The World Bank Senegal Health & Nutrition Financing (P129472) REPORT NO.: RES30619 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF SENEGAL HEALTH & NUTRITION FINANCING APPROVED ON DECEMBER 11, 2013 TO GOVERNMENT OF SENEGAL HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Makhtar Diop Country Director: Louise J. Cord Senior Global Practice Director: Timothy Grant Evans Practice Manager/Manager: Gaston Sorgho Task Team Leader: Maud Juquois The World Bank Senegal Health & Nutrition Financing (P129472) ABBREVIATIONS AND ACRONYMS ACMU Universal Health Insurance Agency (Agence pour la Couverture Maladie Universelle) ANSD National Statistics and Demography Agency (Agence Nationale de Statistiques et Démographie CBHI Community-Based Health Insurance CLM Unit Against Malnutrition (Cellule de Lutte contre la Malnutrition) CMU Universal Health Insurance (Couverture Maladie Universelle) DAGE Fiduciary Unit MoH (Direction de l’Aménagement et de la Gestion des Equipements) DSME Maternal and Child Health unit at MoH (Direction de la Santé de la mère et de l'enfant) GFF Global Financing Facility HNFP Health and Nutrition Financing Project HR Human Resources HRBF Health Results-Based Financing HRITF Health Results and Innovation Trust Fund IC Investment Case IDA International Development Association ISR Interim Status Report IVAs Independent Verification Agencies M&E Monitoring and Evaluation MDTF Multi-Donors Trust Fund MoHSA Ministry of Health and Social Action MTR Mid-Term Review PDO Project Development Objective PNBSF National Family Safety Net Program (Programme National de Bourses de Sécurité Familiale) PNFBR National Results-Based Financing Program (Programme National du Financement Basé sur les Résultats) RBF Results-Based Financing RMNCAH+N Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition TF Trust Fund UHC Universal Health Coverage The World Bank Senegal Health & Nutrition Financing (P129472) BASIC DATA Product Information Project ID Financing Instrument P129472 Investment Project Financing Original EA Category Current EA Category Not Required (C) Not Required (C) Approval Date Current Closing Date 11-Dec-2013 29-Jun-2018 Organizations Borrower Responsible Agency Government of Senegal Ministry of Health and Prevention Project Development Objective (PDO) Original PDO The objective of the project is to increase utilization and quality of maternal, neonatal and child health and nutritional services, especially among the poorest households in Targeted Areas in the Recipient's territory. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-53240 11-Dec-2013 28-Mar-2014 14-May-2014 29-Jun-2018 20.00 9.72 9.07 TF-A0565 28-Jan-2016 28-Jan-2016 28-Jan-2016 31-Dec-2016 .83 .78 .04 TF-16618 17-Dec-2014 17-Dec-2014 17-Dec-2014 31-Mar-2016 .19 .19 0 TF-15872 28-Mar-2014 28-Mar-2014 29-May-2014 29-Jun-2018 20.00 5.15 14.85 The World Bank Senegal Health & Nutrition Financing (P129472) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Introduction The Health and Nutrition Financing Project (HNFP) has been under implementation for almost four years (effective since May 2014) and its Project Development Objective is “to increase utilization and quality of maternal, neonatal and child health and nutritional services, especially among the poorest households in targeted areas of Senegal.” The project targets six of the most underserved regions in Senegal: Kaffrine, Kolda, Tambacounda, Kedougou, Sedhiou and Ziguinchor. Through three components, the project is supporting several aspects of the Senegal Universal Health Coverage (UHC) strategy:  Component 1. Strengthening the supply-side of health system through Results-Based Financing for Health and Nutrition Services (US$$20. 8 million). This component supports the improvement of health and nutrition service delivery in Senegal in six selected regions, using a Results-Based Financing (RBF) mechanism.  Component 2. Demand side interventions for improving accessibility of health care services (US$14 million). This component supports several mechanisms whose main purpose is to subsidize demand for healthcare and nutrition services. These mechanisms are: (i) the Universal Health Insurance Scheme (i.e. Couverture Maladie Universelle or CMU); (ii) the national program for improving demand for nutrition services; and (iii) the maternal health vouchers.  Component 3. Strengthening capacities for better monitoring and evaluation, supervision, and Project Implementation (US$6 million). This component supports activities to increase the capacity of and reliance on national health systems. It is implemented nationwide and includes among others: capacity building for better regulation of the hospital sector, capacity building for better M&E of the overall health system (support to the National Statistical Agency, i.e. ANSD, for its “Senegal continuous survey”), and capacity building for better general and financial management within the health system. The HNFP is funded with three sources: (i) an IDA credit (US$20 million equivalent); (ii) an MDTF TF (Health Results and Innovation Trust Fund-HRITF, US$20 million); and (iii) the HRBF TF (Health Results Based Financing-USAID, initially US$2.3 million, but only the first tranche of US$ 0.8 million was disbursed before closing of the Grant in December 2016). The HNFP was restructured on April 2016 to strengthen institutional capacity and implementation arrangements as well as to increase disbursement and the ultimate impact of the Project (changes included mainly: revision of Component 3 description to reflect activities related to institutional strengthening for Ebola preparedness; Creation of two sub-accounts to improve project implementation for the CLM (Cellule de Lutte contre la Malnutrition) and for ANSD (Agence Nationale The World Bank Senegal Health & Nutrition Financing (P129472) de Statistiques et Démographie); and change in disbursement arrangements (creation of specific disbursement categories for the HRBF TF funded through a USAID grant) in order to facilitate its disbursements. B. Overall implementation progress and progress towards PDO Overall Implementation Progress remains rated as Moderately Unsatisfactorily (ISR January 2018) despite the significant progress made since July 2017; This is because the performance of the project still needs to be strengthened, especially under component 1 (Results-Based Financing), and recent improvement in financial management, facilitating implementation of Project ‘s interventions, needs to continue. Disbursements have increased from 25% (32% IDA and 18% TF) in June 2017 to 40% (52% IDA and 29% TF) in April 2018. Implementation of Components 2 (Demand side interventions for improving accessibility of health care services) and 3 (Strengthening capacities for better monitoring and evaluation, supervision, and Project Implementation) is ongoing, as planned, but there were some initial delays and some fiduciary constraints. However, the main delays which have affected project implementation are related to two critical issues which are currently being addressed: - Implementation of the supply-side Results-Based Financing intervention (Component 1). The HNFP funds were to continue financing the RBF approach in the 2 pilot regions (Kolda and Kaffrine, RBF pilot funded in 2012 and 2013 by USAID) and extend it to four of the most vulnerable regions: Tambacounda, Sédhiou, Kédougou and Ziguinchor (out of the 14 regions of Senegal), building on the existing scheme. One of the key requirements for the RBF approach to work was the recruitment of two Independent Verification Agencies (IVAs). The procurement process to recruit the IVAs was significantly delayed, with contracts finally signed only in January 2016; thus the first verification happened in May 2016 and the first payments in October 2016. Also, the Mid-Term review of the Project (February and May 2017) highlighted several issues with the implementation of the RBF approach, including: lack of national capacities for RBF and reactivity of the National RBF Program unit in the Ministry of Health (PNFBR) to improve the approach; design issues that were still not addressed by the MoH and significant delays. Thus, in June 2017, a 3-months accelerated roadmap for RBF was agreed between the WB team and the Ministry of Health, with a focus on making changes in the technical and operational RBF approach in order to strengthen its impact, such as paying per number of services instead of percentage coverage, clarifying the functions between regulation, purchasing, verification. This included the revision of the RBF Manual and capacity strengthening of staff of the National RBF program. The RBF model in Senegal needed to be revised to achieve the expected results and strengthen the health system, accordingly with global evidence and good practices. However, the new approach still needs to be implemented and to demonstrate results, with a strong leadership from the Ministry of Health. - Financial management and disbursements. There is no outstanding audit report. After almost four years of implementation, disbursements are still low, reflecting implementation delays and not responding to the needs of the project main stakeholders (especially Cellule de Lutte contre la Malnutrition-CLM, Agence pour la Couverture Maladie Universelle-ACMU, Agence Nationale de Statistique Demographique-ANSD …). The reasons for the delays include ineffective cash flow and fiduciary issues. Financial aspects of the project are managed by the DAGE (fiduciary unit of MoH) and capacities were insufficient and the workload significant. Thus, during the second semester of 2017, several measures were taken to address these issues: additional staff within the project have been recruited to support the financial management workload, a training on disbursements has been conducted by colleagues from the disbursements unit, the ceiling of the Designated Account has been increased, and the Bank team is working closely with the Project coordination to ensure smoother disbursements. These two issues have impacted progress in achieving the PDO as some of the indicators of the Results Framework are linked to the RBF (such as Proportion of pregnant women having 4 antenatal care visits and assisted deliveries). Good v The World Bank Senegal Health & Nutrition Financing (P129472) progress on other indicators (New acceptors of modern contraceptive method and severe malnourished detected children who are referred and received at the health center for all necessary visits) are due to interventions implemented by the DSME (Direction de la Santé de la mère et de l'enfant) and CLM (Cellule de Lutte contre la Malnutrition), funded also through the Project. C. Rationale for restructuring Considering the different issues related to the overall implementation progress and delays at the start of the Project, the objective of this restructuring is to ensure achievement of the Project Development Objective by: (i) reallocating funds between components and adding new interventions (supporting directly the PDO), (ii) revising the Results Framework, (iii) changing disbursements categories (due to the closing of the HRBF TF); and (iv) extending the Closing Date by one year to enable the completion of project activities. Performance of the Project following this restructuring is also crucial for the approval of a new IDA-GFF TF operation in the health sector in Senegal. Thus, as part of reallocation between components and addition of new interventions, this restructuring is integrating the results of the significant analytical work conducted by the Government of Senegal, with support from the World Bank, the Global Financing Facility (GFF) Secretariat and other partners, with the finalization of the Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition (RMNCAH+N) Investment Case (IC). Based on the bottleneck analysis conducted by the GFF platform, the Investment Case focuses on the following five key priority areas: 1) Provision of a high-impact RMNCAH package; 2) Enhanced financial access to and socio-cultural acceptability of the RMNCAH package through demand side financing; 3) Improve adolescent health through multi-sectoral approaches; 4) Strengthening supply-side of the health system by scaling up high-impact human resource and supply chain interventions to address low RMNCAH service coverage; and 5) Strengthening health system governance. The Senegal IC targets five priority regions based on a composite index comprised of the following indicators: poverty rate, neonatal mortality, under five mortality, assisted delivery, contraceptive prevalence, proportion of adolescents with active sexual life and ANC coverage. The regions in the South, e.g., Sedhiou, Kolda, Tambacounda, Kedougou and Kaffrine have the lowest index (five of the six regions targeted by the Health and Nutrition Financing Project). Consequently, new interventions included through this restructuring derive from the prioritized and evidence-based GFF Investment Case, especially to complement the RBF intervention to improve the supply-side of health system (pharmaceutical, human resources for health, maternal health, priority 3 of the GFF IC). II. DESCRIPTION OF PROPOSED CHANGES The World Bank received a request from the Government of Senegal on March 28th, 2018 to restructure the Project on the five following aspects: 1- Reallocation of funds between components and addition of new activities; 2- Modification of the results framework; 3- Changes in the disbursements categories; 4- Change in disbursements estimates; and vi The World Bank Senegal Health & Nutrition Financing (P129472) 5- Extension of closing date from June 29, 2018 to June 28, 2019. 1- Reallocation of funds between components and addition of new activities The proposed reallocation of funds between components is based on the following principle: transfer of funds to components/interventions with demonstrated absorption capacity. In addition, a portion of the funding of the RBF component 1 (MDTF TF), which has made little disbursement, will be reallocated to priority interventions identified in the GFF Investment Case (US$ 5.1 million). Component 1. Strengthening the supply-side of health system through Results-Based Financing for Health and Nutrition Services Considering delays and issues to implement the RBF approach, some funds (US$ 5.1 million1) will be reallocated from this component to components two and three. With allocated amounts for sub components 1.1 and 1.2, the revised RBF approach will be implemented in 2018 (RBF contracts until end of December 2018) in the same targeted regions. A new sub-component (US$ 1 million) has been added to complementarily support the strengthening of service delivery: sub- component 1.3 “Improving quality of health services (drugs, HR, maternal and child health)”. This sub-component will provide funding for interventions of the GFF Investment Case related to Priority 4 (“Strengthening the Pillars of RMNACH supply-side) with quality human resources, availability of drugs and quality service delivery). Activities to be funded are the following: transition to scale of the pilot Itinerant Midwives' strategy, support for the revision of the Human Resources for Health National Strategy, support mechanisms for quality control of drugs, procurement of obstetrical and maternal health equipment, RMNACH training of health workers and community health workers, and strengthening the geographical accessibility of essential medicines and supply-chain through supporting the transition of Yeksina Strategy to the National Pharmaceutical Agency (from the Informed-Pushed Model project support information system and contracting of private operators for last mile delivery). Component 2. Demand side interventions for improving accessibility of health care services Amount allocated to component 2 will increase from US$ 14 million to US$15.6 million. Subcomponent 2.1. Although the amount (US$ 7 million) is not changing, activities to be financed are slightly updated from what was originally planned, taken into account the evolution of the Universal Health Insurance in Senegal and the GFF investment case. Activities to be funded are still related to establishing and implementing the universal health insurance system (communication, technical assistance, comprehensive and integrated information system, training, etc..) but also supporting innovative strategies to strengthen the efficiency of the system and its equity. The ACMU will set up pilot interventions to better address the management of free health care for children under 5 and support enrollment of beneficiaries of the National Family Safety Net Program (Programme National de Bourses de Sécurité Familiale- PNBSF) through the Community-Based Health Insurance (CBHI) system. Amounts allocated for these pilot interventions and transfer of funds to CBHIs is US$500,000. A CBHI Manual describing the procedures for the transfer of funds from the Project to the CBHIs and modalities of control is being finalized by the ACMU. Also, the activity related to the scale-up of the National Unified Registry, through the provision of technical assistance, training and equipment to MoH, is removed under this sub-component: indeed, this activity was proposed during preparation of the project, but soon after 1 An additional US $ 1.5 million is decreased from this component due to the decreased amount from USAID grand: indeed, out of the US$2.3 million initially planned from this Grant, only the first tranche (US$ 0.8 million) was disbursed at closing of the HRBF TF (after extension). vii The World Bank Senegal Health & Nutrition Financing (P129472) effectiveness, the responsibility to carry out the scale-up of the National Unified Registry was given to another institution and this activity is now supported by a Social Protection Project supported by the Bank. Sub-component 2.2. Interventions of the CLM (community nutrition) remain the same but with an increased amount (from US$5 to US$6.3 million) to continue the interventions during the one year extension of the Project. Community nutrition interventions are key to achieve the overall Senegal objective to decrease stunting and the CLM has strong implementation capacities (two-third of their envelope already disbursed). No change has been introduced to sub-component 2.3 related to demand-side RBF (maternal health vouchers) to improve access for the poorest pregnant women to antenatal care and assisted deliveries. Finally, a sub-component 2.4 related to promoting adolescent health (one of the five priorities of the GFF Investment Case) is being added (US$ 300,000). Activities under this new sub-component include behavioral change interventions, communication strategies to support demand for health services, especially reproductive health services for adolescent. Component 3. Strengthening capacities for better monitoring and evaluation, supervision, and Project Implementation The amount allocated to this component will increase from US$ 6 million to US$ 9.5 million. Considering implementation delays different activities of the Hospital Directorate (component 3.1 about regulation of the hospital sector), the amount has been decreased from US$3 million to US$1.2 million). Indeed, with delays to launch and finalized the Hospital Information System feasibility study, procurement of IT equipment and some trainings will not be implemented. No change has been introduced to sub-component 2.3 related to capacity building for monitoring and evaluation of the overall health system (surveys conducted by the ANSD). Amount under sub-component 3.3 “ Capacity building for better general and financial management within the health system” is being increased from US$1 million to US$5.5 million to finance major procurement for equipment of the different implementing entities, and also the different capacity building interventions for maternal health directorate, planning directorate and it also include costs of the coordination of the Project (which has increased due to the need to strengthen the fiduciary capacities). Sub-component 3.4 “Support to health financing reforms” is being introduced reflecting the adoption in June 2017 of the Health Financing Strategy, also as part of the GFF process in Senegal. Under this new sub-component, studies, training and dissemination will be funded (such as on domestic resources mobilization, strategic purchasing mechanisms, the role of public-private partnership, etc.). Finally, it should be noted that the total amount of the project is now US$ 40.8 million while at approval it was US$ 42.3 million. Indeed, initially the HRBF TF (USAID funded) was US$ 2.3 million with two tranches, the first one of US$ 828,000. The Grant Agreement for this TF was signed only in January 2016 and by the closing of the Grant (December 2016), only the first tranche was disbursed and it was not possible for USAID to extend it further. Delays to disburse this TF were due to the implementation delays of the RBF program as this TF was contributed to finance this component of the Project. The table below summarizes the reallocations between components and the new sub-components: Table 1: Reallocation between components in $US million viii The World Bank Senegal Health & Nutrition Financing (P129472) Initial Restructured Components allocation allocation Component 1: Result-Based Financing for health and nutrition services and capacity building 22.3 15.7 1.1. Financing of Result Based Financing 14.4 9.2 1.2 : Building capacities for RBF extension 7.9 5.5 1.3. Improving quality of health services (drugs, HR, maternal and child health) – (new) 1 Component 2: Improvement of accessibility to maternal, nutrition, and children health 14 15.6 services 2.1 Support to the implementation of the Universal Health Insurance 7 7 scheme 2.2 Strengthening demand for nutrition services and behavior change 5 6.3 2.3 Setting up demand-side RBF (i.e. maternal health vouchers) to improve access to health care 2 2 2.4 Adolescent health - (new) 0.3 Component 3: Institutional strengthening and project implementation 6 9.5 3.1 Capacity building for better regulation of the hospital sector 3 1.2 3.2 Capacity building for better M&E of the overall health system 2 2 3.3 Capacity building for better general and financial management within the health system 1 5.5 3.4 Support to health financing reforms - (new) 0.8 TOTAL 42.3 40.8 NB: Total amount of the Project decreased from US $42.3 to US $ 40.8 million because the allocation from the HRBF TF was finally US$ 0.8 million and not US $ 2.3 million at closing in December 2016 of this TF (as detailed in the first section of this restructuring paper0. 2- Modification of the Results Framework The PDO remains the same and the Results Framework is modified to adjust indicators to available information, modify targets to reflect the one-year extension to June 2019, and take into account the new activities funded by the Project. The detailed changes are outlined in the table below. PDO INDICATORS Indicator Proposed changes 1. Number of project beneficiaries identified as poor The definition of the indicator was clarified and changed from a percentage to a cumulative value 2. New acceptors of modern contraceptive method No change in the indicator definition. As the target was achieved, a new higher target was identified for 2019 3. Births (deliveries) attended by skilled health No Change. personnel (number) The initial end target was maintained for 2019 4. Percentage of pregnant women having 4 No change in the indicator definition. antenatal care visits (at standard quality) A new lower target was identified for 2019. The baseline identified in the PAD (50%) was incorrect 5. Severely malnourished detected children who are The definition of the indicator was changed to reflect available data: the referred the health center for all necessary visits percentage is replaced by a cumulative number. A new lower target was identified for 2019 ix The World Bank Senegal Health & Nutrition Financing (P129472) 6. Index of quality of health care (percentage) No change in the indicator definition. As the target was achieved, a new higher target was identified for 2019 INTERMEDIATE OUTCOME INDICATORS Indicator Changes 1. Number of health facilities that have an RBF No change in the definition of the indicator. contract A new lower target was identified for 2019 2. Percentage of facilities with verified results and The definition was clarified to include more stringent conditions from having received their payments (%) the manual and as a result a new lower target was identified for 2019 3. Pregnant women receiving antenatal care during No change. a visit to a health provider (cumulative number) The initial end target was maintained for 2019 Direct project beneficiaries (number), The indicator was deleted as it is not a core indicator anymore and is of which female (percentage) (IDA redundant with the new corporate results indicator for health Core Indicator) 4. People who have received essential health, The definition of the indicator was updated and replaced by the new nutrition, and population (HNP) services (Corporate corporate indicator definition indicator) 4. a. People who have received essential health, New indicator, included as part of the definition of the corporate results nutrition, and population (HNP) services - Female indicator (RMS requirement) No change. 4.b. Number of children immunized The initial end target was maintained for 2019 4. c. Number of women and children who have The definition was clarified to reflect available data. received basic nutrition services New higher targets were identified for 2019 5. Children aged 0-23 months who attended at least The definition of the indicator was clarified to reflect available data. The one growth monitoring and promotion service indicator was changed from a percentage to a cumulative number. during the 3 precedent months New higher targets identified for 2019 The definition was revised to reflect more reliable data on the number 6. Number of maternal health vouchers distributed of allocations distributed. New lower targets identified for 2019 7. Percentage of eligible women that have received No change in the definition of the indicator. a maternal health financial incentive New lower targets were identified for 2019 8. Health personnel receiving training (number) No Change 9. Number of hospitals where the cost accounting No Change system has been implemented 10. One continuous Demographic and Health Survey No change (DHS) report and one health Service Delivery report are produced every year 11. Number of people effectively targeted by the New indicator included to reflect additional funding for the CMU’s communication activities of the CMU communication activities 12. Number of operational SIGICMU modules New indicator included to reflect additional funding for the CMU’s Information system 3- Changes in the expenditure categories Changes in the expenditure categories are due to the three following reasons: x The World Bank Senegal Health & Nutrition Financing (P129472) - Follow the reallocation of funds between interventions currently implemented and as part of this restructuring (for example, additional funding for nutrition interventions under component 2); - The HRBF TF was financing the RBF interventions in two regions (Kolda and Kaffrine), while the MDTF TF is financing them in the four other regions targeted by the Project (as part of the first restructuring of the Project in May 2016). Due to the closing of the HRBF TF (USAID Grant), it is needed need to reintegrate interventions funded with this TF (focusing on interventions under component 1 for Kaffrine and Kolda regions) into the other financings. Thus, under MDTF Grant (and as the category was before the first restructuring in May 2016), RBF Grants will be 100% financed for the six targeted regions of the Project; - Add a specific expenditure category for the intervention related to subsidies for enrollment of the poorest under five children (as a small scaled pilot) in community-based health insurances. The table below summarizes these changes. The closed categories are marked in grey: xi The World Bank Senegal Health & Nutrition Financing (P129472) TABLE 2: PROPOSED DISBURSEMENT CATEGORIES WITH RESTRUCTURING IDA CREDIT TF MDTF Comments (in SDR) (in USD) Changes % Amount of Amount of Expenditures % Expenditures Category the Grant the Grant to be to be Financed Allocated Allocated Financed Cat 1 IDA/Cat 7 MTDF Total amount increased by Nutrition Enhancement adding from the TF MDTF 3,300,000 70% 1,300,000 30% Grants under Part B.2 of 1.3 million the Project Cat 2 MDTF No change Maternal Health 2,000,000 100% Vouchers under Part B.3 of the Project Cat 4 IDA/ Cat 8 MDTF New category Goods, non-consulting Adding A.3 and B.4 as new services, and consultants' sub-components of the services Training, and 4,805,900 63% 4,894,788 37% Project, as well as Operating Costs for Parts separation B1 in a and b. A.2, A.3, B.l a, B4 and C of Changes in amounts the Project New category, removing the Cat 6 MDTF regional specificities (a and RBF Grants under Part 6,943,041 100% b with the USAID TF) A.1 of the Project Reduced amount Cat 9 MDTF Community New category for transfers Based health insurance to CBHIs (part B1b of the 1,000,000 100% grants under part B1b of Project) the Project Cat 1 MDTF Category froze with 1st RBF Grants under Part 125,955 86% restructuring A.1 of the Project Cat 2 IDA/Cat 3 MTDF Category froze with 1st Goods, non-consulting restructuring services, and consultants’ services, Training and 857,500 72% 381,152 27% Operating Costs for Parts A.2, B.1 and C of the Project Cat 3 IDA/Cat 5 MTDF Category froze as new Goods, non-consulting activities added (categories services, and consultants’ 4IDA and 8 MDTF) services, Training and 4,136,600 73% 1,724,060 27% Operating Costs for Parts A.2 (a), A.2 (c), B.1 and C of the Project xii The World Bank Senegal Health & Nutrition Financing (P129472) Category froze to have a broader definition (ie, Cat 4 MTDF without regional RBF Grants under Part 1,631,004 100% specificities, new category 6 A.1 (b) of the Project MDTF), as it was initially in the Project TOTAL AMOUNT 13,100,000 20,000,000 4- Change in disbursements estimates To reflect the one-year extension of the closing date as well as current disbursements of the Project, disbursements estimates have been revised, as detailed in Section IV of the Restructuring Paper. 5. Extension of closing date In order to achieve the PDO and implement key interventions while absorbing available resources from the Project, it is proposed to extend the Closing Date from June 29, 2018 to June 30, 2019, for the following reasons: - The project experienced significant delays at the beginning related to the establishment of the coordination team at the Ministry of Health and Social Affairs and to the procurement of certain key contracts (recruitment of the Independent Verification Agencies for the RBF contracted in January 2016); - After implementation issues with the RBF component and weak fiduciary management, significant progress has been made recently to revise the RBF component (September 2017) with the implementation of the roadmap and the strengthening of fiduciary management capacities (last quarter 2017). Now that the implementation is finally working, it is important to allow for this approach to work. - Significant resources remain available in the project to support the Ministry of Health in the implementation of its priority strategies to achieve the PDO. This would be the first extension of the project Closing Date. III. SUMMARY OF CHANGES Changed Not Changed Change in Results Framework ✔ Change in Components and Cost ✔ Change in Loan Closing Date(s) ✔ Reallocation between Disbursement Categories ✔ xiii The World Bank Senegal Health & Nutrition Financing (P129472) Change in Disbursement Estimates ✔ Change in Implementing Agency ✔ Change in DDO Status ✔ Change in Project's Development Objectives ✔ Cancellations Proposed ✔ Change in Disbursements Arrangements ✔ Change in Overall Risk Rating ✔ Change in Safeguard Policies Triggered ✔ Change of EA category ✔ Change in Legal Covenants ✔ Change in Institutional Arrangements ✔ Change in Financial Management ✔ Change in Procurement ✔ Change in Implementation Schedule ✔ Other Change(s) ✔ Change in Economic and Financial Analysis ✔ Change in Technical Analysis ✔ Change in Social Analysis ✔ Change in Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_RESULTS_TABLE RESULTS FRAMEWORK Project Development Objective Indicators PDO_IND_TABLE Number of poor people reached by the project Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 1990565.00 2800000.00 Revised Date 01-Feb-2011 22-Dec-2017 28-Jun-2019 New acceptors of modern contraceptive method xiv The World Bank Senegal Health & Nutrition Financing (P129472) Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 84936.00 107041.00 Revised Date 05-Jun-2013 22-Dec-2017 28-Jun-2019 Births (deliveries) attended by skilled health personnel (number) Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 155397.00 271679.00 Revised Date 01-Feb-2011 22-Dec-2017 28-Jun-2019 Percentage of pregnant women having 4 antenatal care visits (at standard quality) Unit of Measure: Percentage Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 22.00 35.00 Revised Date 01-Feb-2011 22-Dec-2017 28-Jun-2019 Severly malnourished detected children who are referred and received at the health center for all necessary visits Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 4945.00 6745.00 Revised Date 01-Feb-2011 22-Dec-2017 28-Jun-2019 Index of quality of health care Unit of Measure: Percentage Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 72.66 70.00 Revised Date 01-Feb-2011 22-Dec-2017 28-Jun-2019 Intermediate Indicators xv The World Bank Senegal Health & Nutrition Financing (P129472) IO_IND_TABLE Number of health facilities that have an RBF contract Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 318.00 318.00 Revised Date 01-Jul-2013 22-Dec-2017 28-Jun-2019 Percentage of facilities with verified results and having received their payments Unit of Measure: Percentage Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 63.00 85.00 New Date 01-Jul-2013 22-Dec-2017 28-Jun-2019 People who have received essential health, nutrition, and population (HNP) services Unit of Measure: Number Indicator Type: Corporate Baseline Actual (Current) End Target Action Value 0.00 2331326.00 3016899.00 New Date 01-Jul-2013 22-Dec-2017 28-Jun-2019 People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) Unit of Measure: Number Indicator Type: Corporate Supplement Baseline Actual (Current) End Target Action Value 0.00 1355728.00 1778108.00 New Number of children immunized Unit of Measure: Number Indicator Type: Corporate Breakdown Baseline Actual (Current) End Target Action Value 0.00 244653.00 445220.00 New xvi The World Bank Senegal Health & Nutrition Financing (P129472) Date 31-Dec-2013 22-Dec-2017 28-Jun-2019 Number of women and children who have received basic nutrition services Unit of Measure: Number Indicator Type: Corporate Breakdown Baseline Actual (Current) End Target Action Value 0.00 1931276.00 2300000.00 New Date 31-Dec-2013 22-Dec-2017 28-Jun-2019 Number of deliveries attended by skilled health personnel Unit of Measure: Number Indicator Type: Corporate Breakdown Baseline Actual (Current) End Target Action Value 0.00 155397.00 271679.00 New Date 31-Dec-2013 22-Dec-2017 28-Jun-2019 Pregnant women receiving antenatal care during a visit to a health provider (cumulative number) Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 275605.00 468884.00 New Date 31-Dec-2013 22-Dec-2017 28-Jun-2019 Children aged 0-23 months who attended at least one growth monitoring and promotion service during the 3 precedent months (cumulative number) Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 316366.00 585456.00 Revised Date 01-Jul-2013 22-Dec-2017 28-Jun-2019 Number of maternal health vouchers distributed (cumulative number) Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action xvii The World Bank Senegal Health & Nutrition Financing (P129472) Value 0.00 15991.00 50245.00 New Date 01-Jul-2013 22-Dec-2017 28-Jun-2019 Percentage of eligible women that have received a maternal health financial incentive Unit of Measure: Percentage Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 17.00 72.00 New Date 01-Jul-2013 22-Dec-2017 28-Jun-2019 Health personnel receiving training (number) Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 2916.00 3144.00 Revised Date 01-Feb-2011 22-Dec-2017 28-Jun-2019 Number of hospitals where the cost accounting system has been implemented Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 0.00 34.00 New Date 01-Jul-2013 22-Dec-2017 28-Jun-2019 One continuous Demographic and Health Survey (DHS) report and one health Service Delivery report are produced every year (cumulative number) Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 6.00 10.00 Revised Date 01-Jul-2013 22-Dec-2017 28-Jun-2019 Number of people effectively targeted by the communication activities of the CMU (cumulative number) Unit of Measure: Amount(USD) Indicator Type: Custom Baseline Actual (Current) End Target Action xviii The World Bank Senegal Health & Nutrition Financing (P129472) Value 0.00 53571.00 165000.00 New Date 01-Jul-2013 22-Dec-2017 28-Jun-2019 Number of operationnal SIGICMU modules Unit of Measure: Number Indicator Type: Custom Baseline Actual (Current) End Target Action Value 0.00 0.00 5.00 New Date 22-Dec-2017 22-Dec-2017 28-Jun-2019 OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) 1. Result-Based Financing for 1. Result-Based Financing for health and nutrition services and 22.30 Revised health and nutrition services 15.70 capacity building and capacity building 2. Improvement of accessibility 2. Improvement of accessibility to maternal, nutrition, and 14.00 Revised to maternal, nutrition, and 15.60 children health services children health services 3. Institutional strengthening and 3. Institutional strengthening 6.00 Revised 9.50 project implementation and project implementation TOTAL 42.30 OPS_DETAILEDCHANGES_LOANCLOSING_TABLE LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications IDA-53240 Effective 29-Jun-2018 30-Jun-2019 30-Oct-2019 TF-15872 Effective 29-Jun-2018 30-Jun-2019 30-Oct-2019 31-Mar-2016, 27- TF-16618 Closed 30-Jun-2015 Oct-2016 TF-A0565 Closed 31-Dec-2016 OPS_DETAILEDCHANGES_REALLOCATION _TABLE xix The World Bank Senegal Health & Nutrition Financing (P129472) REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-53240-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: Nutrition Enhancement Grants Pt B2 3,300,000.00 1,161,835.88 3,300,000.00 100.00 70.00 iLap Category Sequence No: 2 Current Expenditure Category: GD,NCS,CS,TR & OC Pt A2,B1 & C 857,488.00 857,487.59 857,500.00 72.00 72.00 iLap Category Sequence No: 3 Current Expenditure Category: GD,NCS,CS,TR & OC Pt A2ac,B1 & C 8,942,512.00 4,136,598.21 4,136,600.00 73.00 73.00 iLap Category Sequence No: 4 Current Expenditure Category: GD,NCS,CS,TR & OC Pt A2, A3,B1a, B4 & C 0.00 0.00 4,805,900.00 63 Total 13,100,000.00 6,155,921.68 13,100,000.00 TF-15872-001 | Currency: USD iLap Category Sequence No: 1 Current Expenditure Category: RBF Grants Pt A.1 125,955.00 125,954.35 125,955.00 86.00 86.00 iLap Category Sequence No: 2 Current Expenditure Category: Maternal Health Vouchers Pt B.3 2,000,000.00 204,891.95 2,000,000.00 100.00 100.00 iLap Category Sequence No: 3 Current Expenditure Category: GD,NCS,CS,TR & OC Pt A2,B1 & C 381,152.00 381,151.49 381,152.00 27.00 27.00 xx The World Bank Senegal Health & Nutrition Financing (P129472) iLap Category Sequence No: 4 Current Expenditure Category: RBF Grants Pt A.1 (b) 12,274,045.00 1,631,003.88 1,631,004.00 100.00 100.00 iLap Category Sequence No: 5 Current Expenditure Category: GD,NCS,CS,TR & OC Pt A2ac,B1 & C 5,218,848.00 1,724,059.81 1,724,060.00 27.00 27.00 iLap Category Sequence No: 6 Current Expenditure Category: RBF Grants Pt A.1 0.00 0.00 6,943,041.00 100 iLap Category Sequence No: 7 Current Expenditure Category: Nutrition Enhancement Grants Pt B2 0.00 0.00 1,300,000.00 30 iLap Category Sequence No: 8 Current Expenditure Category: GD,NCS,CS,TR & OC Pt A2, A3,B1a, B4 & C 0.00 0.00 4,894,788.00 37 iLap Category Sequence No: 9 Current Expenditure Category: CBH Grants under Part B1b of the Project 0.00 0.00 1,000,000.00 100 Total 20,000,000.00 4,067,061.48 20,000,000.00 OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 2014 0.00 0.00 2015 1,579,211.00 1,579,210.99 2016 1,920,789.00 1,469,955.95 2017 7,700,000.00 3,249,998.12 2018 7,900,000.00 9,133,889.96 xxi The World Bank Senegal Health & Nutrition Financing (P129472) 2019 900,000.00 4,566,944.98 2020 0.00 0.00 xxii The World Bank Senegal Health & Nutrition Financing (P129472) . . The World Bank Senegal Health & Nutrition Financing (P129472)