not completed, in

progress. To be sent

by June 15, 2015.

6. Action plan based on the 3 pillars for the capacity

building of Provincial health and procurement staff to be

drafted by the MPCRD Procurement Specialist in

coordination with relevant GoSL staff and sent to the

Bank for comments.

January 15, 2015 Not completed and

now in progress and

will be submitted by

June 30, 2015

7. Information about the WB online procurement learning

portal widely disseminated across provinces and MOH.

January 15, 2015 Completed

8. Complete national capacity building plan January 30, 2015 Completed

9. Hold workshops in January 2015 on results-based

planning and monitoring prior to finalizing the annual

plans of the MOH and the provinces for 2015.

January 30, 2015 Dropped by the

MoH as not

required.

10. MoH will organize a presentation of the FMIS system

under development for the Bank team.

January 30, 2015 Not completed. Will

be carried out before

July 30, 2015.

11. Finalize ToR of the Annual Environment Assessment

Review (AEAR) and submit to the Bank for comments.

Contract a consultant/firm for AEAR

January 31, 2015

March 31, 2015

Not completed, task

to be carried out

before June 15,

2015.

12. Strengthen support team for the SAS Medical Services to

expedite implementation of Component 2 and increase

monitoring of activities under Component 1 including

technical support provided to the 9 Provinces.

February 15, 2015 staffing improved.

13. Develop capacity building program for better

commitment planning and management of awarded

contracts

March 31, 2015 Initiated and in

progress.

14. The Environment and Occupational Health unit to

develop a template to prepare integrated province wise

health care waste management activity plans and share

with larger hospitals and the provinces to develop their

2015/2016 plans

March 31, 2015 Completed.

15. Submit Results and DLI report for calendar year 2014. March 31, 2015 Completed.

16. December 2014 IFR reconciled with the appropriations

accounts to be submitted to the Auditor General.

April 10, 2015 Completed.

13

Annex 2. Agreed actions from the current May 2015 mission

No. Action Due Date

1 Annual Plan for 2015 under Component 2 submitted to

Bank.

June 15, 2015

2 Capacity Building approval / clearance letter to be

issued by the Bank.

May 30, 2015

3 Templates required to report back on International

training developed.

June 15, 2015

4 The fund flow mechanism for innovations grants to be

finalized.

June 15, 2015

5 A template of a draft concept note to be used intended

research groups / innovators developed.

June 15, 2015

6 Implementation Guideline for Component 1

implementation at the Province level will be reviewed

and reissued to the provinces.

June 30, 2015

7 ICF International Consultancy to be awarded June 30, 2015

Revised Procurement Plan submitted to the Bank. June 15, 2015

8 Procurement Capacity Building Program submitted to

the bank for review.

June 30, 2015

9 The TOR for the Environmental audit to be submitted to

the Bank.

June 15, 2015

10 Update the implementation plan of activities of the

Environment Management framework.

July 15, 2015

11 A focal point should be appointed for Communication

related to the project.

June 15, 2015

12 GoSL should inform/ provide recommendations to the

Bank on the need for restructuring.

July 30, 2015.

13 A joint MOH / WB assessment of process related bottle

necks in capital budget utilization study to commence

Before September 30, 2015

14 The Bank team to draft a concept note and a plan to

carry out a health sector Supply Chain Assessment

developed and shared with the MOH.

July 30, 2015

15 Presentation of the FMIS system to the Bank team will

be scheduled.

Before July 30, 2015

16 The Audit reports for Component 1 - one for Central

Government Health expenditures and the other for

Provincial Government health expenditures - for year

ending December 31, 2014 submitted to the Bank.

September 30, 2015

17 The audit report for component 2 submitted to the Bank September 30, 2015

14

Annex 3: Cash Flows for 2014

LKR 'Mn

Province (upto

PDHS Level)

Imprest

Requested Imprest Received %

North Western

5,151 4,939 96%

Eastern

4,272 3,575 84%

North Central

3,148 2,749 87%

North

3,692 3,692 100%

Central

5,415 5,349 99%

Uva

4,007 3,361 84%

Southern

5,136 4,544 88%

Sabaragamuwa

3,818 3,619 95%

Western

10,467 9,912 95%

Total Provinces

45,106 41,740 93%

Ministry of Health

35,950 31,754 88%

Grand Total

81,056 73,494 91%

15

ANNEX 4: Updated Results Framework (Based on April 2015 Results Report)

Project Development Objective (PDO): To upgrade the standards of performance of the public health system and enable it to better respond to the challenges of malnutrition and non-communicable diseases.

Indicators

Co

re Unit of

Measure

Baseline

(2012/201

3)

Cumulative Target Values**

Freque

ncy

Data

Source

/

Metho

dology

Responsibili

ty for Data

Collection

Description (indicator definition

etc.)

2013

Target and

achievement

2014

Target and

achievement

2015 2016 2017

PDO Level Indicators

% of persons (over 40 years)

screened for selected NCDs at

healthy lifestyle centers

% 3% Target: 4%

Achievement

: 6.8%

Target: 6%

Achievement

: 19.9%

8% 10% 12% annual Admin

data

Dir NCD,

PDHS,

RDHS

No of persons screened for each

of the selected NCD

(hypertension, diabetes mellitus,

Cancer: breast, and oral) at

healthy life style centers

/Population over 40 years

% of pregnant women with anemia

after the second trimester

% 34% Target: 34%

Achievement

: Not

reported,

used the

same

baseline of

34%.

Target: 31%

(will be

reported

from 2015)

28% 24% 20% annual Survey FHB No. of pregnant women with

anemia (Hb below 11g/dl)/Total

No. of pregnant women

registered. To be introduced from

2014 onwards.

% of centrally managed health

facilities with ETUs for that level

of facility based on standard

guidelines (DLI 1)

% (at

Primary,

Secondary

& Tertiary

levels)

0 Target

achieved and

verified as

90%:

Developed &

finalized the

policy &

guidelines for

Accident &

Emergency

services,

awaiting

cabinet

Target: 10%

Achievement

: 14.3%

(4/28

hospitals)


data

Director

Medical

Services

(MS)

No. of centrally managed health



guidelines/Total No. of health

facilities (at each level) managed

by the MOH

16

Indicators

Co

re Unit of

Measure

Baseline

(2012/201

3)


Freque

ncy

Data

Source

/

Metho

dology

Responsibili

ty for Data

Collection


etc.)

2013

Target and

achievement

2014

Target and

achievement

2015 2016 2017

approval.

% of provincially managed health



guidelines (DLI 2)

% (at

Primary,

Secondary

& Tertiary

levels)

0 Target

achievement,

verified as

90%.

Developed

finalized and

make

available the

policy and

guidelines for

Accident and

Emergency

services,

awaiting

cabinet

approval.

Target: 20%

Achievement

: 28.8%

(157/545

hospitals)


Data

9 PDHS and

26 RDHS

and Dir MS

No. of provincially managed

health facilities with ETUs for

that level of facility based on

standard guidelines/Total No of

health facilities (at each level)

managed by the provinces

% of MOH managed health

facilities sending indoor morbidity

data through e-IMMR (DLI 3)

% 2% Target: 10%

Achievement

: 26.5% ,

verified and

has achieved

100% of

target.

Target: 25%

Achievement

: 49%

(23/47

hospitals)

50% 65% 80% annual E-

IMMR

Medical

Statistics

Unit

No. of central Medical Officer of

Health managed health facilities

sending indoor morbidity data

through e-IMMR/Total No. of

central Medical Officer of Health

managed health facilities

% of provincially managed health

facilities sending indoor morbidity

data through e-IMMR (DLI 4)

% 1% Target: 15%

Achievement

: 15%

verified and

100% of

target

achieved

Target: 30%

Achievement

: 33%

173/525

hospitals

50% 60% 70% annual E-

IMMR

Medical

Statistics

Unit

No. of provincial health facilities

sending indoor morbidity data

through e-IMMR/Total no. of

provincial health facilities

17

Indicators

Co

re Unit of

Measure

Baseline

(2012/201

3)


Freque

ncy

Data

Source

/

Metho

dology

Responsibili

ty for Data

Collection


etc.)

2013

Target and

achievement

2014

Target and

achievement

2015 2016 2017

INTERMEDIATE RESULTS (Outputs)

Intermediate Results Thematic Area 1: Addressing Mother and Child Health and Nutrition

% of MCH clinics with an agreed

package of equipment and

supplies for the provision of care

for pregnant women and children

under five years. (DLI 5)

% 20% Target: 20%

Achievement

: 20%,

verified and

has achieved

84% of

target.

Target: 45%

Achievement

: 41.9%

(1627/3883

MCH

clinics)


data

FHB, PDHS,

RDHS

No. of MCH clinics with a

complete set of equipment and

supplies (to test Hb, Height,

weight and availability of micro

nutrients and deworming

drugs)/Total no of MCH clinics

% of Medical Officer of Health

areas with at least three health and

nutrition community support groups

% <10% Target: 10%

Achievement

: 55%

Target: 20%

Achievement

: 65.5%

(216/330

MOH areas)


data

HEB, PDHS,

RDHS

No. of community health and

nutrition support groups

(established and functioning) in

each Medical Officer of Health

area/Total no. of Medical Officer

of Health areas in a given year

% of CEMOC facilities providing

24x7 CEMOC services.

% 45% Target: 45%

Achievement

: 70% ,

Target: 50%

Achievement

: 75.3%


data

FHB, PDHS No. of centrally and provincially

managed health facilities

providing 24x7 Comprehensive

Emergency Maternal and

Obstetric Care (CEMOC) /70

selected hospitals

18

Indicators

Co

re Unit of

Measure

Baseline

(2012/201

3)


Freque

ncy

Data

Source

/

Metho

dology

Responsibili

ty for Data

Collection


etc.)

2013

Target and

achievement

2014

Target and

achievement

2015 2016 2017

Intermediate Results Thematic Area 2: Improving prevention and control of Non-Communicable Diseases

% of Medical Officer of health

areas with at least two healthy

lifestyle centers (DLI 6)

% 10% Target: 10%

Reported

Achievement

: 25%,

verified and

has achieved

only 64% of

target.

Target: 25%

Achievement

: 49.3%


data

DDG (MSI),

Dir NCD,

PDHS,

RDHS

No of Medical Officer of Health

areas with at least two healthy

lifestyle centers at primary care

institution level /Total No of

Medical Officer of Health areas in

a given year

No. of provinces with at least one

health facility providing

rehabilitation services

No. 1 Target:

Develop and

finalize

guidelines for

disability and

rehabilitation

services.

Achievement

: Standards

being

developed.

Target: 2

Achievement

:3 provinces

(North, East

and Western)

3 5 7 annual Admin

data

9 PDHS and

26 RDHS,

Dir YEDD

No of provinces providing

rehabilitation services in at least

one facility (to be defined) in each

of the provinces

% of primary health care institutions

having one month’s buffer stock for

16 selected NCD drugs

% (to be

presented

by MSD

and at

province

levels)

2% Target:

Develop

capacities for

drug logistics

system to be

improved.

Achievement

: discussions

and actions

initiated.

Target: 20%

Achievement

: 43.4%

30% 40% 60% Quarter

ly– yr 2

onward

Admin

data

Director

MSD

No of primary health care

institutions having one month’s

buffer stock for selected NCD

drugs (16 drugs)/Total No of

primary health care institutions

19

Indicators

Co

re Unit of

Measure

Baseline

(2012/201

3)


Freque

ncy

Data

Source

/

Metho

dology

Responsibili

ty for Data

Collection


etc.)

2013

Target and

achievement

2014

Target and

achievement

2015 2016 2017

Intermediate Result Thematic Area 3: Health systems improvement

% of training institutes managed by

the Ministry of Health meeting

national standards

% N.A. National

standards to

be developed

for

accreditation

Achievement

: National

standards

under

development

Target: 10%

Achievement

: The

National

Standard

developed,

finalized,

4/32 schools

identified

20% 30% 40% Annual Admin

data

DDG ETR No of training institutes meeting

national standards/Total No of

training institutes

% of laboratories in health facilities

(base hospitals and above)

participating in external quality

assurance program for selected tests

conducted by MRI.

% 10% 20%

Achievement

: 46.7%

reporting

though the

frequency is

not regular

and needs

improvement

Tests are

defined and

protocols

developed. A

phase out

plan

developed.

Target: 40%

Achievement

: 94.2%

(65/69

eligible

hospitals)

60% 70% 80% annual Admini

strative

data

DDG LS,

PDHS,

RDHS

Proportion of Hospitals BH-A and

above with laboratories which

participate in external quality

assurance program for selected

tests conducted by MRI

Case detection rate for Tuberculosis

rate 69% Target: 72%

Achievement

Target: 74%

Achievement


data

TB Director, The percentage of newly notified

tuberculosis cases (including

relapses) to estimated incident

20

Indicators

Co

re Unit of

Measure

Baseline

(2012/201

3)


Freque

ncy

Data

Source

/

Metho

dology

Responsibili

ty for Data

Collection


etc.)

2013

Target and

achievement

2014

Target and

achievement

2015 2016 2017

: only 66.9% : 66.1% cases (case detection, all forms).

% of hospitals (base hospitals and

above) that have obtained EPL and

HWL

% <5% Target:

Review

existing

situation

based on the

HCWM

guidelines/fra

mework

Achievement

: Review

ongoing

Target: 10%

Achievement

6%:

4/69 base

hospital –A

and above


data

Director Env

and Occ

Health

No of hospitals that have met

standard waste management

practices

% of fully functioning quality

management Units (QMUs) in

MOH managed base hospitals and

above

(DLI 7)

% 9% Target:

Guideline/pr

otocols for a

fully

functioning

QMU

developed,

appropriate

training

carried out

Achievement

verified as

100%.

Target: 15%

Achievement

:38.1%


data

Director QA

and Safety

No of fully functioning± quality

management units (QMUs) in

MOH managed secondary and

tertiary level (Base hospital and

above) hospitals/Total no of

MOH managed hospitals

% of fully functioning quality


provincially managed base

hospitals and above

(DLI 8)

% 6% Target:

National

Standards to

be developed

for

accreditation

Target: 15%

Achievement

: 43.7% of

provincial

hospitals


data

Director QA

and Safety

No of fully functioning± quality


provincially managed secondary

and tertiary level (Base hospital

and above) hospitals/Total no of

province managed hospitals by

21

Indicators

Co

re Unit of

Measure

Baseline

(2012/201

3)


Freque

ncy

Data

Source

/

Metho

dology

Responsibili

ty for Data

Collection


etc.)

2013

Target and

achievement

2014

Target and

achievement

2015 2016 2017

Achievement

: National

standards

under

development

province

% of NCB contracts awarded

within the first nine months of the

previous calendar year from 2014

onwards

% (to be

presented

by

province s

and the

MOH)

N.A.

Not reported.

Target: 40%

Achievement

: 73.6%

(denominator

total NCB

contracts in

2014)


data

DDG

Logistics and

PDHS

No of NCB contracts awarded

within the first nine months of the

previous calendar year /Total No

of NCB contracts awarded in the

previous year

% of the six monthly cash forecast

(for non-salary recurring and

capital expenditures) released

(DLI 9)

% 81% Equal to or

more than

83%

Achievement

: 100%

(verified)

Target:

Equal to or

more than

85%

Achievement

: 100%,

more than

99% in all

provinces

Equal to

or more

than 88%

Equal to or

more than

90%

Equal to or

more than

90%

6

monthl

y

Admin

data

DDG

Finance and

Provincial

Department

Health

Accountants

Amount of funds released by the

treasury every 6 months/total

value of forecast amount. The

data for this indicator are not

cumulative.

The data will be presented by the

MOH and by Provinces

22

ANNEX 5: Outcome of discussions to Review and Modify the Results Framework, mission meetings May 7 and 9, 2015 with

participation of MoH, MoF, MoPP, Provincial MoHs

The project development objective (PDO) is to upgrade the standards of performance of the public health system and enable it to better

respond to the challenges of malnutrition and non-communicable diseases.

Original indicators Remarks Revised PDO indicators Target Remarks

NCDs

1. % of persons (over 40 years) screened for

selected NCDs at healthy lifestyle centers

(PDO)

modify % of men and women (40-65 years)

screened for selected NCDs for the first

time at HLCs and mobile clinics

(Diabetes and Hypertension)

12% (old)

25% (percentage

points) increase from

2014 baseline (men)

25% (percentage

points) increase from

2014 baseline (women

25% (new) TO BE

DISCUSSEED

The info will come

from the HLCs and

other mobile and

outreach clinics.

- Male/female

ratio

2. % of centrally managed health facilities

with ETUs for that level of facility based

on standard guidelines (DLI 1) (PDO)

modify % of centrally managed health facilities

with accident and emergency services for

that level of facility based on standard

guidelines (DLI 1)

40% (old) - retain Only the word ETU

gets replaced by

Accident and

Emergency in this

indicator.

3. % of provincially managed health

facilities with ETUs for that level of

facility based on standard guidelines

(DLI 2) (PDO)

modify % of provincially managed health

facilities with accident and emergency

services for that level of facility based on

standard guidelines (DLI 2)

50% (old) - retain Only the word ETU

gets replaced by

Accident and

Emergency in this

indicator.

23

4. % of Medical Officer of Health areas

with at least two healthy lifestyle centers

(DLI 6)

Retain 90% Review and edit the

DLI definition provided

for the healthy lifestyle

centres

5. No. of provinces with at least one health

facility providing rehabilitation services

modify % of District General Hospitals and above

that provide rehabilitation services based

on the national guidelines

x% (New)

Province %:

MOH %:

6. % of primary health care institutions

having one month’s buffer stock for 16

selected NCD drugs

retain 60% - retain

7. New Improve the services of clinics in

Secondary and Tertiary Care Hospitals

% The services to include

improvements in basic

infrastructure,

availability of drugs,

Human resources,

waiting times, etc. The

services package needs

to be further discussed.

NUTRITION and MCH

8. % of pregnant women with anemia after

the second trimester (PDO)

Retain

20% (old)

9. New The proportion of anemic pregnant

women treated for anemia under

therapeutic guidelines at MCH clinics

XX (new) A sample clinic based

survey will be required

and can be carried out

24

during third trimester during validation

survey visits.

10. % of MCH clinics with an agreed

package of equipment and supplies for

the provision of care for pregnant women

and children under five years (DLI 5)

Retain 95%

11. % of Medical Officer of Health areas

with at least three health and nutrition

community support groups

Retain 90%

12. % of CEMOC facilities providing 24x7

CEMOC services

Retain 75%

Health Systems Development

13. % of MOH managed health facilities

sending indoor morbidity data through e-

IMMR (DLI 3) (PDO)

Retain 80%

14. % of provincially managed health

facilities sending indoor morbidity data

through e-IMMR (DLI 4) (PDO)

Retain 70%

15. new % of Health facilities with internet

connectivity

. XX%

16. % of training institutes managed by the

Ministry of Health meeting national

standards

Retain 40%

17. New No. of students (by type of school)

registered or completed training annually

XX (Target)

18. % of laboratories in health facilities (base

hospitals and above) participating in

external quality assurance program for

selected tests conducted by MRI

Retain 80% 2018 Target achieved in

2014 but improve

quality

25

19. New % of Secondary and Tertiary laboratories

carrying out the standard tests according

to National Guideline

2016- Review the

guideline and agree on

the tests to be

performed at each level

of hospital and

speciality (micro, path,

bio chemistry) and XX

from 2017 onwards

20. Case detection rate for Tuberculosis Retain

21. New No. of people actively screened for TB in

CMC Colombo, Gampaha and Kalutara

districts

XX (Target) To discuss if Chest

Xray/ Sputum / Gene

expert/ Mantoux should

be used for screening

22. % of hospitals (base hospital and above)

that have obtained EPL and HWL Retain 40%

23. % of fully functioning quality

management units (QMU) in MOH

managed base hospitals and above (DLI

7)

Retain

95%

24. % of fully functioning quality

management units in provincially

managed base hospitals and above (DLI

8)

Retain

90%

25.

New

No of secondary and tertiary hospitals with

QMUs introducing Hand washing for health

users and providers

XX (Target)

26. % of NCB contracts awarded within the

first nine months of the previous calendar

year from 2014 onwards Modify

% of National Competitive Bidding

contracts awarded from the planned tenders

for each calendar year

80% (Target)

26

27. % of the 6 monthly cash forecast (for

non-salary recurring and capital

expenditures) released (DLI 9) modify

% of the annual cash forecast (for non-

salary recurring and capital expenditures)

released (DLI 9)

Target to remain as is.

28.

New % of capital health budget spent annually

(line ministry and Provinces)

10% improvement over

the 2014 baseline of

50% for line Ministry

and XX for the

provinces.

29.

New

Procurement plan approved in the first

quarter of each financial year

Supply chain

assessment carried out

(2016) and Yes/ No

response thereafter.

For procurements over

Rs. Xx M

30. New

% of staff trained on financial management

and procurement

XX (Target)

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