Lebanon Health Resilience Project

Project Implementation Status
(As of December 31, 2022)

Project Rating: The project’s progress towards achieving the PDO and the overall implementation is rated as Moderately Satisfactory.

COVID-19 Response: The project supported the Government of Lebanon (GOL) in the procurement of COVID-19 goods and commodities. Goods and supplies were procured to equip 45 public and private hospitals to increase their ability to test and treat suspected cases. Intensive Care Unit (ICU) beds and their associated equipment were procured to increase the ICU capacity by 180 ICU beds, in addition to the procurement and installation of negative pressure to further increase the ICU capacity by 85 ICU rooms. As of December 2021, the project started supporting the increase in the COVID-19 and non-COVID-19 hospital payments to reduce patient overcharge (i.e. multiplying the hospital share of the claim by a coefficient of 2.5 as of December 2021). To date, 16,792 COVID-19 claims, and 9,866 non-COVID-19 claims have been audited by the Third Party Agency (TPA) and cleared for payment by the World Bank.

COVID-19 Vaccines: This project has supported the procurement of 3.25 million doses of COVID-19 vaccine covering 24 percent of the population with two doses, all of which were financed by the LHRP funds, and 2.75 million of which were already delivered to the country, as well as supplies for vaccine deployment. The MoPH informed the Bank that the order for the remaining doses has been postponed until after the available stock is depleted. The project also financed the pharmacovigilance (PV) program at the MoPH through covering the salaries of four PV personnel, which supported the design and launch of the National Pharmacovigilance System in September 2022. The Third-Party Monitoring (TPM) of COVID-19 vaccination implementation conducted by the International Federation of the Red Cross (IFRC) ended in July 2022. The Bank and the MoPH have agreed to transfer the monitoring function to MoPH’s existing field monitors until the new COVID-19 response project (Strengthening Lebanon’s COVID-19 Response Project) begins implementation. The scope and tools for monitoring have been revised based on the progress in the vaccination campaign and the current risks in agreement with IFRC and MoPH. The Third-Party Monitoring Agency (TPMA) conducted a refresher training for MoPH’s field monitors on data collection and reporting tools on September 9, 2022. However, risks such as the lack of capacity of the MoPH to conduct proper monitoring, low vaccine demand, and persisting stock management issues such as the expiry of vaccines and quality management of the vaccination process remain.

Delays in implementation of Primary Health Care (PHC) Activities: There continues to be significant delays in the implementation of PHC related activities under Component 1 (Scaling up the Scope and capacity of the PHC Universal Health Coverage Program) and Component 2 (Provision of health care services in public hospitals) due to the COVID-19 pandemic. This has impacted the achievement of the initial development objective of the project, which is to increase access to quality healthcare services to poor Lebanese and displaced Syrians in Lebanon. During the last implementation supervision mission conducted by the Bank in June 2022, the MoPH informed the Bank that they are in the process of conducting a consultative process with development partners and relevant actors to inform the National PHC Roadmap. This process would inform the restructuring of the project, especially the design of the activities under Component 1. This process was formally launched on October 3, 2022. Consultations are expected to be completed by December 2022, resulting in a preliminary draft of the PHC strategy for Lebanon. The MoPH expects to pilot the new approaches for PHC delivery in January – June 2023, followed by launching and implementing the PHC Roadmap in July 2023.

Project Restructuring: On March 1, 2022, the Bank received a request for restructuring from the Ministry of Finance (MoF) to increase the funds allocated to component 4 (Strengthen capacity to respond to COVID-19) to support the procurement of additional one million COVID-19 vaccine doses. The restructuring of the project is required to update the results framework in order to reflect the activities conducted to support the GOL response against the COVID-19 pandemic. Additionally, the project requires an extension of the closing date to adjust for the delays to declare effectiveness and the expected changes in design in Component 1. The Bank agreed with MoPH that this restructuring will be conducted in a two-step process (reallocation of funds between project components and categories followed by restructuring). The reallocation of funds was completed on May 24, 2022, through an exchange of official letters, given the urgent needs in the country. The upcoming restructuring will require an amendment to the Loan Agreement as it will entail changes in the component design and scope, the indicators, and their targets under the results framework (as there has been no progress in the indicators under components 1 and 2 since the associated activities have not been executed yet), the disbursement allocation, and the potential extension of the closing date of the project, which has been proposed to be extended by 1 additional year (till June 30, 2024). During the last implementation support mission, the Bank and MoPH discussed the upcoming project restructuring and the potential activities that could be financed using the remaining funds under the LHRP. The MoPH confirmed that the restructuring will be completed once the contents of the reform of the PHC system are defined (as explained above). The Bank agreed with the Project Management Unit (PMU) on the need to complete the restructuring by January 31, 2023, at the latest.

Challenges:
Macroeconomic factors. Currently, Sayrafa exchange rate (which is an exchange rate established by the Central Bank based on a platform used to exchange USD to LBP) is used for locally sourced expenditures financed by the World Bank and USD is used for internationally sourced expenditures. However, the fluidity of the US dollar/ LBP exchange rate remains a risk impacting the monetary value of the funds.
Withdrawal ceiling: The Bank was informed by the MoPH that the hospitals were not able to withdraw the full payments transferred to them due to the withdrawal ceiling set by the local commercial banks on the hospitals’ bank accounts. The Bank sent a letter to the GOL recommending that the MoF coordinate with the Central Bank to remove the withdrawal ceiling on the payments received (in LBP) from the project to the public and private hospitals for the COVID-19 and non-COVID-19 claims paid. Following that, the Central Bank agreed to remove the withdrawal ceiling on the payments received (in LBP) from the Project to the public and private hospitals for the COVID-19 and non-COVID-19 claims paid. This withdrawal ceiling issue is also faced by the TPA.
Delays in recruitment of stock management officer: The Bank agreed to work with the MoPH on a plan to strengthen stock monitoring at the Ministry, which should be enabled for new deliveries of vaccines or any other supplies to be funded by the project. The PMU agreed to hire a stock management officer to address this issue, and the hiring is expected to be completed by January 31st, 2023.