FOR OFFICIAL USE ONLY Report No: RES45418 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT AND/OR INTERNATIONAL DEVELOPMENT ASSOCIATION RESTRUCTURING PAPER ON A PROPOSED PROGRAM RESTRUCTURING OF {NIGERIA - PROGRAM TO SUPPORT SAVING ONE MILLION LIVES} {APPROVED ON APRIL 23, 2015} TO {THE} {FEDERAL REPUBLIC OF NIGERIA} {Health, Nutrition & Population Global Practice} {Africa West Region} Regional Vice President: Ousmane Diagana Country Director: Shubham Chaudhuri Regional Director: Dena Ringold Practice Manager: Magnus Lindelow Task Team Leader(s): Ayodeji Gafar Ajiboye The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) DATA SHEET (Nigeria - Program to Support Saving One Million Lives - P146583) BASIC DATA Project ID Financing Instrument IPF Component P146583 Program-for-Results Financing No Approval Date Current Closing Date 23-Apr-2015 31-Jan-2021 Organizations Borrower Responsible Agency Federal Republic of Nigeria Federal Ministry of Health Program Development Objective(s) The objective of the Program is to increase the utilization and quality of high impact reproductive, child health and nutrition interventions. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Approval Effectiveness Closing Ln/Cr/TF Signing Date Commitment Disbursed Undisbursed Date Date Date IDA-56000 23-Apr-2015 22-May-2015 29-May-2015 31-Jan-2021 500.00 303.50 203.96 Policy Waiver(s) Does the Program require any waivers of Bank policies applicable to Program-for-Results operations? No Page 1 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) I. PROGRAM STATUS AND RATIONALE FOR RESTRUCTURING PROGRAM STATUS 1. Supporting an Important Government Initiative: In response to unsatisfactory progress on improving maternal and child health, the Government of Nigeria launched the Saving One Million Lives (SOML) initiative in 2012. The SOML program for results (SOML PforR), financed by an International Development Association (IDA) credit of US$500 million equivalent is designed as a 5-year (April 2015 – December 2019) program to support the SOML initiative of the Government of Nigeria by providing incentives to States, based on improvements in the coverage and quality of high-impact health services. It also rewards States for strengthening the institutional processes needed to achieve the results and incentivizes the Federal Government to collect and publish data from independent and robust household and health facility surveys. The SOML program represents a shift in focus from financing inputs to paying for results, implements a results-based approach to federalism, and aims to save the lives of one million women and children. Given that the states are responsible for primary health care (PHC), most of the funds (82%) are allocated to state-level. 2. Progress Towards the PDO: The Program Development Objective (PDO) is to “increase the utilization and quality of high impact reproductive, child health and nutrition interventions.” The first of the two PDO indicators is the combined coverage of six key SOML services (immunization [Penta3], skilled birth attendance, Vitamin A supplementation amongst children 6 months to 5 years of age, contraceptive prevalence rate [modern methods], use of insecticide-treated bed nets (ITNs) by children under five, and prevention of mother-to-child transmission of HIV – DLI 1.2. Based on the 2018 Standardized Monitoring and Assessment of Relief and Transitions (SMART) household survey, progress on the combined coverage of these key services has been modest with the index improving from 237 percentage points (% points) in the 2015 SMART survey to 244 % points in 2018, which falls below the target of 271 % points in 2018. The 2019 SMART survey should have provided more recent estimates of progress towards the PDO. However, a review of the 2019 SMART survey led by the World Bank and Bill and Melinda Gates Foundation (in consultation with the Federal Ministry of Health, Nigeria Bureau of Statistics, UNICEF and other development partners) found several technical issues with its implementation, in a way that makes the results unreliable and inaccurate (see summary of some of the technical issues below). Notwithstanding, alternative data sources such as the 2019 General Household Survey (GHS) post-harvest, 2018/19 National Living Standard Survey (NLSS) and the Lot Quality Assurance Sampling (LQAS) point towards progress in the PDO. a. Insufficient documentation related to deviations between the planned and realized survey sample, particularly (but not exclusively) as it relates to any inaccessible areas during the survey and differences in urban / rural balance between the 2019 SMART and 2018 SMART samples. Clear documentation of non- response and replacement to assess sample bias is also not available. b. Identified differences in post-stratification analytic weighting values between the 2018 SMART and 2019 SMART that are unexplained in the 2019 SMART report and which introduce potential biases in results. c. Identified date-related errors and inconsistencies that went unchecked during data cleaning and analysis, indicating possible challenges during field work that appear to have gone unresolved or unidentified by daily data quality checks. 3. Progress on the second PDO indicator on quality of care index at health facilities (DLI 2) is based on the National Health Facility Survey (NHFS) which was last concluded in 2019. The results show overall improvement in the national Quality of Care (QoC) index from baseline of 34 percent in 2016 to 52 percent in 2019, 18 % points Page 2 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) increase in three years. States’ performance shows wide variation in results as 15 of the 36 states (and FCT) performed above the national average. Only one state (Osun) did not record any improvement in the QoC index. Clinical competence, the diagnostic accuracy of health workers and adherence to clinical guidelines, is the area that showed the most improvement with 5.5 percentage points above the baseline of 8.5 percent. Financial management and quality of HMIS data is the least improved area with 1 percentage points above the baseline of 4.7 percent. Other improved results areas include increased availability of drugs and equipment by 4.1 percentage points from a baseline of 5.9 percent; increase in frequency and quality of supervision by 4.6 percentage points from a baseline of 8.6 percent; and readiness to deliver key SOML services increasing by 2.6 percentage points from a baseline of 6.1 percent. US$16.4m has been recently disbursed against this DLI. 4. Implementation progress (IP): The program overall IP has been moderately satisfactory (MS) over the last two implementation status and results report (ISR). Before then, the program IP had also been MS for about two years (from June 2017) before it was downgraded to moderately unsatisfactory (MU) in April 2019 initially due to poor performance of the Independent Verification Agency (IVA) and later due to new fiduciary concerns that emerged on the program, including payment of performance bonus to high level Federal Ministry of Health officials and allegations of fraud in the use of program funds and procurement processes. These issues have been resolved and the fiduciary risk rating of the program has also been upgraded to MS in July 2020. There are no outstanding audits for the program. 5. Program disbursements: Disbursement on SOML program to date stands at US$ 303.5 million, equivalent to a disbursement ratio of 60%. The program has made only two rounds of performance disbursements based on the SMART survey rather than the envisaged four rounds of performance disbursement for SMART survey. Unfortunately, the 2019 SMART survey cannot be used for the third round of performance disbursement, given the unreliable and inaccurate results stemming from the sub-optimal implementation of the survey. However, an alternate data source (the 2019 General Household Survey - post harvest) has been used to estimate national performance on one of the SOML indicators (use of ITNs by under-fives) and this is likely to disburse all the remaining funds of USD 83.65m on DLI 1.2 (after the restructuring). In addition, a further disbursement of USD 600,000 is expected on DLI 5.1(ii) taking the program disbursement ratio to 76%. Even after these additional disbursements, USD 120.39 million will be left undisbursed under various DLIs as the results required to trigger the disbursement will not be achieved before program close. 6. Previous restructuring: The SOML program has experienced three rounds of restructurings. First, between the program effectiveness date (May 2015) and the first disbursement in June 2016, the Government of Nigeria requested for a level II restructuring to: (i) reward all states with US$1.5 million under DLI 1.1 (instead of US$2 million for the 20 poorest performing (“lagging”) States and US$1 million for the remaining 17 states); and (ii) use the 2015 SMART survey results as the baseline instead of the 2014 SMART survey. Second, in December 2019, the program closing date was extended by 9 -months to close in September 2020 to allow for the conclusion of two ongoing surveys (NHFS and 2019 SMART survey) that will lead to large disbursements and help measure progress towards the PDO. Following the review of the 2019 SMART survey and the inability of the program to use the results for disbursements against DLI 1.2, another restructuring was done to extend the closing date of the program from September 30, 2020 to January 31, 2021 to allow time to seek a credible alternative to the SMART survey and disburse against DLI 1.2. Page 3 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) RATIONALE FOR RESTRUCTURING 7. There are two principal reasons for this restructuring. First, it will allow the Bank and Government to implement a solution that provides an alternative to the use of 2019 SMART survey as the basis of disbursement against DLI 1.2. As earlier documented, the technical issues with the implementation of the 2019 SMART survey resulted in unreliable and inaccurate results that could not be used by the program as the basis of disbursement against DLI 1.2. Several alternative household surveys such as the NLSS, LQAS, Multiple Indicators Cluster Survey (MICS) Demographic and Household Survey (DHS) and GHS were explored to measure the progress in the six key SOML indicators between the years 2018 and 2019. There were challenges using most of these alternative data sources, either as a result of: methodological difference in comparing two data sources across years; or unavailable data on the indicators of interest to compare across the two years of interest; or unavailable subnational level data for measurement of individual state performance on the key indicators of interest for SOML. It was also not possible to conduct another round of the SMART survey given the program closing date of January 2021. Following this comprehensive review of alternate data sources and several rounds of consultations with the FMOH, State Commissioners of Health, Nigeria Governors Forum and the steering committee of the program, a decision was taken to proceed with the use of the 2019 GHS (post-harvest) as the alternative to 2019 SMART survey. Using the 2019 GHS as an alternative meant that improvement in DLI 1.2 can only be measured based on national (and not individual state) performance and on the use of one key SOML indicator – use of ITNs. Since there was no state- level performance data, a further decision was taken that the earnings from DLI 1.2 will be shared equally amongst all the 36 states and the Federal Capital Territory. It should be noted that the national performance on the use of ITNs alone (13.7 percentage-point increase nationally) is significant enough to lead to disbursement of all remaining funds on DLI 1.2. 8. Secondly, this restructuring will allow for the partial cancellation of IDA in the amount of USD 120.39 million to the SOML PforR. The cancellation is due to the team’s assessment that the program will not be able to achieve the remaining results required to trigger disbursements against the various DLIs before the program closing date of January 31, 2021. 9. Request from Government: The Government has requested for the restructuring of DLI 1.2 and partial cancellation of undisbursed funds its letter dated January 27, 2021 (see attachment). Page 4 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) II. DESCRIPTION OF PROPOSED CHANGES 10. Restructuring of DLI 1.2 I. Revision of means of verification of DLI 1.2: Definition of DLI 1.2 in Schedule 4 (table on DLI matrix) of the Financing Agreement will be revised to DLI 1.2: Increase in quantity of high impact Reproductive, Child Health and Nutritional interventions as measured by improvements on key health indicators as indicated by SMART or other quality-assured household Surveys with data from SMART Survey 2015 providing the baseline. II. Change from State level performance to average national performance reward and removal of national and zonal best performers rewards on DLI 1.2: A revision of results to be achieved in Year 4 (only) for DLI 1.2 in Schedule 4 (table on DLI matrix) of the Financing Agreement will be revised to % improvements in average national performance of the Key Health Indicator relating to the use of insecticide treated nets by children under 5. III. Revision of the allocated amounts (earnings) for DLI 1.2: A revision of the allocated amounts in Year 4 (only) for DLI 1.2 in Schedule 4 (table on DLI matrix) of the Financing Agreement will be revised to SDR 145,000 (USD 205K) per 1% increase in average national performance above 1%, allocated to each state of the Federation and FCT. If the overall total amount earned exceeds remaining funds on DLI 1.2, disbursements will be pro-rated to states and FCT based on available funds. 11. Partial cancellation of IDA: This restructuring entails cancellation of USD 120.39 million from IDA credit number 5600-NG, as at January 27, 2021 and this is summarized below: I. Change in amount allocated to DLI category schedule (i) Category 2: DLI 2 - Increase in quality of high impact Reproductive, Child Health and Nutritional interventions from 38,300,000 to 11,495,750 expressed in SDR; (ii) Category 3: DLI 3 - Improvement in monitoring and evaluation systems and data utilization from 56,800,000 to 29,652,217.80 expressed in SDR; (iii) Category 4: DLI 4 - Establishment and operations of Innovation Fund designed to support private sector innovations aimed at increasing utilization and quality of maternal and child health interventions from 14,200,000 to 0.00 expressed in SDR; and (iv) Category 5: DLI 5 - Increase transparency in management and budgeting of primary health care from 29,000,000 to 13,693,852.91 expressed in SDR. Page 5 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) III. SUMMARY OF CHANGES Changed Not Changed Change in Cancellations Proposed ✔ Reallocation between and/or Change in DLI ✔ Change in Implementing Agency ✔ Change in Program's Development Objectives ✔ Change in Program Scope ✔ Change in Results Framework ✔ Change in Loan Closing Date(s) ✔ Change in Disbursements Arrangements ✔ Change in Disbursement Estimates ✔ Change in Systematic Operations Risk-Rating Tool ✔ (SORT) Change in Safeguard Policies Triggered ✔ Change in Legal Covenants ✔ Change in Institutional Arrangements ✔ Change in Technical Method ✔ Change in Fiduciary ✔ Change in Environmental and Social Aspects ✔ Change in Implementation Schedule ✔ Other Change(s) ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_COMPONENTS_TABLE OPS_DETAILEDCHANGES_CANCELLATIONS_TABLE Page 6 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) CANCELLATIONS PROPOSED Value Current Cancellation New Reason for Ln/Cr/TF Status Currency Date of Amount Amount Amount Cancellation Cancellation Disburs UNDISBURSED IDA-56000- 354,700,000.0 271,241,820. ing&Re XDR 83,458,179.29 27-Jan-2021 BALANCE AT 001 0 71 paying CLOSING OPS_DETAILEDCHANGES_EA_TABLE . Page 7 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) ANNEX 1: RESULTS FRAMEWORK . . Results framework Program Development Objectives(s) The objective of the Program is to increase the utilization and quality of high impact reproductive, child health and nutrition interventions. Program Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline End Target Increased utilization and quality of high impact interventions Combined coverage of six key SOML services; (a) vaccination coverage among young children (Penta3); (b) contraceptive 237.60 284.00 prevalence rate (modern methods); (c) Vitamin A supplementation among children 6 m (Percentage) Quality of care index at health center level based on 6 domains 38.10 42.00 with data from national health facility survey (Percentage) PDO Table SPACE Page 8 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) Intermediate Results Indicators by Result Areas RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target Improved Management of Primary Health Care Number of States with performance management systems in 10.00 30.00 place (Number) States in which SPHCDA or equivalent have managerial authority 4.00 37.00 over PHC staff (Number) Improve quality of care and ability to deliver key SOML Interventions Impact evaluation of Results based disbursements for MNCH No Yes weeks (Yes/No) People who have received essential health, nutrition, and 9,456,221.00 10,667,509.00 population (HNP) services (CRI, Number) People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) (CRI, 9,456,221.00 10,667,509.00 Number) Number of children immunized (CRI, Number) 3,343,939.00 3,944,000.00 Number of women and children who have received basic 2,871,128.00 3,158,240.00 nutrition services (CRI, Number) Number of deliveries attended by skilled health personnel 3,241,154.00 3,565,269.00 (CRI, Number) IO Table SPACE Page 9 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) Disbursement Linked Indicators Matrix DLI IN00951408 ACTION DLI 1: Increase of utilization of High Impact Reproductive, Child Health and Nutrition Interventions - DLI 1.1 States produce DLI 1 plans for achieving reductions in maternal, perinatal and under-5 mortalit Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Number 57,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Annual 37.00 57,000,000.00 DLI IN00951409 ACTION DLI 1: Increase of utilization of High Impact Reproductive, Child Health and Nutrition Interventions - DLI 1.2 Improvements DLI 2 on 6 key health indicators Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Percentage 232,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 273.60 Annual 284.00 232,000,000.00 Page 10 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) DLI IN00951410 ACTION DLI 1: Increase of utilization of High Impact Reproductive, Child Health and Nutrition Interventions - DLI 1.3 Lagging States DLI 3 strengthen their MNCH weeks as part of an impact evaluation Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Percentage 16,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Annual 21.00 16,000,000.00 DLI IN00951411 ACTION DLI 4 DLI 2: Increase of quality of High Impact Reproductive, Child Health and Nutrition Interventions Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Percentage 54,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 34.40 Annual 34.40 54,000,000.00 DLI IN00951412 ACTION DLI 5 DLI 3: Improvement of monitoring and evaluation systems and data utilization - DLI 3.1 Improving M&E Systems Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 35,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Page 11 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) Baseline Yes Annual Yes 35,000,000.00 DLI IN00951413 ACTION DLI 6 DLI 3: Improvement of monitoring and evaluation systems and data utilization - DLI 3.2 Improving Data Utilization Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process Yes Yes/No 27,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline No Annual Yes 27,000,000.00 DLI IN00951414 ACTION DLI 3: Improvement of monitoring and evaluation systems and data utilization - DLI 3.3 Implementing Performance DLI 7 Management in States Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process Yes Number 18,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Annual 37.00 18,000,000.00 Page 12 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) DLI IN00951415 ACTION DLI 4: Establishment and operation of the Innovation Fund designed to support private sector innovations aimed at DLI 8 increasing utilization and quality of maternal and child health interventions Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Yes/No 20,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline No Annual Yes 20,000,000.00 DLI IN00951416 ACTION DLI 5: Increase of transparency in management and budgeting of primary health care - DLI 5 (i) Number of States that have DLI 9 transferred health staff to entity responsible for PHC Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Number 18,500,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 4.00 Annual 37.00 18,500,000.00 Page 13 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) DLI IN00951417 ACTION DLI 5: Increase of transparency in management and budgeting of primary health care - DLI 5 (ii) Number of States that have DLI 10 produced and published a consolidated budget execution report Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Number 20,500,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Annual 24.00 20,500,000.00 DLI IN00951418 ACTION DLI 5: Increase of transparency in management and budgeting of primary health care - DLI 5 (iii) FGON publishes a DLI 11 consolidated budget execution report Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 2,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline No Annual Yes 2,000,000.00 Page 14 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) ANNEX 2: PROGRAM ACTION PLAN . . PAP_NOT_CHANGE_TBL Action Description Source DLI# Responsibility Timing Completion Measurement Prepare standardized template for financial reporting Annual reports on facility sources and pilot and roll- and uses of funds published out at facilities Other Client Due Date 28-Nov-2016 conspicuously at facility level. Publish annual consolidated PHC expenditure report for the state based on 3 economic classifications: compensation; Consolidated PHC expenditure goods & services; report published on state investments. Other DLI 10 Client Recurrent Yearly government website. Annual federal level budget execution report prepared at the economic (object) classification level for PHC sub- function (SOML- focused) Other DLI 11 Client Recurrent Yearly Federal budget excution report. PMU in the FMOH has at least 1 financial management staff that focus on SOML management, monitoring, and Staff with requisite skills are reporting. Other Client Recurrent Monthly working full time in the PMU. Internal audit units in FMOH assign internal auditors for ex- poste systemic and risk-based audits of the Program and report quarterly to permanent secretary, FMOH Other Client Recurrent Quarterly Quarterly internal audit reports. Page 15 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) after capacity strengthening in risk-based internal audits. Procurement plans for SOML related activities to be prepared by FMOH and approved by Minister or permanent Procurement plan with approval secretary, FMOH Other Client Recurrent Yearly by the appropriate authority. Capacity building on procurement procedures and contract management conducted Attendance sheet, increased use annually Other Client Recurrent Continuous of BPP standard templates. In accordance with 2007 Procurement Act an independent procurement audit will be conducted on random sample of at least 5% of transactions under the SOML program. Other Client Recurrent Continuous Procurement audit report. Fraud and corruption complaints redress - Formal policy and procedural Documented policy & guidance prepared procedures, with assigned and approved as applicable to the responsibilities and oversight. program Other Client Recurrent Continuous Strengthen capacity of ACTU network to deliver on mandate – assign full time Additional full-time staff assigned staff with to ACTU and resources budgeted mandate and in FMOH annual resources and budgets. Preventive measures to build on the risk be agreed on based on the assessment at the findings of the risk assessment. level of primary health centers led Other Client Recurrent Continuous Page 16 of 17 The World Bank Nigeria - Program to Support Saving One Million Lives (P146583) by the ICPC. Undertake an expenditure Completed report with tracking survey, recommendations about focusing on recording & reporting at the financial and facility commodity flows that are critical to level. SOML results Other Client Due Date 28-May-2016 Establish communication Plan to inform stakeholders on strategy for SOML PforR and the results stakeholder achieved. engagement Other Client Due Date 28-May-2016 Capacity building for FMOH staff and other health workers on health care waste management and equity issues. Other Client Recurrent Continuous Attendance sheets. Carry out annual Report on progress related to assessment of health care waste management progress on environmental and equity issues. and social issues. Other Client Recurrent Continuous Timely transfer of Financing proceeds to States through government processes for results achieved by the states under DLIs 1, 2, 3, These have been carried out and 5 Other Client Recurrent Continuous without delay. . Page 17 of 17