The World Bank Health System Support (P156165) REPORT NO.: RES35761 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SYSTEM SUPPORT (INAYA) APPROVED ON MAY 19, 2017 TO ISLAMIC REPUBLIC OF MAURITANIA HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Hafez M. H. Ghanem Country Director: Nathan M. Belete Senior Global Practice Director: Muhammad Ali Pate Practice Manager/Manager: Gaston Sorgho Task Team Leader: Christophe Rockmore, Moussa Dieng The World Bank Health System Support (P156165) ABBREVIATIONS AND ACRONYMS AF Additional Financing CCT Conditional Cash Transfer CHW Community Health Worker DAF Direction of Finance and Administration HMIS Health management information system IDA International Development Association MoH Ministry of Health INAYA Health System Support Project IRI Intermediate Results Indicator PDO Project Development Objective PBF Performance-based Financing RMNCH Reproductive, Maternal, Neonatal and Child Health RBF Results-based Financing The World Bank Health System Support (P156165) BASIC DATA Product Information Project ID Financing Instrument P156165 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 19-May-2017 30-Jun-2021 Organizations Borrower Responsible Agency Islamic Republic of Mauritania Ministry of Health Project Development Objective (PDO) Original PDO The Project Development Objective is to improve utilization and quality of Reproductive Maternal Neonatal and Child Health (RMNCH) services in selected regions, and, in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-D1890 19-May-2017 16-Jun-2017 15-Nov-2017 30-Jun-2021 17.00 3.07 14.30 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Health System Support (P156165) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Project summary 1. The Health Systems Support Project (INAYA) is a USD 19 million operation, including USD 17 million IDA grant funds and 2 million in counterpart financing from the Government of the Islamic Republic of Mauritania. INAYA became effective in November 2017. The PDO is to improve utilization and quality of RMNCH services in selected regions. Through INAYA, the government is developing its strategy for a results-based system to finance the delivery of quality health services, focusing initially on a pilot in two regions (wilaya): Guidimagha and Hodh El Gharbi. 2. The March 2019 supervision mission conducted a complete review of the implementation and results of INAYA, in view of expanding the INAYA activities to the Hodh El Charghi region through a possible additional financing (AF; P170585). This review provides the basis for the proposed restructuring. B. Project status 3. Project implementation is Moderately Satisfactory. Project disbursement is 18 percent and has rapidly increased; the disbursement for the first four months of 2019 is already about 50 percent above the total disbursements for the 2018 calendar year. The operation had a slow start, given the heavy upfront need to build capacity of the Ministry of Health (MoH) to manage the performance-based financing (PBF). However, the results from the first quarter rollout of the PBF show progress toward the PDO is on-track. The results show an increasing utilization of services in the first quarter of 2019: women receiving four pre-natal care visits and children receiving consultations in health facilities reached almost 50 percent of the 2018 achievement in the first quarter. In total, about 150,000 people used primary health services in health centers and health posts in Guidimagha and Hodh El Gharbi in the first quarter of 2019. The score of the quality of services in health facilities and the percent of facilities with basic equipment should increase by the end of 2019, with the allocation of quality bonuses to facilities and the execution of the investment grants for equipment, latrines and other improvements. 4. The below provide a summary of progress by component: (a) Component 1: Improving the utilization of quality RMNCH services through PBF (US$10.5 million: US$9.5 million IDA; US$1 million counterpart funding). The first PBF cycle (January to March 2019) successfully paid incentives to hospitals and health facilities. The PBF activities for community health workers (CHWs) will start in the third PBF cycle (July to September 2019). (b) Component 2: Increasing the demand for health services (US$2.5 million). The project is supporting Conditional Cash Transfers (CCT) to poor families through the Tekavoul program. The first CCT will be paid by September 2019. The project will also support health communication activities to implement the Community Health Strategy, focused on rural populations not covered by health services, as well as poor populations in the Tekavoul program. (c) Component 3: Capacity Building and Project Management (US$6 million: US$5 million IDA; US$1 million counterpart funding). This includes support for project management and to reinforce the results-based systems of the MoH, including training on PBF, data collection, and strengthening of the health management information system (HMIS) and the Direction of Finance and Administration (DAF). C. Rationale for restructuring 5. The restructuring proposes the following revisions to improve implementation and results of INAYA: (a) Creation of new categories to simplify disbursement arrangements and reallocation of funds from categories where savings have been identified to categories where more funding is needed. The World Bank Health System Support (P156165) II. DESCRIPTION OF PROPOSED CHANGES D. Reallocation between disbursements categories 6. The restructuring proposes the following changes to amend the disbursement table in the INAYA Financing Agreement. More specifically the restructuring proposes to: (a) Create one Category 8 that supports the PBF payments to health facilities and community actors; i. Reallocate undisbursed funds from Category 2 to Category 8 (see details in table IV); ii. Reallocate undisbursed funds from Category 3 to Category 8 (see details in table IV); iii. Reallocate US$ 0.6 million (435,668 SDR)1 of IDA financing from Category 1 to Category 8. (b) Reallocate US$1.4 million (1,016,558 SDR) of IDA financing from Category 1 to Category 4 to support the PBF bonus payment to actors involved in implementation at all levels. (c) Create a new Category 7 in place of Category 1. Category 1 requires 74 percent IDA and 26 percent counterpart funding for each disbursement. Category 7 separates IDA and counterpart categories to facilitate INAYA’s disbursement, as 26 percent of an expenditure is not easily managed by the Government budgetary system. Experience to date shows that the requirement to pay a proportion from each has been difficult and it has slowed overall progress. 7. The revised disbursement table for the INAYA financing agreement is shown in Table 1. Table 1: Revised disbursement table Percentage of Amount of the financing expenditures to Category allocated (expressed in be financed SDR) (inclusive of Taxes) (1) Goods, works, non-consulting services, Training, Operating Costs, and consulting services for Parts A (except 733,416.00 74% Part A.1.a, A.1.b, and Part A.2.b), B (except Part B.1.a(ii)), and C of the Project (2) PBF payments and small investment grants under Part 473,321.00 100% A.1.a of the Project (3) PBF payments Part A.1.b of the Project 0 100% 1 US1$ = 0.726113, May 21, 2019 IMF The World Bank Health System Support (P156165) (4) Performance bonuses to RBF implementing bodies under 1,384,560.00 100% Part A.2.b of the Project (5) Conditional Cash Transfers under Part B.1.a(ii) of the 1,100,000.00 100% Project (6) Emergency Expenditures under Part D of the Project 0 100% (7) Goods, works, non-consulting services, Training, Operating Costs, and consulting services for Parts A (except 2,014,353.00 100% Part A.1.a, A.1.b, and Part A.2.b), B (except Part B.1.a(ii)), and C of the Project (8) PBF payments and small investment grants under Part 6,894,350.00 100% A.1.a and Part A.1.b of the Project Total amount 12,600,000 III. SUMMARY OF CHANGES Changed Not Changed Reallocation between Disbursement Categories ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ The World Bank Health System Support (P156165) Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-D1890-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: GD,WK,NCS,TR,OC & CS - Pt A,B & C 4,200,000.00 733,415.49 733,416.00 74.00 74 iLap Category Sequence No: 2 Current Expenditure Category: PBF pymts & small invstmt - Pt A1a of the Project 6,195,000.00 473,320.07 473,321.00 100.00 100.00 iLap Category Sequence No: 3 Current Expenditure Category: Closed 737,000.00 0.00 0.00 100.00 0 iLap Category Sequence No: 4 Current Expenditure Category: Per. bonuses to RBF bodies-Pt A2b 368,000.00 285,548.66 1,384,560.00 100.00 100.00 iLap Category Sequence No: 5 Current Expenditure Category: Cond. Cash Transfers - Pt B1a(ii) The World Bank Health System Support (P156165) 1,100,000.00 0.00 1,100,000.00 100.00 100.00 iLap Category Sequence No: 6 Current Expenditure Category: Emergency Expenditures - Pt D 0.00 0.00 0.00 100.00 100.00 iLap Category Sequence No: 7 Current Expenditure Category: GD,WK,NCS,TR,OC & CS - Pt A,B & C 0.00 0.00 2,014,353.00 100 iLap Category Sequence No: 8 Current Expenditure Category: PBF pymts & small invstmt - Pt A1a and Pt A1b 0.00 0.00 6,894,350.00 100 Total 12,600,000.00 1,492,284.22 12,600,000.00 .