Document of The World Bank FOR OFFICIAL USE ONLY Report No: 75430-BR RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF SECOND FAMILY HEALTH EXTENSION ADAPTABLE LENDING PROJECT LOAN NUMBER 7545-BR APPROVED APRIL 25, 2008 TO THE FEDERATIVE REPUBLIC OF BRAZIL March 7, 2013 HUMAN DEVELOPMENT SECTOR MANAGEMENT UNIT BRAZIL COUNTRY MANAGEMENT UNIT LATIN AMERICA AND THE CARIBBEAN REGION This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. ABBREVIATIONS AND ACRONYMS AMAQ Self-appraisal for Quality and Access Improvement in Primary Care (Autoavaliação para Melhoria do Acesso e da Qualidade de Atenção Básica) AMQ Appraisal for Quality Improvement of the Family Health Strategy (Avaliação para a Melhoria da Qualidade da Estratégia Saúde da Família) DPT Diphtheria, Pertussis, Tetanus e-SUS-AB e-Unified Health System – Primary Health Care (e – Sistema Único de Saúde - Atenção Básica) Hib Haemophilus Influenzae B MoH Ministry of Health PMAQ National Program for Access and Quality Improvement (Programa Nacional de Melhoria do Acesso e da Qualidade) PROESF 1 Family Health Extension Project, APL Phase 1 PROESF 2 Family Health Extension Project, APL Phase 2 PSF Family Health Program (Programa Saúde da Família) QUALISUS Brazil Health Network Forming and Quality Improvement Project SES State Secretariats of Health (Secretarias Estaduais de Saúde) SIAB Primary Care Information System (Sistema de Informação de Atenção Básica) SIM Mortality Information System (Sistema de Informações sobre Mortalidade) SINASC Information System for Life Births (Sistema de Informações sobre Nascidos Vivos) SIS-AB Health Information System for Primary Care (Sistema de Informação em Saúde da Atenção Básica) SUS Unified Health System (Sistema Único de Saúde) UBS Primary Care Unit (Unidade Básica de Saúde) TB Tuberculosis Regional Vice President: Hasan A. Tuluy Country Director: Deborah L. Wetzel Sector Manager: Joana Godinho Task Team Leader: Tania Dmytraczenko 2 Restructuring Status: Draft Restructuring Type: Last modified on date : 03/07/2013 1. Basic Information Project ID & Name P095626: BR (APL2)Family Health Extension 2nd APL Country Brazil Task Team Leader Tania Dmytraczenko Sector Manager/Director Joana Godinho Country Director Deborah L. Wetzel Original Board Approval Date 04/25/2008 Original Closing Date: 03/30/2013 Current Closing Date 03/30/2013 Proposed Closing Date [if applicable] 12/31/2014 EA Category B-Partial Assessment Revised EA Category B-Partial Assessment-Partial Assessment EA Completion Date 12/15/2006 Revised EA Completion Date 2. Revised Financing Plan (US$m) Source Original Revised BORR 83.25 83.25 IBRD 83.45 83.45 Total 166.70 166.70 3. Borrower Organization Department Location Federative Republic of Brazil Brazil 4. Implementing Agency Organization Department Location MINISTRY OF HEALTH Brazil 5. Disbursement Estimates (US$m) Actual amount disbursed as of 03/07/2013 38.44 Fiscal Year Annual Cumulative 2013 8.00 46.44 2014 28.00 74.44 2015 9.01 83.45 Total 83.45 3 6. Policy Exceptions and Safeguard Policies Does the restructured project require any exceptions to Bank policies? N Does the restructured projects trigger any new safeguard policies? If yes, please select N from the checklist below and update ISDS accordingly before submitting the package. 7a. Project Development Objectives/Outcomes Original/Current Project Development Objectives/Outcomes The objectives of the second phase APL are: (i) increase access to family health-based primary care in large, urban municipalities; (ii) raise the technical quality of and patient satisfaction with primary care; and (iii) improve the efficiency and effectiveness of family health service providers as well as the broader delivery system. 7b. Revised Project Development Objectives/Outcomes [if applicable] 4 BRAZIL SECOND FAMILY HEALTH EXTENSION PROJECT CONTENTS Page A. SUMMARY ........................................................................................................................... 4 B. PROJECT STATUS .............................................................................................................. 4 C. PROPOSED CHANGES ...................................................................................................... 4 D. APPRAISAL SUMMARY.................................................................................................... 5 ANNEX 1: REVISED RESULTS FRAMEWORK AND MONITORING............................... 6 5 Second Family Health Extension Project - PROESF RESTRUCTURING PAPER A. SUMMARY 1. The major changes to the project and rationale are the following: a) The Results Framework - including indicators, baseline, and targets – has been revised with updated available statistics to increase clarity and reduce repetition by improving the accuracy of indicator definitions and data. b) Proceeds have been reallocated to transfer resources not utilized by the states, the Federal District and municipalities by March 30, 2013 to the federal component (Component 3). c) The closing date has been extended by 21 months from March 30, 2013 to December 31, 2014 to allow the Government sufficient time for implementation and goal achievement of three new priority activities under Component 3 of the Project. B. PROJECT STATUS 2. The Second Family Health Extension Project was approved by the Board on April 25, 2008 and declared effective on October 15, 2009. As of March 7, 2013 US$38.4 million (46 percent) have been disbursed. The Project represents the second Phase of the seven-year US$ 550 million Family Health Extension APL Program (PROESF), which was approved by the Bank’s Board in 2002 and is planned to be implemented in th ree phases. Phase I was successfully completed on June 30, 2007. 3. Consonant with the Program goals, the Project’s Development Objectives (PDOs) are to: (i) increase access to family health-based primary care in large, urban municipalities; (ii) raise the technical quality of and patient satisfaction with primary care; and (iii) improve the efficiency and effectiveness of family health service providers as well as the broader delivery system. The Project has three components: Component 1 – Expansion and consolidation of family health care in municipalities; Component 2 – Strengthening state capacity for supervision, monitoring and technical support of family health services and Component 3 – Strengthening federal oversight of the family health program. 4. The Project progress towards achieving its development objectives is rated “Satisfactory�, and the overall implementation progress is rated “Moderately Satisfactory�. The population coverage of the Government’s Family Health Program (PSF) in participating municipalities increased from 36.4 percent in 2009 to 39.5 percent in 2011 and the average coverage rate in those municipalities is higher than among non- participating municipalities of similar size. Population coverage increased by 5 percent per annum on average. One of the two PDOs – decrease of infant mortality per 1,000 births in participating municipalities – has already been achieved. Most of the intermediate results indicators are on track or have been achieved, including the establishment of a results-based management system at the federal level linking project 6 finances to states and municipalities, establishing performance agreements, and almost 100 percent of states and municipalities participating in quality assessment programs. Intermediate results already achieved by the Project include an increase in PSF teams applying quality evaluation instruments from 7 percent in 2006 to 75 percent in 2011, and an increase in the proportion of patients with hypertension registered by PSF teams from 23 percent (2006) to 51 percent (2012). 5. While performance as measured by progress on Project indicators is good, the slow execution of Project funds is a reason for concern. Project resources were especially underutilized under Component 2 and Component 3. The reason for this is related to an increase in the Government budget for the Department of Primary Care (DAB) of almost 40 percent under the current administration, as well as to an increase in funding at the state and municipal levels. At the same time, the political environment fostered a refocusing on primary health care, which in turn led to the development of new programmatic priorities for primary care, including family health. C. PROPOSED CHANGES Monitoring and Results Framework 6. The following changes have been made and the revised Monitoring and Results Framework is included as Annex 1: PDO Indicator Two (indicator revised; baseline and target revised). The indicator measuring per capita contacts with primary care providers has been specified to include not only doctors but also nurses in the definition of primary care providers. This definition is in accordance with the one adopted by the Ministry of Health (MoH). The baseline was corrected accordingly, using the best available data from the primary health care information system (SIAB). The target for phase 2 (current phase) has been defined as an increase of 5 percent compared to the baseline.  Revised indicator: “Increase of per capita contacts with primary care providers (doctors and nurses) in participating municipalities� - Baseline in PAD: 1.4 percent in 2003 - Target in PAD: N/AP1 - Baseline revised: 1.7 percent in 2003 - Target revised: 1.8 percent in 2014 A. Component One: Indicator Two (indicator revised). This indicator measures the percentage of registered people with high blood pressure among the estimated hypertensive population aged 15 and older in participating municipalities of the year considered. The indicator was 1 According to Table 3.1 on page 50 of the PAD, the target for phase 2 was not applicable (N/AP). 7 formally calculated as a ratio of these two groups and will now be calculated as a proportion, to better align with the Government’s monitoring system.  Revised indicator: “Proportion of patients with hypertension registered by PSF teams, among estimated population with hypertension (15 years of age and older)� Indicator Three (indicator unchanged; baseline and target revised). This indicator measures the vaccination coverage of DPT + Hib (tetravalent) in children less than one year of age in the participating municipalities. The Brazilian vaccination program was upgraded to a penta-, and hexavalent scheme. The indicator is hence calculated based on the sum of completed tetra-, penta-, and hexavalent schemes in children below one year of age.  Original indicator from the PAD: “Percentage of infants < 1 with full vaccination regimen (DPT-H, polio, measles, tuberculosis)� - Baseline in PAD: 71 percent in 2006 - Target in PAD: 85 percent in 2013 - Baseline revised: 100.8 percent in 2008 - Target revised : ≥95 percent in 2014 Indicator Four (indicator revised; baseline revised). This indicator measures the percentage distribution of women with live births, with 7 or more prenatal consultations in participating municipalities. The baseline was updated based on actual data for 2006 from the SINASC information system.  Revised indicator: “Percentage of women with live births, attended by PSF teams, that had 7 or more pre-natal consultations� - Baseline in PAD: 53 in 2006 - Baseline revised: 60 percent in 2006 Indicator Eight (indicator revised) This indicator measuring the proportion of municipalities applying quality evaluation instruments in the areas of PSF management and coordination (AMQ parts 1&2) needed to be updated to reflect the evolution and scale up of quality improvement instruments in Brazil. Besides AMQ 1&2, the system now features two follow-on systems: AMAQ and PMAQ.  Revised Indicator: “Proportion of municipalities that conduct self- assessment to improve access and quality of primary care� The following Component 1 indicators have been dropped: Former PDI (dropped). The indicator measuring the rate of hospital admissions of children <5 for ARI in participating municipalities has been dropped. It was agreed that this indicator is not adequately measuring the attainment of development goals. Both 8 positive and negative changes to the indicator point at potential improvements in primary health care, as envisioned by the Project. Former PDI (dropped). For the same reason as above, the indicator measuring hospital admissions for stroke in participating municipalities has been dropped. B. Component Two: Indicator Nine (indicator revised; target revised). This indicator measuring the percentage of states establishing performance agreements with eligible municipalities with population smaller than 100,000 was revised to reduce unnecessary complexity.  Revised indicator: “Proportion of states that establish performance agreements with at least 25% of municipalities <100,000 population� - Target in PAD: 25 percent municipalities; 40 percent states in 2013 Target revised: 40 percent of states in 2014 Indicator Eleven (indicator revised; target revised). This indicator measures the percentage of municipalities with population smaller than 100,000 in eligible states participating in the quality assessment program (AMQ), which includes self-assessment and development of plans to address quality gaps. It was revised to reduce unnecessary complexity and to transform it into a numeric indicator, eliminating ambiguity on how it is being tracked over time. Further, AMQ has been replaced by follow-on systems, AMAQ and PMAQ, which were implemented on a large scale. Hence, this indicator has already been attained.  Revised indicator: “Proportion of states with 10% of municipalities <100,000 inhabitants that implemented self-assessment� - Target in PAD: 10 percent municipalities; 50 percent states in 2013 - Target revised: 50 percent of states in 2014 C. Component Three: Indicator Fifteen (indicator revised; baseline and target revised). This indicator which measures the proportion of primary health care teams that implement a results- based management system has been updated to reflect the current development in results- based management at the federal level, including the evolution of the AMQ system into the new PMAQ system. The target was revised accordingly to better reflect continued progress on this indicator. - Revised indicator: “Proportion of family health teams participating in the Program of Improving Access and Quality (PMAQ-AB)� - Baseline in PAD: 0 percent in 2006. - Target in PAD: model developed & tested in 2013 9 - Baseline revised: 50 percent in 2011 - Target revised: 60 percent in 2014 Indicator Sixteen (new). This indicator will monitor the upgrading of information systems and integrated data systems to support performance monitoring of primary health care and the family health program. - New indicator: “Proportion of participating municipalities that implemented the Health Information System for Primary Care (SIS-AB)� - Baseline: 0 percent in 2011 - Target: 70 percent in 2014 Indicator Seventeen (new). This indicator will monitor the upgrading of primary care units to units with Tele-health access points. These access points play a key role in raising the technical quality of primary care and have a direct role in promoting continued professional learning for family health professional across the Tele-health network.  New indicator: “Proportion of primary care units (UBS) in participating municipalities that have a Tele-health access point� - Baseline: 0 percent in 2011 - Target: 20 percent in 2014 The following Component 3 indicators have been dropped: Former PDI (dropped). This indicator measuring the completion of at least three out of six major research projects on PSF has become obsolete due to the fact that the Government is funding research projects with its own resources. Former PDI (dropped). For the same reason as above, the indicator monitoring the preparation of an impact evaluation is dropped. The Government is funding the impact evaluation of its major quality improvement initiative, PMAQ, with its own resources. Furthermore, major research studies focusing on the Brazilian PSF have been carried out and published by renowned research institutions.2 Therefore, the demand and need for similar studies and evaluations funded with Project resources has diminished. Former PDI (dropped). This indicator, which measures the development of a proficiency test of PSF professionals, has become obsolete due to the introduction of the 2 Macinko J, Guanais FC, de Souza M . Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health 2006; 60: 13-19. Macinko J, de Oliveira V, Turci M et al. The influence of primary care and hospital supply on ambulatory care – sensitive hospitalization among adults in Brazil, 1999-2007. American Journal of Public Health 2011. Vol 101, No.10. Rocha R, Soares R. Evaluating the impact of community-based health interventions: Evidence from Brazil’s Family Health Program. Health Econ. 19: 126-158 (2010). 10 PMAQ system, involving an external evaluation of PSF professionals. It is, therefore, dropped. Reallocation of Loan Proceeds 7. Resources not utilized by the states, the Federal District and municipalities by March 30, 2013 will be transferred to the federal Component (Component 3). Municipalities and states underutilized available Project funds under Component 1 and 2 in part due to greater availability of own resources and are, therefore, not expected to need Project funds in the future. Component 3 resources were used to co-finance the International Seminar of Primary Care, which took place in July of 2012; however, several studies planned under Component 3 were completed with the Government’s own resources. The Government proposes that remaining Project resources be used for the deployment of e-SUS-AB, financed under Component 3. This new programmatic priority set by the Government is in accordance with the original PDO. 8. Proceeds will be reallocated as follows: Table 1: Reallocation of Loan Proceeds Category of Expenditure Allocation % of Financing Current Revised 1. Goods and non-consultant services; Consultant services and Training (except for Municipal 11,100,000.00 41,256,196.82 100% Subprojects and State Subprojects 2. Municipal Subproject Transfers and Prior Review Consultants disbursed by the 55,000,000.00 29,000,000.00 100% MOH’s Fund under each Municipal Subproject Agreement 3. State Subproject Transfers and Prior Review Consultants disbursed by the MOH’s Fund 12,450,000.00 9,485,178.18 100% under each State Subproject Agreement 4. Incremental Operational Costs 3,500,000.00 3,500,000.00 100% 5. Front-end fee Amount payable pursuant to Section 2.03 of the Loan 208,625.00 208,625.00 Agreement in accordance with Section 2.07 (b) of the General Conditions 6. Premia for Interest Rate Caps and Interest Rate Collars 0.00 0.00 7. Unallocated 1,191,375.00 0.00 Total 83,450,000.00 83,450,000.00 11 Extension of the Closing Date 9. The closing date has been extended to December 31, 2014. This extension is necessary to give the Government time to (i) achieve the PDO; (ii) consolidate the activities under Component 3 after restructuring; (iii) successfully implement the new activities introduced into the scope of the Project with the goal of improving health information systems and continued professional learning across the family health network; and to (iv) attain the data and information under the revised Monitoring and Results Framework to ensure complete monitoring of targets by the extended closing date. 10. Most of the activities currently supported under Component 1 and 2 of the Project will be completed by the original closing date on March 30, 2013. By then one PDO and eight PDIs will already have been achieved. The 21 months extension will allow implementation of the activities under Loan Agreement Schedule 1. Section 1.(e) and Section 5.(c)/ Component 3, namely: a. Deploy the new electronic primary health care information system, designated as e-SUS-AB (e – Sistema Único de Saúde - Atenção Básica), in primary care units in nine regions of the QUALISUS Project (P088716). b. Boost the functionality of the care networks for people with chronic diseases by outfitting primary care units with Tele-health access and in- service training. c. Establish areas of cooperation and synergy between the QUALISUS and PROESF projects to optimize the implementation, exchange of experiences and to align Bank projects under the MoH. 11. The restructuring does not trigger any new safeguard policies nor affect the environmental safeguard rating of the Project. 12 ANNEX 1: Results Framework and Monitoring D=Dropped Cumulative Target Values** Core C=Continue PDO Level Results N= New Unit of Data Source/ Responsibility for Baseline Frequency Indicators* R=Revised Measure Phase 2 Methodology Data Collection Indicator One: Decrease of Sistema de infant mortality per 1000 live Informações sobre births in participating Mortalidade (SIM) C % 17.8 (2003) 16.9 Annual e Sistema de MoH municipalities. Informações sobre Nascidos Vivos (SINASC) Indicator Two: Increase of per Sistema de capita contact with primary Informação de care providers (doctors and Atenção Básica R % 1.7 (2003) 1.8 Annual (SIAB) or Sistema MoH nurses) in participating de Informação em municipalities Saúde da Atenção Básica (SIS-AB) INTERMEDIATE RESULTS Intermediate Result (Component One): Expansion and Consolidation of Family Health Care in Municipalities Intermediate Result Indicator Departamento de One: Percentage of PSF Atenção Básica/ population coverage in Ministério da C % 33 (2006) 37 Annual Saúde and MoH participating municipalities population estimate IBGE/TCU Intermediate Result Indicator SIAB and Two: Proportion of patients Pesquisa Nacional with hypertension registered by por Amostra de R % 23 (2006) 35 Annual Domicilios MoH PSF teams, among estimated (PNAD-2008) or population with hypertension SIS-AB and (15 years of age and older). PNAD-2008 Intermediate Result Indicator Sistema de Three: Percentage of infants < Informação do 1 with full vaccination regimen Programa Nacional de (DPT-H, polio, measles, Imunização - tuberculosis) in participating R % 100.8 (2006) ≥95 Annual MoH Avaliação do municipalities (as a group) Programa de Avaliações (SI- PNO/API) and SINASC Intermediate Result Indicator Four: Percentage of women with live births attended by PSF teams that have 7 or more R % 60 (2006) 70 Annual SINASC MoH pre-natal consultations in participating municipalities (as a group). Intermediate Result Indicator Five: Percentage of total medical consultations referred C % < 10 (2006) <10 Annual MoH from PSF to hospital specialty services in participating municipalities (as a group). Intermediate Result Indicator Banco de dados do Six: Percentage of all PSF Programa de teams applied quality Melhoria do Acesso e da evaluation instrument and are Qualidade ranked according to standard in (PMAQ-AB) and participating municipalities (as C % 7 (2006) 15 Annual Projeto Avaliação MoH a group). para a Melhoria da Qualidade (AMQ) do Departamento de Atenção Básica/ Ministério da Saúde Intermediate Result Indicator Seven: Percentage of PSF teams in a sample of municipalities using evidence- C % N/A 15 Annual PMAQ-AB MoH based clinical guidelines for hypertension and diabetes (based on sample survey) in participating municipalities (as 14 a group). Intermediate Result Indicator Eight: Proportion of municipalities that conducted self-assessment to improve R % 0 (2006) 10 Annual PMAQ-AB MoH access to and quality of primary care in participating municipalities (as a group). Dropped Intermediate Result Indicator: Rate of hospital admissions of children <5 for D # 24/1000 22/1000 ARI in participating municipalities (as a group). Dropped Intermediate Result Indicator: Rate of hospital admissions for stroke in D # 27/1000 26/1000 participating municipalities (as a group). Intermediate Result (Component Two): Strengthening State Capacity for Supervision, Monitoring and Technical Support of Family Health Services Intermediate Result Indicator Nine: Proportion of states that establish performance Sistema de 40 agreements with at least 25% of R % 0 (2006) . Annual Gerenciamento de MoH municipalities <100,000 Projetos - SGP 2 population, for participating states (as a group). Intermediate Result Indicator Ten: Proportion of states with monitoring and evaluation C % 0 (2006) 50 Annual SGP 2 MoH plans implemented and evaluated in participating states (as a group). Intermediate Result Indicator Eleven: Proportion of states with 10% of municipalities R % 0 (2006) 50 Annual PMAQ-AB MoH <100 000 inhabitants that implemented self-assessment. 15 Intermediate Result (Component Three): Strengthening Federal Oversight of the Family Health Program Intermediate Result Indicator Twelve: Establishment, at Departamento de federal level, of a results-based Atenção Básica/ C Text N/A System developed and tested Annual MoH management system that links Ministério da project financing to states and Saúde municipalities. Intermediate Result Indicator Departamento de Thirteen: Cost accounting Atenção Básica/ C Text N/A Study concluded & system developed Annual MoH system (at federal level) Ministério da Saúde Intermediate Result Indicator Fourteen: Inter-municipal cooperation plan implemented Departamento de in each state to strengthen PSF, Plan implemented Atenção Básica/ C Text N/A Annual MoH specifying activities in three (20 states). Ministério da areas: management, Saúde coordination, Service Provision. Intermediate Result Indicator Fifteen: Proportion of family health teams participating in R % 0 (2006) 60 Annual PMAQ-AB MoH the Program for Improving Access and Quality (PMAQ- AB). Intermediate Result Indicator Sixteen: Proportion of participating municipalities that N % 0 70 Annual SIS-AB MoH implemented the Health Information System for Primary Care (SIS-AB). Intermediate Result Indicator Seventeen: Proportion of Sistema de primary care units (UBS) in N % 0 20 Annual Monitoramento do MoH participating municipalities that Telessaúde have a Tele-health access point. Dropped Intermediate Result Indicator: Proficiency test of D Text N/A Test developed PSF professionals. 16 Dropped Intermediate Result Baseline D Text Plans, methods & ToRs Indicator: Impact evaluation collected Dropped Intermediate Result Indicator: Six major research projects on PSF (at least one on chronic diseases, one on D Text N/A 3 studies concluded patient satisfaction, and one on PSF impact on hospital admissions). (see further http://coreindicators) **Target values should be entered for the years data will be available, not necessarily annually 17