The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) REPORT NO.: RES46134 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF MALI - ACCELERATING PROGRESS TOWARDS UNIVERSAL HEALTH COVERAGE APPROVED ON MARCH 19, 2019 TO REPUBLIC OF MALI HEALTH, NUTRITION & POPULATION AFRICA WEST Regional Vice President: Ousmane Diagana Country Director: Soukeyna Kane Regional Director: Dena Ringold Practice Manager/Manager: Magnus Lindelow Task Team Leader(s): Jean Claude Taptue Fotso, Haidara Ousmane Diadie, Patrick Hoang-Vu Eozenou The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) ABBREVIATIONS AND ACRONYMS ANAM Agence Nationale d’Assistance Médicale (National Medical Assistance Agency) CHWs Community Health Workers CoD Cause of Death CRI Corporate Results Indicator CYP Couple-Year Protections DHIS2 District Health Information System 2 ECD Équipes Cadre de District (District Health Services) FA Financing Agreement GFF Global Financing Facility HMIS Health Management Information System HNP Health Nutrition and Population IDA International Development Association IP Implementation Progress ISR Implementation Status and Results Report MDTF Multi-Donor Trust Fund MOH Ministry of Health PBF Performance Based Financing PDO Project Development Objective PIU Project Implementation Unit RAMED Régime d’Assistance Médicale (Medical Assistance Plan) RETF Recipient Executed Trust Fund RMS Results Measurement System The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) BASIC DATA Product Information Project ID Financing Instrument P165534 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 19-Mar-2019 31-Dec-2023 Organizations Borrower Responsible Agency Republic of Mali Ministère de la Santé et du Développement Social Project Development Objective (PDO) Original PDO The objective of the project is to improve the utilization and quality of reproductive, maternal, neonatal, child, adolescent health and nutrition services, especially among the poorest households, in targeted areas. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-D4420 19-Mar-2019 31-May-2019 27-Dec-2019 31-Dec-2023 50.00 9.82 41.29 TF-B3548 31-May-2019 07-Jan-2021 07-Jan-2021 31-Dec-2023 7.32 .46 6.86 TF-A9738 19-Mar-2019 31-May-2019 27-Dec-2019 31-Dec-2023 10.00 2.00 8.00 The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING Project status The Project remains at an early stage of implementation. The political situation in Mali which resulted in triggering an OP 7.30 portfolio review and disbursement suspension between August and November 2020 has resulted in an accumulation of payment delays for performance incentives directed to health facilities, and to a suspension of some implementation activities such as the payment of PBF grants to health facilities. External factors outside the control of the Project resulted in important implementation delays and liquidity constraints faced by the Project Implementation Unit (PIU). As these delays have translated into lower disbursement rates compared to what was expected, and as they negatively affected the likelihood that the Project Development Objective (PDO) would be achieved, the Task Team proposed to downgrade the Progress towards achievement of PDO to Moderately Satisfactory (MS), and to downgrade the Overall Implementation Progress (IP) to Moderately Unsatisfactory (MU) (see latest ISR, seq. #4). Since November 24, 2020, the Bank has resumed its engagement with Mali, A Level 2 restructuring which was necessary to reflect the Netherland’s co-financing contribution was processed and signed on December 18, 2020. The resumption of activities, and the additional resources available to the Project have allowed the PIU to increase the pace of activity implementation,. Now that the World Bank has reengaged with the transitional Government of Mali, the Task Team is working closely with the PIU to catch up on the previous delays in activities and payments. Since December 2020 and the resumption of disbursements after the conclusion of the OP7.30 process, disbursements for IDA (GFF) have increased from 7.4 percent (8.3 percent) to 19.2 percent (14.2 percent), reflecting an increasing maturity of the PBF model. Rationale for restructuring There are two rationales for the proposed Level 2 restructuring: 1. Adjusting the disbursement ratios between the three sources of Project funding1 to reflect the full committed contribution of the co-financing from the Netherlands instead of basing the disbursement ratios on the individual tranches released. 2. Adjusting some indicator definitions and indicators targets in the Project’s Results Framework to better match the definitions used in the routine health management information system (HMIS). II. DESCRIPTION OF PROPOSED CHANGES 1 IDA, GFF TF, and MDTF with Netherlands contribution. The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) (1) Disbursement ratios adjustment In the amended Financing Agreement (FA) signed in December 2020, the disbursement ratio for component 1 of the project is based on the first tranche of co-financing from the Netherlands (USD 7.3 million), and not on the total RETF contribution (USD 30.4 million) committed by the Netherlands in the Administrative Agreement signed on November 2019 (Table 1). The disbursement schedule for eligible expenditure follows a pari passu ratio between the IDA Grant, the GFF Grant, and the MDTF. This proposed restructuring will change the disbursement ratio based on committed MDTF amount; the Grant amount in the Grant Agreement remains the same at present as the Bank has only received the first installment of the Donor’s contribution. Table 1: Current project disbursement structure for IDA, GFF, and MDTF The contributing donor has however indicated that the next co-financing installments would be released only after full expenditure commitment of the first co-financing installments. The current disbursement schedule with pari passu ratio established between IDA, GFF and the first tranche of co-financing is thus inconsistent with the disbursement schedule agreed on between the Bank and the Netherlands in their Administrative Agreement. The team thus proposes to adjust the disbursement ratios between the three sources of funding so as to establish the pari passu mechanism on the full co-financing amount committed by the Netherlands, and not on the first co- financing installment (see Table 2). Table 2: Revised project disbursement structure for IDA, GFF, and MDTF The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) (2) Revision of RF’s indicators definitions and targets Following a series of technical working sessions on the Project’s Results Framework with the PIU and with the MoH Directorate overseeing the health management information system (HMIS), the team would like to propose the following revisions to the results framework indicator definition and targets (see Table 3). Table 3: Revised RF indicator definitions Results Framework Proposed revision Note Indicator current definition PDO indicator 1-b Nombre d’enfants de Rationale : Nombre d’enfants < 5 moins de 5 ans qui ont Analog indicator to match the routine HMIS definition. ans complètement reçu tous les antigènes Immunisés jusqu’au VAR 2. [Number of children [Number of children immunized (CRI, who received all Number)] recommended antigens until the second dose of measles-containing vaccine (CRI, Number)] Since the indicator is a CRI, the proposed revision is a complement to the generic CRI definition in the results framework which will not be revised. PDO indicator 5 : Nombre de personnes Rationale : bénéficiaires du RAMED The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) Results Framework Proposed revision Note Indicator current definition Nombre de ménages recevant des soins The ANAM indicator is defined at individual level and not at household bénéficiaires du gratuits pour des level. RAMED recevant des services de santé soins gratuits pour des essentiels. 2019 2020 2021 2022 2023 services de santé hh 35 40 50 55 60 essentiels. [Number of RAMED ind 50 75 100 125 150 [Number of RAMED beneficiary individuals ratio 1.43 1.88 2.00 2.27 2.50 beneficiary receiving free care for households receiving essential health free care for essential services. (Number)] health services. (Number)] Target schedule revision : Year 1 (2019): 50k instead of 35k Year 2 (2020): 75k instead of 40k Year 3 (2021): 100k instead of 50k Year 4 (2022): 125k instead of 55k Endline (2023): 150k instead of 60k Intermediary Indicator Nombre de ménages Rationale : The HMIS definition uses the term “visite à domicile” and C2-11: recevant des visites à not “visite proactive”. Nombre de ménages domicile de l’Agent de recevant des visites Santé Communautaire proactives des ASC. (ASC). [Number of [Number of households households receiving receiving CHW home proactive CHW visits. visits. (Number (Number (Thousand))] (Thousand))] Intermediary Indicator Pourcentage de cas Rationale : The measurement of 24h timespan between diagnostic C2-12: confirmé de paludisme and treatment is not feasible in the current information system. Pourcentage d'enfants simple chez les enfants de moins de 5 ans de moins de 5 ans ayant atteints de paludisme reçu un traitement confirmé qui ont reçu conforme aux normes un traitement de prise en charge antipaludique dans nationales. les 24 heures suivant The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) Results Framework Proposed revision Note Indicator current definition l'apparition des [Percentage of children symptômes. under 5 with confirmed malaria who received [Percentage of an appropriate children under 5 with antimalarial treatment. confirmed malaria (Percentage)] who received antimalarial treatment within 24 hours of symptom onset. (Percentage)] Intermediary Indicator Taux de promptitude Rationale : C2-15: des Rapports Mensuels Analog indicator to match the routine HMIS definition. Taux d'achèvement (de d’Activités du premier complétude) des échelon des formations formations sanitaires sanitaires Rapports du DHIS2 [Completion rate of [Timely completion rate health facilities DHIS2 of monthly primary reports. (Number care health facilities (Thousand))] DHIS2 reports. (Number (Thousand))] Intermediary Indicator Taux de réalisation des Rationale : C2-16: audits de décès peri et Analog indicator to match the routine HMIS definition. Pourcentage de décès néonataux. maternels et infantiles avec cause de décès déterminée [Percentage of perinatal and neonatal [Percentage of deaths with maternal and child determined cause of deaths with death (CoD). determined cause of (Percentage)] death (CoD). (Percentage)] The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Other Change(s) ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ PBCs ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) . The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) . Results framework COUNTRY: Mali Mali - Accelerating Progress Towards Universal Health Coverage Project Development Objectives(s) The objective of the project is to improve the utilization and quality of reproductive, maternal, neonatal, child, adolescent health and nutrition services, especially among the poorest households, in targeted areas. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Increased utilization of maternal, child, neonatal, and adolescent services People who have received essential health, nutrition, and 0.00 530,000.00 1,330,000.00 2,170,000.00 3,000,000.00 3,300,000.00 population (HNP) services (CRI, Number) People who have received essential health, nutrition, and population (HNP) 0.00 120,000.00 300,000.00 480,000.00 670,000.00 710,000.00 services - Female (RMS requirement) (CRI, Number) Number of children 0.00 100,000.00 170,000.00 210,000.00 230,000.00 250,000.00 immunized (CRI, Number) Rationale: Action: This indicator has Number of children who received all recommended antigens until the second dose of measles-containing vaccine (CRI, Number). been Revised Analog indicator to match the routine HMIS definition. Number of women and 0.00 700,000.00 1,000,000.00 1,265,000.00 1,330,000.00 1,400,000.00 children who have received The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 basic nutrition services (CRI, Number) Number of deliveries attended by skilled health 0.00 130,000.00 170,000.00 190,000.00 205,000.00 225,000.00 personnel (CRI, Number) Percentage of girls, aged 15-19, who are currently using any 5.80 9.00 12.00 15.00 18.00 20.00 method of contraception. (Percentage) Improve the quality of health services in targeted areas. Percentage of pregnant women receiving at least 4 13.30 15.00 18.00 21.00 23.00 25.00 antenatal care visits from health provider (Percentage) Average score of the quality of 0.00 70.00 care checklist (Percentage) Increased utilization of essential health services among the poorest households. Number of RAMED beneficiary individuals receiving free care 30,000.00 50,000.00 75,000.00 100,000.00 125,000.00 150,000.00 for essential health services. (Number) Rationale: Action: This indicator has been The ANAM indicator is defined at individual level and not at household level. Revised PDO Table SPACE The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Strengthening Health Service Delivery through Performance Based Financing at Facility Level Health facilities receiving PBF 0.00 30.00 50.00 65.00 75.00 80.00 grants on time. (Percentage) Percentage of new curative consultations per capita/year. 0.20 0.22 0.25 0.30 0.35 0.40 (Percentage) Percentage of facilities with 100% tracer drugs available in 0.00 20.00 25.00 30.00 35.00 40.00 targeted health facilities on the day of the visit. (Percentage) Percentage of health facilities benefiting from quarterly technical supervision visits by 50.00 55.00 60.00 70.00 75.00 80.00 district health services (ECD). (Percentage) Number of CHWs benefiting from dedicated supervision. 0.00 500.00 1,000.00 2,000.00 2,500.00 3,000.00 (Number) Percentage of beneficiaries satisfied with quality of 0.00 35.00 45.00 55.00 65.00 75.00 services provided in health facilities (Percentage) Strengthening Community Health Activities Number of households receiving CHW home visits. 0.00 150.00 350.00 500.00 650.00 750.00 (Number (Thousand)) The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Rationale: Action: This indicator has been The HMIS definition uses the term “visite à domicile” and not “visite proactive”. Revised Percentage of children under 5 with confirmed malaria who received an appropriate 0.00 20.00 35.00 50.00 60.00 70.00 antimalarial treatment. (Percentage) Rationale: Action: This indicator has been The measurement of 24h timespan between diagnostic and treatment is not feasible in the current information system. Revised Number of Couple-Year Protections (CYP) reached 0.00 200.00 400.00 600.00 800.00 1,000.00 through project interventions. (Number (Thousand)) Percentage of children aged 6- 59 months screened by community health workers for 50.00 55.00 60.00 75.00 85.00 90.00 acute malnutrition. (Percentage) Institutional strengthening for improved stewardship and health system performance Timely completion rate of monthly primary care health 50.00 60.00 70.00 80.00 85.00 90.00 facilities DHIS2 reports. (Number (Thousand)) Action: This indicator has been Rationale: Revised Analog indicator to match the routine HMIS definition. The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Percentage of perinatal and neonatal deaths with 0.00 10.00 20.00 30.00 40.00 50.00 determined cause of death (CoD). (Percentage) Rationale: Action: This indicator has been Analog indicator to match the routine HMIS definition. Revised Number of private health facilities assessed for 0.00 30.00 75.00 120.00 180.00 250.00 accreditation by MoH. (Number) Percentage of health facilities producing annual micro-plans 0.00 25.00 50.00 75.00 85.00 95.00 validated by district health services (ECD). (Percentage) IO Table SPACE The World Bank Mali - Accelerating Progress Towards Universal Health Coverage (P165534)