The World Bank Investing in Maternal, Child and Adolescent Health (P162042) REPORT NO.: RES59874 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF INVESTING IN MATERNAL, CHILD AND ADOLESCENT HEALTH APPROVED ON SEPTEMBER 26, 2019 TO REPUBLIC OF SENEGAL HEALTH, NUTRITION & POPULATION WESTERN AND CENTRAL AFRICA Regional Vice President: Ousmane Diagana Country Director: Keiko Miwa Regional Director: Trina S. Haque Practice Manager/Manager: Gaston Sorgho Task Team Leader(s): Laurence Elisabeth Marie-Paule Lannes The World Bank Investing in Maternal, Child and Adolescent Health (P162042) ABBREVIATIONS AND ACRONYMS ANACMU National Agency for Universal Health Coverage (Agence Nationale pour la Couverture Maladie Universelle) BNDE Banque Nationale de Developpement Economique CERC Contingency Emergency Response Component CNDN National Council for the Development of Nutrition (Conseil National de Développement de la Nutrition) DHIS2 District Health Information Software 2 DHS Demographic and Health Survey FY Fiscal Year GFF Global Financing Facility IDA International Development Association IP Implementation Progress IRI Intermediate Result Indicator ISMEA Investing in Maternal, Child and Adolescent Health (Investir dans la santé de la mère, de l'enfant et des adolescents) ISR Implementation Status & Results Report M&E Monitoring & Evaluation NGO Non-Governmental Organization NRA National Regulatory Authority PDO Project Development Objective RMNCAH-N Reproductive, Maternal, Neonatal, Child and Adolescent Health and Nutrition SITFAC Integrated Invoice Processing System (Système intégré de traitement de factures) SPA Service Provision Assessment WHO World Health Organization The World Bank Investing in Maternal, Child and Adolescent Health (P162042) BASIC DATA Product Information Project ID Financing Instrument P162042 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 26-Sep-2019 31-Dec-2024 Organizations Borrower Responsible Agency Republic of Senegal Project Development Objective (PDO) Original PDO The proposed Project Development Objective is to improve utilization of essential reproductive, maternal, neonatal, child and adolescent health and nutrition (RMNCAH-N) services meeting quality standards in Priority Regions. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-64950 26-Sep-2019 21-Feb-2020 14-Apr-2020 31-Dec-2024 120.00 82.76 31.47 TF-B0766 26-Sep-2019 07-Feb-2020 14-Apr-2020 31-Dec-2024 10.00 10.00 0 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Investing in Maternal, Child and Adolescent Health (P162042) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Project Status 1. Project overview: The investing in maternal, child and adolescent health (ISMEA) project included an initial funding of US$150 million out of which USD$20 million were cancelled in June 2021. The remaining US$130 million is comprised of US$120 million from the International Development Association (IDA) and US$10 million from the Global Financing Facility (GFF). As of April 2024, total disbursements amount to US$92.76 million, representing 74.7 percent of the total project amount. For the current fiscal year (FY24), disbursements stand at US$31.2 million. The scheduled project closure date is December 31, 2024. 2. Key ratings: The January 2024 tenth Implementation Status & Results Report (ISR) reflects a moderately satisfactory status across key performance indicators. Specifically, the Project Development Objective (PDO) and Overall Implementation Progress (IP) are both rated as Moderately Satisfactory. Component-wise assessments are as follows: Component 1: Moderately Satisfactory, Component 2: Moderately Satisfactory, Component 3: Moderately Satisfactory, Procurement: Moderately Satisfactory, Financial Management (FM): Moderately Unsatisfactory, Project Management: Moderately Satisfactory, and Monitoring & Evaluation (M&E): Moderately Unsatisfactory. 3. Project Development Objective (PDO): to improve utilization of essential reproductive, maternal, neonatal, child and adolescent health and nutrition (RMNCAH-N) services meeting quality standards in Priority Regions. 4. Implementation progress: Despite facing financial constraints arising from unresolved Withdrawal Applications in December 2023, which have impacted the scheduled activities and influenced the disbursement rate, there was still a commendable 10-point increase in disbursement between October 2023 and January 2024. The Demographic and Health Survey (DHS) results, released in December 2023, provided partial insights into the results framework. However, challenges persist due to the absence of consistent health data from facilities. Despite these hurdles, the project has demonstrated notable progress in the ISMEA regions, aligning with the equity objective. Significant improvements were observed in malnutrition rates, with a decline from 17.1 percent to 17.5 percent nationally and from 22.3 percent to 18.7 percent in ISMEA regions in 2023. Nonetheless, the lack of persistent health data complicates a comprehensive evaluation of the project's investments. 5. Implementation of Components a. Component 1: The recruitment of 890 out of 905 planned health professionals has been achieved, covering diverse roles such as physicians, pharmacists, midwives, technicians, nurses, pediatricians, nutritionists, and maintainers. The government has reaffirmed its commitment to assume responsibility for health personnel recruited by the project at the end of their contract with ISMEA. A proposal for a personnel incentive program in challenging zones has been shared and discussed during the mission, awaiting revision and validation by end-February 2024. Capacity-building efforts have impacted over 2,300 healthcare professionals. The rehabilitation works for obstetric and neonatal emergency care units have been completed in 4 out of 6 regions. Logistics enhancements, including ambulances, vehicles, and medical equipment, have been implemented. b. Component 2: The development of a comprehensive communication plan and related materials stands out as a pivotal achievement. Activities targeting adolescent girls have commenced following the recruitment of NGOs and a payment agency, demonstrating proactive project momentum. The signed agreement with the National Council for the Development of Nutrition (CNDN) for women's The World Bank Investing in Maternal, Child and Adolescent Health (P162042) empowerment activities further propels impactful initiatives. Safe space mapping has identified eligible structures for project support, ensuring the establishment of functional safe spaces across the entire ISMEA region by project conclusion. c. Component 3: The assessment of beneficiaries under the ANACMU agreement reveals critical challenges in managing health insurance at the regional level. Revised procedures and equipment allocation have enhanced the professionalism of district-level mutual health organizations. In Sedhiou, the pilot usage of the invoicing system (SITFAC) by healthcare providers has been initiated and will be documented for learning before a wider rollout. The incentive program targeting vulnerable pregnant women is performing well, and the mission recommended an evaluation to report on results achieved. The project's multifaceted contributions extend to governance enhancements within the health system, including activities such as developing health accounts for 2022, monitoring the National Health Development Plan (PNDSS), formulating the SRMNIA-N plan (2024-2028), spearheading human resources reform, and evaluating the health information system. 6. Monitoring & Evaluation: The evaluation of project indicators draws from the 2023 DHS and the health information system (DHIS2) platform. While some indicators are achieved or on a positive trajectory, others remain unrealized or cannot be documented. Data retention challenges, which started in the fall of 2022 persist, with the DHIS2 data completeness falling below 10 percent for some indicators and reaching on average 23 percent for 2023. B. Rationale for Restructuring 7. The need for the restructuration of the ISMEA project was formally conveyed by the government on January 24, 2024. While the ISMEA project has made notable progress in several areas, challenges remain in component implementation and results monitoring. The proposed restructuring aims to address these challenges and ensure the project's objectives are effectively met by the closing date of December 31, 2024. Project restructuring was discussed during the September 2023 mission and the official government request was received in January 2024. The proposed restructuring will facilitate fund absorption, address implementation gaps, and accelerate the achievement of the project's development objectives. It involves a revision of the results framework and reallocations between components and disbursement categories. 8. Results framework: The results framework, derived from data sources such as the DHS, DHIS2 reports, and the Service Provision Assessment (SPA) survey, has encountered challenges in reporting specific indicators. This is primarily due to issues related to data retention and, in certain instances, the absence of data, especially since the SPA survey was not conducted as planned. Consequently, there is a need to modify or delete certain indicators. Additionally, some targets were initially overestimated, particularly concerning program beneficiaries, and these will be subject to a more accurate assessment. Furthermore, the restructuring provides an opportunity to introduce new indicators that can effectively capture the project's activities and achievements. This is particularly pertinent in areas such as the recruitment of human resources for health, the rehabilitation of health facilities, and support for women's empowerment, as well as bolstering the pharmaceutical regulatory system. The inclusion of these new indicators aims to enhance the overall monitoring and evaluation of the project's progress and impact. 9. Components and Cost: The restructuring involves adjustments to resource allocation across various components of the project, necessitating changes in budget allocations for specific project components. The changes in components and costs are prompted by the need to address delays in implementing specific project activities and to optimize resource utilization to achieve the project's development objectives. While Component 1 implementation The World Bank Investing in Maternal, Child and Adolescent Health (P162042) shows satisfactory implementation, delays in executing Components 2 and 3 have been noted and Sub-Component 3.1 faced budget overestimation. Actual enrollments for children aged 0-5 and pregnant women fell significantly below projections. A reallocation of resources between components and disbursement categories is viewed as strategic approach to effectively align resources with the evolving needs of the project and contribute to achieving its objectives. 10. Reallocation between Disbursement Categories: The proposed restructuring introduces a reallocation between disbursement categories to enhance the efficiency and effectiveness of fund utilization while accommodating changing project needs and the reallocation of funds between components. II. DESCRIPTION OF PROPOSED CHANGES 11. Results framework: Proposed changes in the results framework are detailed below. a. Indicators to be deleted: i. PDO level indicator “Quality index of health services (Percentage)”. The rationale for the deletion of this PDO level indicator within the ISMEA project is primarily driven by the unavailability of crucial SPA survey data. Despite exhaustive efforts by the project team to explore alternative options, such as secondary data analysis or data collection to reconstruct a quality index, it was found unfeasible due to several reasons. Firstly, attempting to reconstruct a quality index without comparable baseline data posed significant challenges. Given the inability to collect all the data used in the original SPA survey, estimating a new baseline became practically unattainable. Moreover, the collection of new data would have incurred substantial costs without guaranteeing representative samples, as only a small subset could have been feasibly collected. Furthermore, concerns arose regarding the feasibility of data collection from health facilities by survey firms, particularly due to persistent data retention issues spanning for over 18 months, with no imminent resolution in sight. This ongoing challenge significantly hindered the reliability and completeness of routine data, rendering it unsuitable for filling the gap left by the absence of SPA survey data. In light of these constraints and limitations, the project team concluded that there was no viable alternative, but to delete the indicator in question. However, it's worth noting that despite this deletion, the project's commitment to measuring quality in health services remains. Quality assessment will still be facilitated through the second PDO level indicator, namely the "Completion rate for ANCs," providing a tangible metric to gauge the project's impact and effectiveness in improving healthcare services. ii. Intermediate Results Indicator (IRI) “Percentage of C-sections in the priority regions (Percentage)”. This indicator relies on DHIS2 as its data source. Due to a persistent data retention issue spanning approximately a year and a half, and with no foreseeable resolution soon, the decision has been made to remove this indicator from the project's results framework. iii. IRI “Percentage of newborns who benefited from an immediate care package at birth (Percentage)”. The rationale is the same as the above IRI. iv. IRI “Number of Scorecards made and disseminated annually at regional and national level (Number). The rationale is the same as the above IRI. b. New indicators: i. IRI on “Nurses per 5,000 Population (Number)”. The inclusion of an indicator on nurses is crucial to highlight the impact of the ISMEA project on addressing significant workforce gaps in targeted The World Bank Investing in Maternal, Child and Adolescent Health (P162042) regions. The ISMEA project, aimed at recruiting nurses in areas with noticeable shortages, has successfully recruited over 900 healthcare professionals overall. This strategic recruitment is aligned with the project's objective of enhancing healthcare services in underserved regions. Furthermore, it is noteworthy that, as per the financing agreement, these recruited nurses will be integrated into the public service upon the project's completion. Therefore, showcasing the nurse indicator is essential not only to demonstrate the ISMEA project's substantial contribution to improving human resource availability in these regions but also to emphasize its lasting impact through the integration of recruited nurses into the public sector workforce. ii. IRI on “Midwives per 1,500 women of reproductive age (Number)”. The inclusion of an indicator on midwives is crucial to highlight the impact of the ISMEA project on addressing significant workforce gaps in targeted regions. The ISMEA project, aimed at recruiting midwives in areas with noticeable shortages, has successfully recruited over 900 healthcare professionals overall. This strategic recruitment is aligned with the project's objective of enhancing healthcare services in underserved regions. Furthermore, it is noteworthy that, as per the financing agreement, these recruited midwives will be integrated into the public service upon the project's completion. Therefore, showcasing the midwives indicator is essential not only to demonstrate the ISMEA project's substantial contribution to improving human resource availability in these regions but also to emphasize its lasting impact through the integration of recruited midwives into the public sector workforce. iii. IRI on “Functional health posts in the intervention area (Number)”. The inclusion of the indicator "Functional health posts in the intervention area" is crucial to highlight the tangible impact of the ISMEA project in the targeted regions. The project has been instrumental in supporting the rehabilitation, procurement of equipment, and hiring of staff for health facilities in these areas. This strategic investment is aimed at ensuring that the health posts are not only established but also fully operational and capable of providing essential healthcare services. ISMEA's commitment to enhancing healthcare infrastructure is evident through its comprehensive approach to health post development. The rehabilitation efforts aim to revitalize existing structures, creating a conducive environment for effective healthcare delivery. The procurement of equipment further contributes to the operational efficiency of these health posts, enabling them to meet the diverse healthcare needs of the communities they serve. Moreover, the hiring of staff is a fundamental aspect of ISMEA's strategy, ensuring that these health posts have qualified personnel to deliver healthcare services. By including the indicator on the number of functional health posts, ISMEA can quantitatively measure the success of its initiatives in establishing and sustaining operational healthcare facilities in the intervention areas. This indicator serves as a key metric to showcase the project's overarching goal of improving healthcare accessibility and quality in the regions it serves. iv. IRI on “Women benefiting from revolving credit (Number). The inclusion of the indicator on the number of women benefiting from revolving credit within the ISMEA project is a strategic move to underscore the project's commitment to empowering women in regions marked by gaps in development. Through a series of meticulously planned activities, the project has informed various stakeholders about its initiatives aimed at enhancing women's autonomy. This includes targeted literacy programs combined with the implementation of revolving credit systems. The significance of this initiative lies in its comprehensive approach, addressing not only financial aspects through revolving credit but also incorporating literacy programs centered around nutrition and financial management. The training and support provided to community facilitators ensure that the program is executed effectively, covering essential components such as agricultural and nutritional value chains, entrepreneurship ideation, and financial management. By tracking the number of women benefiting from revolving credit, the ISMEA project can quantitatively measure the impact of these efforts in fostering economic independence and social development among women in Sédhiou, Kedougou, and Ziguinchor. The World Bank Investing in Maternal, Child and Adolescent Health (P162042) v. IRI on “Maturity level achieved on the WHO Global Benchmarking Tool for evaluation of national regulatory systems of medical products (Number)”. The introduction of an indicator on the maturity level is imperative to effectively capture and measure the advancements made by the ISMEA project in supporting the Pharmaceutical Regulatory Agency (Agence de Reglementation Pharmaceutique) as it progressed from regulatory maturity Level 1 to Level 3, and its subsequent efforts to sustain this elevated level. This initiative aligns with the evolving global standards for regulatory systems evaluation set by the World Health Organization (WHO). The WHO, since 1997, has been actively assessing regulatory systems, initially focusing on vaccines, and subsequently expanding its scope. The introduction of the WHO Global Benchmarking Tool (Revision VI) consolidates and replaces all previous tools, offering a comprehensive assessment of national regulatory systems for medical products. The proposed indicator would align with the tool's framework, evaluating the overarching regulatory framework and its associated functions. The nine critical functions encompass the national regulatory system, registration and marketing authorization, vigilance, market surveillance and control, licensing establishments, regulatory inspection, laboratory testing, clinical trials oversight, and National Regulatory Authority (NRA) lot release. The sub-indicators within these functions provide a nuanced view of the regulatory maturity, allowing for a more granular analysis. Furthermore, by adopting a cross-cutting category approach, such as quality and risk management system, the indicator can capture the multidimensional aspects of regulatory maturity. This holistic perspective enables the ISMEA project to showcase its substantial contributions to enhancing the regulatory landscape and maintaining elevated regulatory standards. The introduction of this indicator is essential not only for documenting achievements but also for fostering continuous improvement and ensuring the sustained effectiveness of the regulatory systems supported by the ISMEA project. c. Indicators to be revised: i. IRI target on “Number of adolescent girls who benefited from cash transfers (Number)”. The intended target (115,000) is deemed overly ambitious given the delays in starting Component 2 and the prerequisites for identifying adolescent girls to be enrolled. The proposed target for the enrollment extension is now set at 49,391 adolescent girls. This adjustment aims to align with the project's current circumstances and challenges, ensuring a more realistic and achievable target. ii. IRI statement on “Adolescent girls pregnancy rate among the beneficiaries of cash transfer initiatives (Percentage)”. The existing indicator, "Adolescent girls' pregnancy rate," poses a potential misunderstanding as a 0 percent value may be perceived negatively against a target of 4 percent. To address this and enhance clarity, it is proposed to revise the indicator. The proposed replacement is the "Percentage of adolescent girls not pregnant among cash transfer beneficiaries" with a target of 96 percent. This modification provides a more intuitive metric, aligning with the project's objectives and facilitating a clearer interpretation of success by emphasizing the prevention of pregnancies among the target population. 12. Components and Cost: Balancing categories based on revised priorities involves reallocation of surpluses and deficits. This reallocation spans all categories, with specific adjustments proposed for each in the below table, in million US$. Component No Component Name Current Cost Proposed Cost (US$M) (US$M) 1 Improving availability of RMNCAH-N services of adequate quality 50.00 78.00 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 2 Promoting adolescent health and women’s empowerment 20.00 19.60 3 Supporting reforms to strengthen governance, equity, and 60.00 32.40 financing sustainability in the health sector 4 Contingency Emergency Response Component (CERC) 0.00 0.00 TOTAL 130.00 130.00 13. Reallocation between Disbursement Categories: Reallocation between disbursement categories follows the reallocation of funds between components. The table below summarizes the proposed reallocation in euros. Category No Current Expenditure Category Current Allocation Proposed Allocation Percentage of (expressed in EUR) (expressed in EUR) Expenditures to be Financed (inclusive of Taxes) 1 GW N/CSTOC except Part A.1(a), Part 45,219,619.00 49,100,000.00 100% A.3(a), Part B.2(a), Part C.1(a),Part C.1(c)(i) 2 HR Contr Inc Prog Part A.1(a) 22,000,000.00 21,600,000.00 100% 3 Nutrition Enhancmt Grants Part A.3(a) 4,400,000.00 4,030,000.00 100% 4 Cash Transfers Part B.2(a) 7,497,248.00 13,100,000.00 100% 5 CBH Grants Part C.1(a) 24,600,000.00 16,050,000.00 100% 6 Maternal health vouchers Part C.1(c)(i) 2,600,000.00 2,436,867.00 100% 7 Emerg Expndtr Part D 0.00 0.00 8 PPF REFINANCING 1,175.00 1,175.00 Amount payable pursuant to Section 2.07 of the General Conditions Total 106,318,042.00 106,318,042.00 III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Reallocation between Disbursement Categories ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ PBCs ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) 1. Improving availability of 1. Improving availability of RMNCAH-N services of adequate 50.00 Revised RMNCAH-N services of 78.00 quality adequate quality 2. Promoting adolescent health 2. Promoting adolescent health 20.00 Revised 19.60 and women’s empowerment and women’s empowerment 3. Supporting reforms to 3. Supporting reforms to strengthen governance, equity, strengthen governance, equity, 60.00 Revised 32.40 and financing sustainability in the and financing sustainability in health sector the health sector 4. Contingency Emergency 4. Contingency Emergency 0.00 No Change 0.00 Response Component (CERC) Response Component (CERC) TOTAL 130.00 130.00 OPS_DETAILEDCHANGES_REALLOCATION _TABLE The World Bank Investing in Maternal, Child and Adolescent Health (P162042) REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-64950-001 | Currency: EUR iLap Category Sequence No: 1 Current Expenditure Category: GW N/CSTOC excpt PtA1aA3aB2aC1aC1ci 45,219,619.00 36,405,590.33 49,100,000.00 100.00 100.00 iLap Category Sequence No: 2 Current Expenditure Category: HR Contr Inc Prog Part A1(a) 22,000,000.00 17,053,035.81 21,600,000.00 100.00 100.00 iLap Category Sequence No: 3 Current Expenditure Category: Nutrition Enhancmt Grant Part A3(a) 4,400,000.00 3,171,358.61 4,030,000.00 100.00 100.00 iLap Category Sequence No: 4 Current Expenditure Category: Cash Transfers Part B2(a) 7,497,248.00 785,591.23 13,100,000.00 100.00 100.00 iLap Category Sequence No: 5 Current Expenditure Category: CBH Grants Part C1(a) 24,600,000.00 9,903,929.23 16,050,000.00 100.00 100.00 iLap Category Sequence No: 6 Current Expenditure Category: Maternal health vou Part C1(c)(i) 2,600,000.00 912,800.71 2,436,867.00 100.00 100.00 iLap Category Sequence No: 7 Current Expenditure Category: Emer Expnd Part D 0.00 0.00 0.00 100.00 100.00 iLap Category Sequence No: 8 Current Expenditure Category: PPF REFINANCING 1,175.00 1,174.76 1,175.00 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Total 106,318,042.00 68,233,480.68 106,318,042.00 . The World Bank Investing in Maternal, Child and Adolescent Health (P162042) . Results framework COUNTRY: Senegal Investing in Maternal, Child and Adolescent Health Project Development Objectives(s) The proposed Project Development Objective is to improve utilization of essential reproductive, maternal, neonatal, child and adolescent health and nutrition (RMNCAH-N) services meeting quality standards in Priority Regions. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Increased utilization of RMNCAH-N services in the targeted regions Utilization of health services by patients covered by a 15.00 20.00 25.00 30.00 35.00 40.00 community-based insurance mechanism (Percentage) Action: This indicator has been Revised Percentage of children under 5 suffering from childhood 17.00 15.00 13.75 12.50 11.25 10.00 stunting in Senegal (Percentage) Percentage of children under 5 suffering from childhood stunting in the 22.30 priority regions (Percentage) Contraceptive prevalence rate 26.00 28.00 30.00 32.00 34.00 36.00 (Percentage) (Percentage) The World Bank Investing in Maternal, Child and Adolescent Health (P162042) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Improved quality of health services in the 6 priority regions Quality index of health services 76.00 76.00 78.00 80.00 82.00 85.00 (Percentage) Action: This indicator has been Marked for Deletion Completion rate for ANCs 66.00 66.20 71.70 77.20 80.00 81.00 (Percentage) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 1. Improve availability of RMNCAH and nutrition services People who have received essential health, nutrition, and 0.00 2,843,864.00 population (HNP) services (CRI, Number) People who have received essential health, nutrition, and population (HNP) 0.00 1,189,760.00 services - Female (RMS requirement) (CRI, Number) Number of children 0.00 826,108.00 immunized (CRI, Number) Number of women and 0.00 1,148,169.00 children who have received The World Bank Investing in Maternal, Child and Adolescent Health (P162042) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 basic nutrition services (CRI, Number) Number of deliveries attended by skilled health 0.00 869,587.00 personnel (CRI, Number) Percentage of C-sections in the 3.16 3.20 4.00 4.10 4.30 4.50 priority regions (Percentage) Action: This indicator has been Marked for Deletion Percentage of newborns who benefited from an immediate 83.00 85.00 88.00 91.00 94.00 97.00 care package at birth (Percentage) Action: This indicator has been Marked for Deletion Percentage of deliveries in 60.00 65.00 70.00 72.00 75.00 80.00 health facilities (Percentage) Nurses per 5,000 Population 0.34 1.00 (Number) Rationale: The inclusion of an indicator on nurses is crucial to highlight the impact of the ISMEA project on addressing significant workforce gaps in targeted regions. The ISMEA project, aimed at recruiting nurses in areas with noticeable shortages, has successfully recruited over 900 healthcare professionals overall. This strategic recruitment is aligned with the project's objective of enhancing healthcare services in underserved regions. Furthermore, it is noteworthy that, as Action: This indicator is New per the financing agreement, these recruited nurses will be integrated into the public service upon the project's completion. Therefore, showcasing the nurse indicator is essential not only to demonstrate the ISMEA project's substantial contribution to improving human resource availability in these regions but also to emphasize its lasting impact through the integration of recruited nurses into the public sector workforce. The World Bank Investing in Maternal, Child and Adolescent Health (P162042) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Midwives for 1,500 women of 0.78 1.00 reproductive age (Number) Rationale: The inclusion of an indicator on midwives is crucial to highlight the impact of the ISMEA project on addressing significant workforce gaps in targeted regions. The ISMEA project, aimed at recruiting midwives in areas with noticeable shortages, has successfully recruited over 900 healthcare professionals overall. This strategic recruitment is aligned with the project's objective of enhancing healthcare services in underserved regions. Furthermore, it is noteworthy that, as Action: This indicator is New per the financing agreement, these recruited midwives will be integrated into the public service upon the project's completion. Therefore, showcasing the midwives indicator is essential not only to demonstrate the ISMEA project's substantial contribution to improving human resource availability in these regions but also to emphasize its lasting impact through the integration of recruited midwives into the public sector workforce. Functional health posts in the 572.00 616.00 intervention area (Number) Rationale: The inclusion of the indicator "Functional health posts in the intervention area" is crucial to highlight the tangible impact of the ISMEA project in the targeted regions. The project has been instrumental in supporting the rehabilitation, procurement of equipment, and hiring of staff for health facilities in these areas. This strategic investment is aimed at ensuring that the health posts are not only established but also fully operational and capable of providing essential healthcare services. ISMEA's commitment to enhancing healthcare infrastructure is evident through its comprehensive approach to health post development. The rehabilitation Action: This indicator is New efforts aim to revitalize existing structures, creating a conducive environment for effective healthcare delivery. The procurement of equipment further contributes to the operational efficiency of these health posts, enabling them to meet the diverse healthcare needs of the communities they serve. Moreover, the hiring of staff is a fundamental aspect of ISMEA's strategy, ensuring that these health posts have qualified personnel to deliver healthcare services. By including the indicator on the number of functional health posts, ISMEA can quantitatively measure the success of its initiatives in establishing and sustaining operational healthcare facilities in the intervention areas. This indicator serves as a key metric to showcase the project's overarching goal of improving healthcare accessibility and quality in the regions it serves. 2. Promote adolescent health and women’s empowerment Adolescent girls who benefited 0.00 780.00 49,391.00 from cash transfers (Number) The World Bank Investing in Maternal, Child and Adolescent Health (P162042) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator has been Revised Adolescent girls not pregnant among cash transfer 0.00 96.00 beneficiaries (Percentage) Rationale: The original indicator, "Adolescent girls' pregnancy rate," poses a potential misunderstanding as a 0 percent value may be perceived negatively against a Action: This indicator has been target of 4 percent. To address this and enhance clarity, it is proposed to revise the indicator. The proposed replacement is the "Percentage of adolescent Revised girls not pregnant among cash transfer beneficiaries" with a target of 96 percent. This modification provides a more intuitive metric, aligning with the project's objectives and facilitating a clearer interpretation of success by emphasizing the prevention of pregnancies among the target population. Utilisation rate of modern contraceptive methods by adolescent girls in a 8.00 12.50 14.00 15.50 17.00 18.50 relationship, aged 15-19 (Percentage) Women benefiting from 0.00 9,000.00 revolving credit (Number) Rationale: The inclusion of the indicator on the number of women benefiting from revolving credit within the ISMEA project is a strategic move to underscore the project's commitment to empowering women in regions marked by gaps in development. Through a series of meticulously planned activities, the project has informed various stakeholders about its initiatives aimed at enhancing women's autonomy. This includes targeted literacy programs combined with the implementation of revolving credit systems. Action: This indicator is New The significance of this initiative lies in its comprehensive approach, addressing not only financial aspects through revolving credit but also incorporating literacy programs centered around nutrition and financial management. The training and support provided to community facilitators ensure that the program is executed effectively, covering essential components such as agricultural and nutritional value chains, entrepreneurship ideation, and financial management. By tracking the number of women benefiting from revolving credit, the ISMEA project can quantitatively measure the impact of these efforts in fostering economic independence and social development among women in Sédhiou, Kedougou, and Ziguinchor. The World Bank Investing in Maternal, Child and Adolescent Health (P162042) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Ultimately, the inclusion of this indicator serves as a clear testament to the project's dedication to sustainable development, emphasizing the tangible outcomes of its initiatives and showcasing a holistic approach to empower women in underserved regions. Support reforms to strengthen equity and financing sustainability in the health sector Number of beneficiaries of the 816,393.00 2,283,108.00 2,564,461.00 2,650,520.00 2,742,365.00 2,837,532.00 CBHIS (Number) Number of vulnerable beneficiaries (children aged 0- 0.00 36,199.00 868,375.00 893,662.00 923,666.00 954,465.00 5) covered by the CBHIS (Number) Number of vulnerable beneficiaries (pregnant 0.00 169,998.00 174,159.00 179,452.00 184,830.00 184,830.00 women) covered by the CBHIS (Number) Completion rate of health facilities data reports 91.50 93.00 94.50 96.00 97.50 99.00 (Percentage) Number of Scorecards made and disseminated annually at 0.00 3.00 3.00 3.00 3.00 15.00 regional and national level (Number) Action: This indicator has been Marked for Deletion Maturity level achieved on the WHO Global Benchmarking Tool for evaluation of national 1.00 3.00 regulatory systems of medical products (Number) The World Bank Investing in Maternal, Child and Adolescent Health (P162042) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Rationale: The introduction of an indicator on the maturity level is imperative to effectively capture and measure the advancements made by the ISMEA project in supporting the Pharmaceutical Regulatory Agency (Agence de Réglementation Pharmaceutique) as it progressed from regulatory maturity Level 1 to Level 3, and its subsequent efforts to sustain this elevated level. This initiative aligns with the evolving global standards for regulatory systems evaluation set by the World Health Organization (WHO). The WHO, since 1997, has been actively assessing regulatory systems, initially focusing on vaccines and subsequently expanding its scope. The introduction of the WHO Global Benchmarking Tool (Revision VI) consolidates and replaces all previous tools, offering a comprehensive assessment of national regulatory systems for medical products. The proposed indicator would align with the tool's framework, evaluating the overarching regulatory framework and its associated functions. The nine Action: This indicator is New critical functions encompass the national regulatory system, registration and marketing authorization, vigilance, market surveillance and control, licensing establishments, regulatory inspection, laboratory testing, clinical trials oversight, and NRA lot release. The sub-indicators within these functions provide a nuanced view of the regulatory maturity, allowing for a more granular analysis. Furthermore, by adopting a cross-cutting category approach, such as quality and risk management system, the indicator can capture the multidimensional aspects of regulatory maturity. This holistic perspective enables the ISMEA project to showcase its substantial contributions to enhancing the regulatory landscape and maintaining elevated regulatory standards. The introduction of this indicator is essential not only for documenting achievements but also for fostering continuous improvement and ensuring the sustained effectiveness of the regulatory systems supported by the ISMEA project. IO Table SPACE The World Bank Investing in Maternal, Child and Adolescent Health (P162042)