FOR OFFICIAL USE ONLY Report No: RES38287 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT RESTRUCTURING PAPER ON A PROPOSED PROGRAM RESTRUCTURING OF IMPROVING PRIMARY HEALTH IN RURAL AREAS PROGRAM APPROVED ON APRIL 24, 2015 TO THE KINGDOM OF MOROCCO Health, Nutrition & Population Global Practice Middle East And North Africa Region Regional Vice President: Ferid Belhaj Country Director: Jesko S. Hentschel The World Bank MA-Health Sector Support (P148017) Senior Global Practice Director: Keiko Miwa Practice Manager: Rekha Menon Task Team Leader(s): Aissatou Diack, Fatima El Kadiri El Yamani The World Bank MA-Health Sector Support (P148017) ABBREVIATIONS AND ACRONYMS ANC Antenatal Care CRI Corporate Results Indicator CSCA Centre de Santé avec Module d’Accouchement (Community health center with a delivery unit) DLI Disbursement-Linked Indicator DLR Disbursement-Linked Result ENPSF Enquête nationale sur la population et la santé familiale (National Population and Family Health Survey) ESSP Établissement de Soins de Santé Primaires (Primary health care facility) GOM Government of Morocco GRM Grievance Redress Mechanism HIV Human Immunodeficiency Virus HMIS Health Management Information System HR Human Resources IBRD International Bank of Reconstruction and Development MEF Ministère de l’économie et des finances (Ministry of Economy and Finances) MCH Maternal and child health MOH Ministry of Health MTR Mid-Term Review NCDs Non-communicable diseases PDO Program Development Objective PforR Program for Results SMIPF-SC Santé maternelle et infantile, planification familiale, et soins curatifs (Information system for maternal and child health, family planning and curative care) The World Bank MA-Health Sector Support (P148017) DATA SHEET (MA-Health Sector Support - P148017) BASIC DATA Project ID Financing Instrument IPF Component P148017 Program-for-Results Financing No Approval Date Current Closing Date 24-Apr-2015 31-Dec-2019 Organizations Borrower Responsible Agency MINISTRY OF ECONOMY AND FINANCE (TGR) Ministry of Health Program Development Objective(s) The objective of the Program is to expand access to primary healthcare in targeted rural areas in the Program Area. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Approval Effectiveness Closing Ln/Cr/TF Signing Date Commitment Disbursed Undisbursed Date Date Date IBRD-85070 24-Apr-2015 02-Jul-2015 21-Sep-2015 31-Dec-2019 100.00 80.14 19.86 Policy Waiver(s) Does the Program require any waivers of Bank policies applicable to Program-for-Results operations? No Page 1 of 30 The World Bank MA-Health Sector Support (P148017) I. PROGRAM STATUS AND RATIONALE FOR RESTRUCTURING Program Background 1. The Morocco Improving Primary Health in Rural Areas Program for Results (PforR) was approved on April 24, 2015 and became effective on September 21, 2015, with an original closing date of December 31, 2019. The development objective of the PforR is to expand access to primary healthcare in targeted rural areas in the program area. The expected key results of the PforR are to increase the use of primary healthcare services in targeted rural areas, improve accountability of the health system and establish a health information system in public health facilities. These are accomplished through two results areas: first, improving health at the primary level in rural areas, and second, improving governance in healthcare. This PforR incentivizes progress for these results areas through seven Disbursement-Linked Indicators (DLIs), as shown in Table 1. Table 1. Disbursement-Linked Indicators of the Program Results Area 1: Expanding Equitable Access to Primary Care in Rural Areas DLI 1: Increase in number of pregnant women receiving antenatal care during a visit to a rural primary healthcare facility (ESSP) in the Program Area DLI 2: Increase in number of deliveries of rural women attended by skilled health personnel in public health facilities in the Program Area DLI 3: Increase in number of new visits of children under 5 to a rural ESSP in the Program Area for curative care DLI 4: Increase in number of patients with diabetes diagnosed and treated at a rural ESSP in the Program Area DLI 5: Increase in number of visits to rural ESSPs in the Program Area Results Area 2: Improving Health System Governance at the Primary Level DLI 6: % of rural health centers with delivery services in the Program Area that participate in the main annual quality assessment (concours qualité) DLI 7: Establishment of the health management information system (HMIS) in one region within the Program Area 2. The PforR was the first IBRD-funded health operation in Morocco since a small project financed by a trust fund closed in 2008. At preparation, Morocco suffered from low public health financing, lack of financial risk protection and significant inequality between urban and rural areas in terms of access to health services. The rural areas in particular suffered from poor maternal and child health outcomes associated with low utilization of health services and a lack of an integrated focus on primary care. In addition, the Moroccan health system was also struggling to respond to a dual burden of disease emerging from a significant increase in the burden of non-communicable diseases (NCDs) with limited coverage for the diagnosis and treatment of hypertension. Through the preparation of the operation, the World Bank engaged with the Government of Morocco (GOM) to define the two results areas to strengthen the health system with a focus on benefiting the rural population, by expanding the coverage of maternal and child health services and primary level services addressing NCDs and improving quality assurance and information systems. The process of defining these results areas was an entry point into a sector with limited ongoing policy dialogue, as well as an opportunity to address the constraints related to the building blocks of the health system. 3. Despite challenges, the performance of the Moroccan health system, particularly as it pertains to rural primary healthcare, has been showing positive trends for several years. This has been done through a concerted effort by The World Bank MA-Health Sector Support (P148017) the GOM to increase maternal and NCD service utilization and quality. Analysis of the National Population and Family Health Survey (ENPSF) data from 2011 and 2018 points to an overall increase in skilled birth attendance level, with a significantly faster increase in rural areas from 55 percent to 74 percent (a 35 percent rise), compared to urban areas (rising from 91 percent to 97 percent). Antenatal care visits had a similar trend, with an increase of 27 percent in rural areas, from 63 percent to 80 percent for the same years, compared to 92 percent to 96 percent in urban areas. These trends align with a decline in maternal mortality from 148/100,000 in 2009-2010 to 111/100,000 in 2015-2016 in rural areas, and nationally from 112/100,000 to 73/100,000 for the same period. Similarly, NCD treatment coverage has increased significantly: even though type 2 diabetes prevalence has gone up, coverage for diabetes treatment has accelerated significantly, going up from 625,000 people covered in 2015 to 823,000 in 20171 (>30 percent increase) in rural areas of the regions covered by the PforR, resulting in a reduction in unmet treatment needs. Similar improvements were made with hypertension: even as new cases stabilized between 2015 and 2017, the number of those undergoing treatment went up from 663,061 in 2015 to 882,485 in 2017.2 These changes can also be attributed to increases in health financing since the launch of the PforR: the public per capita health budget in real terms has gone up from US$61 in 2015 to US$69 in 2017,3 and large increases are reported for 2019 and 2020.4 Implementation Progress 4. Following a level II restructuring in 2017, Program implementation has been satisfactory. The restructuring approved on July 3, 2017 documented the baseline values (as previously agreed during negotiations) and the list of revised targeted regions. The restructuring also confirmed the achievement of Disbursement-Linked Result (DLR) 7.1 (first year result for 2015) and the revision and implementation of the verification protocol leading to three exercises of verification (indicators for years 2014, 2015 and 2016). Progress towards achievement of the Project Development Objective (PDO) and Implementation Progress are rated Moderately Satisfactory and the program has disbursed US$80.14 million to date at 80.14 percent disbursement rate. This amount includes US$25 million advance which is yet to be recovered. There is no overdue audit. 5. PforR indicators for the program on expanding equitable access to primary care in rural areas have mostly met or surpassed the targets, attributable to the reallocation of funds to priority areas. In 2017, antenatal care coverage increased by almost 18 percent against a target of 4 percent, an increase due to improved availability of infrastructure and medical equipment in rural health centers and expanded scope of antenatal care, which now include ultrasound and higher technical capacity. Similarly, proactive outreach by health workers to mothers in remote areas and an increase in the availability of mobile medical units have resulted in this improvement: mobile medical units have been scaled up significantly in the course of the program. In 2018, in rural areas, the units supported a total of 13,745 antenatal care (ANC) visits (about 10 percent of all ANC visits in program regions) and 184,586 outpatient visits for under children under the age of five and 286,011 outpatient visits for those over five years of age. Not only did the 1 Direction de la planification et des ressources financières, division de la coopération, May 2019. « Programme Pour Résultats du Secteur de la Santé ‘PPR-Santé’ – Rapport d’Avancement du Programme » 2 Ibid. 3 World Health Organization, Global Health Expenditure Database. https://apps.who.int/nha/database 4 According to the MOH, public health budget increased from around 13.5 billion MAD in 2015 to almost 19 billion in 2020 in nominal terms. The World Bank MA-Health Sector Support (P148017) GOM scale-up mobile medical units, but it also improved its investments and prioritized outreach by health workers based in health centers, through offering home-based care for a set of services as well as identifying conditions. 6. Indicators relating to NCD coverage in rural areas have substantially out-performed the targets. The GOM’s commitment to both prevention and treatment of diabetes and hypertension has seen a dramatic increase since the launch of the PforR. There has been an increase in the number of diabetic patients monitored through diagnostic and therapeutic management in rural primary healthcare facilities (ESSPs) in the program's target regions due to a significant increase in the priority given by the GOM to the diagnosis and treatment of diabetes and hypertension. This was corroborated by improved GOM spending on awareness, drugs and medical equipment. GOM counterparts confirm that the PforR played catalyst role in setting priorities in the diagnosis and treatment of diabetes and high blood pressure in rural areas. The disease burden has increased due to lifestyle factors, especially for type 2 diabetes. The improvement in diagnosis and treatment capacity in rural areas is therefore an important step towards primary and secondary prevention. 7. The only under-performing DLI under the program on primary care in rural areas has been the deliveries attended by skilled health personnel in public health facilities. The target for 2017 is a 5.13 percent increase from the baseline, while the realized increase is 0.51 percent. This trend, however, does not necessarily mean that there has not been progress among rural women in receiving this important type of care. In fact, skilled attendance at childbirth for rural women (at any location) has increased from 53 percent in 2011 to 69 percent in 2018 according to the ENPSF, with increases especially in public hospitals (where 50 percent of deliveries for rural women currently take place) and private clinics (which currently supports 4.5 percent of deliveries for rural women). The stagnated number of deliveries among rural women at public facilities may be partly attributable to increased urbanization, declining fertility rates and increased deliveries in private facilities. The total number of pregnancies in rural areas fell from 315,000 in 2015 to 300,000 in 2018, according to GOM projections. This is consistent with the national trend of declining fertility, which has gone down from 2.6 in 2011 to 2.38 in 2018, with a significant decline in rural areas from 3.2 to 2.8 during the same period. At the national level, the rate of deliveries attended by skilled health personnel in public facilities fell from 78 percent in 2015 to 69 percent in 2018. Given that 30% of deliveries are not attended by skilled health personnel in rural areas, targeted efforts may be needed to increase demand for deliveries at public facilities to ensure this service is accessible and available to all women, especially those with financial constraints. 8. The PforR operation has been successful in terms of improving the quality and accountability of the health system and has played a key role in the transition of the Moroccan health system towards an evolving health system through learning; it has also contributed to policy discussions on improving the availability of the health workforce. The increases in service utilization have been complemented by a focus on improvements in quality of care. The PforR includes a DLI on quality assessments as well as an indicator on the establishment of a grievance redress mechanism (GRM),5 both of which are operational and enable stakeholders to incorporate feedback from patients in their practice, which would help increase accountability of the health system. These activities have catalyzed a broader 5From 2016-2018, the GRM (“Chikaya Santé”) has received 4295 calls, mostly related to high waiting times, absenteeism and drug stock-outs. In 2018, a decision was made to collect and address grievances at the decentralized/service delivery level; most regions, districts and hospitals have already established these mechanisms. This process is expected to be completed by the end of 2019. The World Bank MA-Health Sector Support (P148017) focus on quality of care, and during the PforR implementation period, the Moroccan health system has made great strides in becoming an evolving health system through learning. The implementation of maternal death audits has been institutionalized, with the results of these assessments6 being used to address key challenges in quality of care, together with the continuous feedback received from patients. Service packages have been defined for maternal health to ensure improved availability, and trainings have been conducted based on these packages as well as the results of the assessments to ensure continued learning. There has been an increase in the institutionalization of studies similar to maternal death audits. As an example of the institutionalization of learning, two of the program regions have started a pilot of a family medicine model to reorganize care in their districts, where patients have digitized medical records and are assigned a family doctor who is their primary source of contact for all matters related to primary care. Such a model is employed in different countries, and if the results are promising, the model can be scaled up. Another example relates to the scarcity of the health workforce which is a key bottleneck for quality of care in rural areas. Exploring incentives to improve the retention of health workers in rural areas has been identified as a potential way to alleviate the situation. The PforR has supported studies on implementing incentives to improve both the presence and performance of human resources for health. The implementation of the recommendations from these studies hinges upon changes in the legal framework, as currently many civil servants, including health workers, are managed centrally by the civil service directorate, and it is not currently possible to implement differential incentive structures for different civil servants. 9. Another key improvement in the governance of the health system is the digitization of a health information system that have taken place during the PforR implementation period. At the launch of the PforR, the GOM did not have a comprehensive strategy with regards to an integrated, digitized health information system, and health data was almost exclusively paper-based. The PforR envisioned the development of building blocks for an integrated information system, as well as piloting an integrated approach in one region. During the process, the GOM completed an urbanization study and a roadmap (masterplan) of an integrated health information system strategy, which were DLRs 7.1 and 7.2. As a first step towards laying down the building blocks of an integrated health system, the GOM has launched an integrated computerized health system for Maternal and Child Health, Family Planning and Curative Care (santé maternelle et infantile, planification familiale et soins curatifs - SMIPF-SC). While the GOM has not achieved original DLRs 7.3 and 7.4, SMIPF-SC is fully operational, comprehensive and digitally available, as of 2017. SMIPF-SC includes all indicators related to maternal, newborn and child health including immunization, nutrition and family planning, information relating to cancers, Human Immunodeficiency Virus (HIV) and sexually transmitted infections, and all curative care interventions including diabetes and hypertension. It should be noted that there is a separate paper-based registry for diabetes and hypertension, which is more comprehensive than the information available on SMIPF-SC. There are plans to fully integrate the diabetes registry with the hypertension registry, and integrate them with the SMIPF-SC, over the next few years. SMIPF-SC was launched in 2010 as a paper-based system, and its scope has expanded significantly from 2015. As of 2017, the system is completely computerized at the hospital level, and all ESSPs send data at the provincial delegation for data entry and reporting to the central level. 6Morocco’s concours qualité program, involving self-assessment conducted by health facilities and audit by peers, recognizes good work and incentivizes improvement. The World Bank MA-Health Sector Support (P148017) 10. Steady progress has been observed on the fiduciary aspects. The MOH has been addressing the 2018 audit recommendations, particularly those related to stock-outs of medicines and supply chain management, through an action plan. This includes the adoption of three-year framework contracts for supplies, some of which have already been signed. In addition, all health personnel involved in medicine supply chain management has been trained on stock management and quality control through an initiative implemented by the Supply Division of the MOH. In October 2019, it was agreed that the MOH produce interim financial report on a semi-annual basis, which will help consolidate financial information, track spending history and provide more visibility on budget planning. The World Bank will continue to follow up closely with the MOH to: (i) monitor progress and support capacity building efforts; and (ii) use the DLRs for which achievement is yet to be confirmed to justify/account for the initial advance of US$25million disbursed at project effectiveness. Despite the progress made, however, the MOH continues to face complex issues and constraints in procuring essential medicines and strategic public health supplies. This is mainly because the public sector entities responsible for procurement of essential medicines and health commodities are still using inflexible procurement methods and dependent on cumbersome tendering processes, as the existing public procurement decree does not allow for the use of appropriate/specific procurement approaches for the health sector. Furthermore, the media has recently reported governance issues and lack of transparency in the procurement of essential medicines. Therefore, it is essential that the MOH implement and monitor appropriate and good procurement practices in order to ensure timely procurement and good quality of drugs. Rationale for Restructuring 11. The PforR has been successful in building momentum in terms of improved rural primary care and governance in the Moroccan health system. During the PforR implementation, the GOM has made progress on all the agreed PDO indicators, except for the one regarding skilled birth attendance at public facilities. As highlighted above, the PforR has catalyzed an increase in utilization for key services in rural areas through mobile medical units and improved physical quality of health facilities. Improvements in health system governance have also been achieved through enhancing information systems, collecting evidence on human resources for health retention mechanisms, and focusing on governing for quality of care and institutionalizing quality improvement processes through “quality assessments”. Health budget increased by 10.4% between 2018 and 2019, and even further between 2019 and 2020 at 13.7%, which is a key factor as the GOM moves towards implementing its ambitious Plan Santé 2025, centered on improving quality and service utilization. Even though the program experienced start-up delays and operational bottlenecks, implementation momentum has been building since the mid-term review (MTR). 12. In order to achieve the Program targets and in line with the MTR recommendations, the Ministry of Health (MOH) through the Ministry of Economy and Finance (MEF) submitted a request for a level 2 restructuring on October 16, 2019. Subsequently, a review of the restructuring request was undertaken in November 2019, and the amendments detailed in the next section were agreed between the World Bank and the GOM. These amendments are based on two main reasons: (i) the lack of progress on skilled birth attendance for rural women at public facilities, despite commendable progress in all other areas; and (ii) the significant progress made with the operationalization of a national health information system nationwide. The World Bank MA-Health Sector Support (P148017) 13. With regards to DLI 2, skilled birth attendance for rural women at public facilities, a review did not find conclusive evidence that the PforR played a role in incentivizing an increase in deliveries at public facilities, unlike other DLIs on antenatal care, diabetes or outpatient consultations, as well as on the improvement of quality of care and accountability mechanisms. Even though progress was made in expanding the coverage of skilled birth attendance for rural women in general according to the ENPSF, the progress for this DLI has been constantly below targets, and the role of the PforR in this regard is unclear especially in terms of increasing deliveries in public facilities. As highlighted above, even though skilled birth attendance in public facilities has been declining nationally due to an overall decline in the number of expected pregnancies and an increase in deliveries at private facilities, it is difficult to determine that these shifts alone can justify the stagnated delivery rates at public facilities. 14. As for DLI 7, the GOM has indicated that SMIPF-SC will continue to be their main information system as the country transitions towards operationalizing the integrated data system strategy which was developed through the PforR. SMIPF-SC forms the main building block for the integrated information system that the GOM is seeking to develop, which would be based on an electronic medical records system at the patient level. Patient data is already collected at every public health facility, including demographic information of patients. The next step in the GOM’s strategy is to ensure this patient-level data is captured electronically and can be transmitted easily from one facility to another, from the primary to the secondary and to the tertiary level. There are ongoing efforts to enable computerized data entry in all ESSPs; yet, given the operational and financial constraints, this transition is expected to take time. The GOM has been increasing its budgetary commitments, thanks to upcoming projects financed by the African Development Bank and the European Union. Both the GOM and the development partners indicated that the PforR has served as a catalyst in elevating the profile, attracting interest, and laying down the building blocks for an integrated information system, a process which takes a significant amount of time to complete. Until full digitization takes place under the vision of a fully digitized Morocco by 2030, SMIPF-SC will serve as the main information system of the country. II. DESCRIPTION OF PROPOSED CHANGES 15. In light of these contextual observations and deliberations, the following changes were agreed: (i) revise the 2014 baseline value for DLI 5 to 3,794,877 instead of 3,753,120 to include mobile clinic consultations; (ii) modify DLI 6 as follows: (a) change the name of DLI 6 as “% of rural health centers with delivery services (CSCAs) in the Program Area that participate in the main biennial quality assessment (concours qualité); (b) revise the 2014 baseline value for DLI6 from 11.49 percent to 13 percent; (c) reformulate DLRs 6.1, 6.2, 6.3 and 6.4 as “30% of CSCAs in the Program Area participating in the main biennial quality assessment (concours qualité), in CY15”, “The guide of self-evaluation of rural health centers has been updated in a manner acceptable to the Bank”, “The Borrower, through its MOH, has approved/adopted the guide of self-evaluation of rural health centers updated under DLR#6.2”, and “44% of CSCAs in the Program Area have participated in the main biennial quality assessment (concours qualité) and been assessed based on the guide of self-evaluation of rural health centers approved/adopted under DLR#6.3”; (iii) reformulate DLI 7 as follows: (a) revise the name of DLI7 to “Establishment of an HMIS in the Program Area; (b) modify DLR 7.3 to read “The national digitized health management information system on maternal and child health, family planning, and curative care (SMIPF-SC) has been operationalized in the 100% of public health centers of at least 4 regions within the The World Bank MA-Health Sector Support (P148017) Program Area”; and (c) modify DLR 7.4 to read “The SMIPF-SC has been operationalized in the 100% of public health centers of all the regions within the Program Area”; (iv) extend the closing date to December 31, 2020 with the disbursement deadline of June 30, 2021. Changes in the baseline value are to record more reliable data and do not impact disbursements already made against achieved results. The end target date for the intermediate results indicator, “Definition of a Human resources (HR) incentive mechanism in rural ESSPs” will also be revised to June 30, 2020. 16. One-year extension provides an opportunity to monitor and capture the trend for the year 2019. While the DLI targets will continue to be for four years (2015-2018), the results framework will be modified to include 2019 data for several indicators. This does not affect past or future disbursements. 17. Revision of the DLI 6 name, 2013 baseline value for DLI 6 and 2015, 2016, 2017 and 2018 targets (% of rural health centers with delivery services (CSCAs) in the Program Area that participate in the main annual quality assessment - concours qualité). Due to the implementation schedule of this quality assessment which is every two years with one transitional year, the MOH was only able to complete two cycles for 2014-2015 and 2017-2018. The name of DLI6 is revised to reflect the frequency, biennial rather than annual, and the targets are reformulated to reflect the frequency of these assessments. The baseline value is amended to 13 percent instead of the original 11.49 percent due to the availability of more reliable baseline data. 18. Regarding DLI 7, as described above, the GOM has made significant progress in operationalizing and scaling up SMIPF-SC, which is going to remain the main integrated information system until the scale-up of patient-level electronic medical records. The GOM and development partner consultations have demonstrated that this process will take a significantly longer time than anticipated, and in the meantime, the GOM has spent technical, financial and operational resources on scaling up the coverage of SMIPF-SC. Changing the DLRs of this indicator would recognize the progress made to date and support the long-term task of moving towards a comprehensive patient-level integrated information system. In light of this, the DLI name is also revised. 19. Extension of the closing date to December 31, 2020. The proposed closing date extension will allow enough time to capture the results achieved for the years 2017 and 2018 as the MOH has faced a delay in publishing its annual health outcomes report “Santé en Chiffre”. Most indicators in the results framework are based on this annual report. The verification report of 2017 data has been submitted to the Bank on November 27, 2019. The data for 2018 is expected to be validated and published significantly faster, in the first half of 2020, given the completed transition process of digitized SMIPF-SC. One-year extension will not only ensure that the DLI achievements are captured but also provides an opportunity to monitor the trend for 2019 for service related indicators as well. Verification of these data is not necessary, thus 2019 data will be available during 2020, before the closing date. Finally, the extension also allows additional time for the ongoing activities for the HR incentive mechanism (intermediate results indicator) as well as program action items related to safeguards and fiduciary measures to be completed under the PforR. The World Bank MA-Health Sector Support (P148017) 20. The implications of these changes on disbursement are shown in the table below. This restructuring is likely to result in the GOM to request disbursement for DLRs worth $31.8 million, of which US$25 million will be used to recover the advance. Disbursement Linked Disbursements Disbursements after restructuring Disbursements after Indicators to date and Bank’s acceptance of the 2017 restructuring and data verification report verification of 2018 data DLI1 $12,100,015 $1,899,985 DLI2 $1,158,761 $289,488 $289,488 (estimate) DLI3 $6,496,315 $3,503,685 DLI4 $20,000,000 DLI5 $8,894,331 $1,105,669 DLI6 $1,243,652 $6,000,000 DLI7 $5,000,000 $5,000,000 $13,750,000 Unrecovered Advance $25,000,000 Disbursement Total $79,893,074* $ 17,798,827 $ 14,039,488 * Total disbursed under DLIs + $250,000 front end fee=$80.14 million total disbursement to date III. SUMMARY OF CHANGES Changed Not Changed Change in Results Framework ✔ Change in Loan Closing Date(s) ✔ Reallocation between and/or Change in DLI ✔ Change in Disbursement Estimates ✔ Change in Implementation Schedule ✔ Change in Implementing Agency ✔ Change in Program's Development Objectives ✔ Change in Program Scope ✔ Change in Cancellations Proposed ✔ Change in Disbursements Arrangements ✔ Change in Systematic Operations Risk-Rating Tool ✔ (SORT) Change in Safeguard Policies Triggered ✔ The World Bank MA-Health Sector Support (P148017) Change in Legal Covenants ✔ Change in Institutional Arrangements ✔ Change in Technical Method ✔ Change in Fiduciary ✔ Change in Environmental and Social Aspects ✔ Other Change(s) ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_LOANCLOSING_TABLE LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/TF Status Closing Date Closing(s) Date Closing Date for Withdrawal Applications IBRD-85070 Effective 31-Dec-2019 31-Dec-2020 30-Apr-2021 OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Year Current Proposed 2015 0.00 0.00 2016 25,000,000.00 25,000,000.00 2017 23,000,000.00 26,243,652.00 2018 25,000,000.00 11,268,797.00 2019 27,000,000.00 17,380,625.00 2020 0.00 6,838,315.00 OPS_DETAILEDCHANGES_EA_TABLE . The World Bank MA-Health Sector Support (P148017) ANNEX 1: RESULTS FRAMEWORK . . Results framework Program Development Objectives(s) The objective of the Program is to expand access to primary healthcare in targeted rural areas in the Program Area. Program Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 The objective of the program is to expand access to primary health care in targeted rural areas Increase in number of pregnant women receiving 0.97% increase from 2.18% increase from 3.88% increase from 5.83% increase from 19% increase from antenatal care during a visit to 161 829 baseline baseline baseline baseline baseline a rural ESSP in the Program Area (Text) Rationale: Action: This indicator has been 2019 target is added given the one-year extension. This does not affect DLI targets or disbursement. Revised Increase in number of deliveries of rural women 1.71% increase from 3.42% increase from 5.13% increase from 7.26% increase from 7.26% increase from 180 812 attended by skilled health baseline baseline baseline baseline baseline personnel in public health Page 11 of 30 The World Bank MA-Health Sector Support (P148017) RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 facilities in the Program Area (Text) Rationale: Action: This indicator has been 2019 target (maintained at the same level as 2018) is added given the one-year extension. This does not affect DLI targets or disbursement. Revised Increase in number of new visits of children under 5 to a 1.50% increase from 2.50% increase from 3.50% increase from 5.00% increase from 7.00% increase from 1 013 436 rural ESSP in the Program Area baseline baseline baseline baseline baseline for curative care (Text) Rationale: Action: This indicator has been 2019 target is added given the one-year extension. This does not affect DLI targets or disbursement. Revised Increase in number of patients with diabetes diagnosed and 4.09% increase from 8.62% increase from 13.1% increase from 17.63% increase from 38% increase from 136 238 treated at a rural ESSP in the baseline baseline baseline baseline baseline Program Area (Text) Rationale: Action: This indicator has been 2019 target is added given the one-year extension. This does not affect DLI targets or disbursement. Revised PDO Table SPACE Page 12 of 30 The World Bank MA-Health Sector Support (P148017) Intermediate Results Indicators by Result Areas RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Expanding equitable access to primary care in rural areas Increase in number of visits to 1.30% increase from 2.30% increase from 3.30% increase from 4.30% increase from 13% increase from rural ESSPs in the Program 3,794,877 baseline baseline baseline baseline baseline Area (Text) Rationale: Action: This indicator has been The baseline is revised to take medical units into consideration. 2019 target is added given the one-year extension. This does not affect DLI targets or Revised disbursement. Number of patients with hypertension diagnosed and 180,000.00 273,000.00 277,000.00 280,000.00 287,000.00 287,000.00 treated in rural ESSPs (Number) Rationale: Action: This indicator has been 2019 target (maintained the same level as 2018) is added given the one-year extension. Not a large increase is expected from year to year. Revised Establishment of a Roll out of the GRM not established comprehensive GRM (Text) comprehensive GRM Implementation mechanism defined, Definition of an HR incentive Diagnostic study including target mechanism in rural ESSPs Diagnostic not completed completed indicators, performance (Text) criteria, and beneficiaries. Legal documents drafted. Page 13 of 30 The World Bank MA-Health Sector Support (P148017) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Rationale: Action: This indicator has been End target date is changed to June 30, 2020. Revised The national digitized health management information system on maternal and child The SMIPF-SC has been health, family planning, operationalized in the Establishment of an HMIS in ‘Urbanization’ process ‘Master Plan” updated and curative care HMIS not established 100% of public health the Program Area (Text) completed and validated (SMIPF-SC) has been centers of all the regions operationalized in the within the Program Area 100% of public health centers of at least 4 regions within the Program Area Rationale: Action: This indicator has been DLRs 7.3 and 7.4 are reformulated to capture the digitization of SMIPF-SC. DLI name is also modified to reflect these changes. Revised People who have received essential health, nutrition, and 0.00 181,535.00 363,070.00 544,786.00 726,502.00 908,218.00 population (HNP) services (CRI, Number) Rationale: Action: This indicator has been 2019 target is added given the one-year extension. Revised Page 14 of 30 The World Bank MA-Health Sector Support (P148017) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Number of deliveries attended by skilled health 0.00 181,535.00 363,070.00 544,786.00 726,502.00 908,218.00 personnel (CRI, Number) Rationale: Action: This indicator has 2019 target is added given the one-year extension. been Revised Improving health system governance at the primary level 44% of CSCAs in the Program Area have participated in the main % of rural health centers with 30% of CSCAs in the The Borrower, through The guide of self- biennial quality delivery services (CSCAs) in the Program Area its MOH, has evaluation of rural assessment (concours Program Area that participate participating in the main approved/adopted the 13% health centers has been qualité) and been in the main biennial quality biennial quality guide of self-evaluation updated in a manner assessed based on the assessment (concours qualité) assessment (concours of rural health centers acceptable to the Bank guide of self-evaluation of (Text) qualité), in CY15 updated under DLR#6.2. rural health centers approved/adopted under DLR#6.3 Rationale: DLRs 6.1, 6.2, 6.3 and 6.4 are reformulated due to the implementation schedule of this quality assessment which is every two years with one transitional Action: This indicator has been year. The MOH was only able to complete two cycles for 2014-2015 and 2017-2018. The name of the DLI is also revised to say "biennial" instead of "annual" Revised quality assessment. IO Table SPACE Page 15 of 30 The World Bank MA-Health Sector Support (P148017) Disbursement Linked Indicators Matrix DLI IN00735878 ACTION DLI 1 Increase in number of pregnant women receiving antenatal care during a visit to a rural ESSP in the Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 14,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 161,829.00 CY2015 14,000,000.00 CY2016 0.00 CY2017 0.00 CY2018 0.00 0.00 0.00 Action: This DLI has been Revised. See below. DLI IN00736029 ACTION DLI 1 Increase in number of pregnant women receiving antenatal care during a visit to a rural ESSP in the Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 14,000,000.00 86.43 Period Value Allocated Amount (USD) Formula Page 16 of 30 The World Bank MA-Health Sector Support (P148017) Baseline 161,829.00 CY2015 0.97% increase from baseline 2,329,331.00 See description of DLI CY2016 2.18% increase from baseline 2,905,660.00 CY2017 3.88% increase from baseline 4,082,333.00 CY2018 5.83% increase from baseline 4,682,676.00 0.00 0.00 Rationale: There is no change to this DLI: details are added in the datasheet. DLI IN00735879 ACTION Increase in number of deliveries of rural women attended by skilled health personnel in public health facilities in the DLI 2 Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 14,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 180,812.00 CY2015 14,000,000.00 CY2016 0.00 CY2017 0.00 Page 17 of 30 The World Bank MA-Health Sector Support (P148017) CY2018 0.00 0.00 0.00 Action: This DLI has been Revised. See below. DLI IN00736030 ACTION Increase in number of deliveries of rural women attended by skilled health personnel in public health facilities in the DLI 2 Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 14,000,000.00 8.28 Period Value Allocated Amount (USD) Formula Baseline 180,812.00 CY2015 1.71% increase from baseline 3,297,521.00 See description of DLI CY2016 3.42% increase from baseline 3,297,521.00 CY2017 5.13% increase from baseline 3,297,521.00 CY2018 7.26% increase from baseline 4,107,437.00 0.00 0.00 Rationale: There is no change for this DLI: details are added in the datasheet. Page 18 of 30 The World Bank MA-Health Sector Support (P148017) DLI IN00735880 ACTION DLI 3 Increase in number of new visits of children under 5 to a rural ESSP in the Program Area for curative care Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 10,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 1,013,436.00 CY2015 10,000,000.00 CY2016 0.00 CY2017 0.00 CY2018 0.00 0.00 0.00 Action: This DLI has been Revised. See below. DLI IN00736066 ACTION DLI 3 Increase in number of new visits of children under 5 to a rural ESSP in the Program Area for curative care Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 10,000,000.00 64.96 Period Value Allocated Amount (USD) Formula Baseline 1,013,436.00 Page 19 of 30 The World Bank MA-Health Sector Support (P148017) CY2015 1.50% increase from baseline 3,000,000.00 CY2016 2.50% increase from baseline 2,000,000.00 CY2017 3.50% increase from baseline 2,000,000.00 CY2018 5% increase from baseline 3,000,000.00 0.00 0.00 Rationale: There is no change for this DLI: details are entered in the datasheet. DLI IN00735881 ACTION DLI 4 Increase in number of patients with diabetes diagnosed and treated at a rural ESSP in the Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 20,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 136,238.00 CY2015 20,000,000.00 CY2016 0.00 CY2017 0.00 CY2018 0.00 Page 20 of 30 The World Bank MA-Health Sector Support (P148017) 0.00 0.00 Action: This DLI has been Revised. See below. DLI IN00736067 ACTION DLI 4 Increase in number of patients with diabetes diagnosed and treated at a rural ESSP in the Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 20,000,000.00 100.00 Period Value Allocated Amount (USD) Formula Baseline 136,238.00 CY2015 4.09% increase from baseline 4,639,818.00 See description of DLI CY2016 8.62% increase from baseline 5,138,968.00 CY2017 13.1% increase from baseline 5,082,246.00 CY2018 17.63% increase from baseline 5,138,968.00 0.00 0.00 Rationale: There is no change for this DLI: details are entered in the datasheet. Page 21 of 30 The World Bank MA-Health Sector Support (P148017) DLI IN00735882 ACTION DLI 5 Increase in number of visits to rural ESSPs in the Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 10,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 3,794,877.00 CY2015 10,000,000.00 CY2016 0.00 CY2017 0.00 CY2018 0.00 0.00 0.00 Action: This DLI has been Revised. See below. DLI IN00736068 ACTION DLI 5 Increase in number of visits to rural ESSPs in the Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 10,000,000.00 88.94 Period Value Allocated Amount (USD) Formula Baseline 3,794,877 Page 22 of 30 The World Bank MA-Health Sector Support (P148017) CY2015 1.30% increase from baseline 3,023,257.00 CY2016 2.30% increase from baseline 2,325,581.00 CY2017 3.30% increase from baseline 2,325,581.00 CY2018 4.30% increase from baseline 2,325,581.00 0.00 0.00 Rationale: The baseline is updated to take mobile units into account. DLI IN00735883 ACTION % of rural health centers with delivery services (CSCAs) in the Program Area that participate in the main annual quality DLI 6 assessment (concours qualité) Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Percentage 8,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 11.49 CY2015 8,000,000.00 CY2016 0.00 CY2017 0.00 CY2018 0.00 Page 23 of 30 The World Bank MA-Health Sector Support (P148017) 0.00 0.00 Action: This DLI has been Revised. See below. DLI IN00736069 ACTION % of rural health centers with delivery services (CSCAs) in the Program Area that participate in the main biennial quality DLI 6 assessment (concours qualité) Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 8,000,000.00 15.55 Period Value Allocated Amount (USD) Formula Baseline 13% 30% of CSCAs in the Program Area participating in CY2015 the main biennial quality assessment (concours 2,000,000.00 qualité), in CY15 The guide of self-evaluation of rural health centers CY2016 has been updated in a manner acceptable to the 2,000,000.00 Bank The Borrower, through its MOH, has CY2017 approved/adopted the guide of self-evaluation of 2,000,000.00 rural health centers updated under DLR#6.2. 44% of CSCAs in the Program Area have participated in the main biennial quality assessment (concours CY2018 qualité) and been assessed based on the guide of 2,000,000.00 self-evaluation of rural health centers approved/adopted under DLR#6.3 0.00 Page 24 of 30 The World Bank MA-Health Sector Support (P148017) 0.00 Rationale: DLRs 6.1, 6.2, 6.3 and 6.4 are reformulated due to the implementation schedule of this quality assessment which is every two years with one transitional year. The MOH was only able to complete two cycles for 2014-2015 and 2017-2018. The name of the DLI is also revised to say "biennial" instead of "annual" quality assessment. DLI IN00735884 ACTION DLI 7 Establishment of the HMIS in one region within the Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 24,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline Not established CY2015 24,000,000.00 CY2016 0.00 CY2017 0.00 CY2018 0.00 0.00 0.00 Action: This DLI has been Revised. See below. Page 25 of 30 The World Bank MA-Health Sector Support (P148017) DLI IN00736070 ACTION DLI 7 Establishment of an HMIS in the Program Area Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 23,750,000.00 21.05 Period Value Allocated Amount (USD) Formula Baseline Not established CY2015 Urbanization process complete 5,000,000.00 CY2016 Master Plan updated and validated 5,000,000.00 The national digitized health management information system on maternal and child health, family planning, and curative care (SMIPF-SC) has CY2017 7,000,000.00 been operationalized in the 100% of public health centers of at least 4 regions within the Program Area The SMIPF-SC has been operationalized in the 100% CY2018 of public health centers of all the regions within the 6,750,000.00 Program Area 0.00 0.00 Rationale: DLRs 7.3 and 7.4 are reformulated to capture the digitization of SMIPF-SC. DLI name is also modified to reflect these changes. Page 26 of 30 The World Bank MA-Health Sector Support (P148017) ANNEX 2: PROGRAM ACTION PLAN . . PAP_CHANGE_TBL Action Completion Description Source DLI# Responsibility Timing Measurement Action Finalize the POM Client Due Date 31-May-2016 No Change by incorporating the new procedures of the National Plan for Medical and Pharmaceutical Waste Management. The responsible Client Due Date 31-Dec-2018 Revised persons in the seven targeted regions will ensure follow up of environmental aspects according to regulation (decret 2009). Proposed The responsible Environmental and Client Due Date 30-Jun-2020 --- persons in the Social Systems seven targeted regions will ensure follow up of environmental aspects according to regulation (decret 2009). Creation of a Client Due Date 30-Mar-2018 No Change budgetary line in the annual Budgetary of MoH regional directorate and of MoH delegations to externalize the medical and pharmaceutical waste management at the ESSP levels The seven target Client Due Date 31-May-2019 Revised regions implement the Page 27 of 30 The World Bank MA-Health Sector Support (P148017) externalization of the medical and pharmaceutical waste management. Proposed The seven target Environmental and Client Due Date 30-Jun-2020 --- regions Social Systems implement the externalization of the medical and pharmaceutical waste management. The diagnosis of Client Due Date 31-Dec-2015 No Change the current GRMs, the strategy and the draft GRM implementation manual are completed. The pilot GRM Client Due Date 30-Dec-2016 No Change was completed and the GRM is scaled up is at national level. The pilot GRM is Client Due Date 31-Dec-2017 No Change evaluated and the implementation manual is reviewed. The GRM is rolled Client Due Date 31-Dec-2021 Revised out at the regional level. Proposed The GRM is rolled Environmental and Client Due Date 30-Jun-2020 --- out at the Social Systems regional level. Audit: Client Due Date 31-Dec-2019 Revised 1) Setting up of internal audit and management control functions at the central and regional levels of the MoH. At the Page 28 of 30 The World Bank MA-Health Sector Support (P148017) regional levels, these functions will be located within the Regional directorate of Health. Proposed Audit: Fiduciary Systems Client Due Date 30-Jun-2020 --- 1) Setting up of internal audit and management control functions at the central and regional levels of the MoH. At the regional levels, these functions will be located within the Regional directorate of Health. Audit: Client Due Date 09-Jun-2017 No Change 2) Agree on improved terms of reference for audit, including procurement and governance. Support to the Client Due Date 31-Dec-2019 Revised implementation of the new PFM framework and organic finance law. This involves support in the preparation of a multi-year budget and a draft performance plan, contracting and monitoring and evaluation system. Proposed Support to the Fiduciary Systems Client Due Date 30-Jun-2020 --- implementation of the new PFM Page 29 of 30 The World Bank MA-Health Sector Support (P148017) framework and organic finance law. This involves support in the preparation of a multi-year budget and a draft performance plan, contracting and monitoring and evaluation system. . Page 30 of 30