THE WORLD BANK IBRD *IDA I WOR BMNKROUP April 12th, 2023 H.E Ernesto Max Tonela Minister Ministry of Economy and Finance Av. 10 de Novembro, No. 929, 10 Andar Maputo, Mozambique Excellency, Republic of Mozambique: Primary Health Care Strengthening Program (FCDO SDTF Grant Number TFOB4481) Second Amendment to the Grant Agreement We refer to the Grant Agreement for the above-captioned Project between the Republic of Mozambique ("Recipient") and the International Bank for Reconstruction and Development and International Development Association ("World Bank"), acting as administrator of the Mozambique Primary Health Care Strengthening Program Single Donor Trust Fund, dated May 21, 2021 as amended (the "Agreement"). Further to your letter dated December 27, 2022, we are pleased to inform you that the World Bank proposes to amend the Agreement as follows: (a) The table in Section IV.A of Schedule 2 to the Agreement is hereby deleted and replaced with the table in Annex to this amendment letter. All other provisions of the Agreement, except as amended herein shall remain in full force and effect. Sincerely, Idah aP,s#a6yi-Riddihough ountry Director Mozambique, Co ioros, Madagascar, Mauritius, and Seychelles Easteri and Southern Africa Region AGREED: REPUBLIC OF MOZAMBIQUE Authorized Representative Name: Ernesto Max Elias Tonela Title: Minister of Economy and Finance Date: 12 L 3 -2- Annex Category Disbursement Linked Amount of the Grant Disbursement Calculation (including Result Allocated Formula Disbursement (as applicable) (expressed in USD) Linked Indicator as applicable) (1) DLI #1: The Previous: FY2018 - No scalability Recipient has The Recipient has increased FY2019 - FY Allocated increased the the percentage of Amount x [Actual number of Institutional Deliveries in Achievement up to DLR 1.2 - districts, out of the the 42 lagging districts DLR 1.1] / [DLR 1.2 - DLR 42 defined as defined in the Investment 1.1] + undisbursed amount lagging in the Case from previous targets met Investment Case, FY2020 No scalability with at least 85 percent DLR#1.1: The Recipient has FY2021 - FY Allocated Institutional increased the percentage of Amount x [Actual Deliveries. Institutional Deliveries in 42 Achievement up to DLR 1.4 - Lagging Districts to 66.8% DLR 1.3] / [DLR 1.4 - DLR [FY 2018] 1.3] + undisbursed amount (Baseline: 66.1%) from previous targets met FY2022 - FY Allocated DLR#1.2: The Recipient has Amount x [Actual Achievement up to DLR 1.5 - increased the percentage of DR14![L . L Institutional Deliveries in 42 1.4 / Di R amount Lagging Districts to 81% 1.4 + undisbursed amount [FY 2019] from previous targets met. Revised: The Recipient has increased the number of districts, out of the 42 defined as lagging in the Investment Case, with at least 85 percent institutional deliveries DLR#1.3: The Recipient has increased the number of districts with at least 85 percent institutional deliveries to 29 [FY 2020] DLR#1.4: The Recipient has increased the number of districts with at least 85 percent institutional deliveries to 32 [FY 2021] DLR#1.5: The Recipient has increased the number of districts with at least 85 -3- percent institutional deliveries to 37 [FY 2022] (2) DLI #2: The DLR#2.3. 1: The Recipient USD 500,000 is FY2020 - No scalability Recipient has has increased the percentage allocated in FY 2021. FY2021 - increased the of Secondary and Technical percentage of Schools offering sexual and USD 1,000,000 is x.4.1:uFY Acatemnt USD 1000,00 is x [Actual Achievement up to Secondary and reproductive health services allocated in FY2022 DLR 2.4.1 - DLR 2.3.1] / Technical Schools to 19% [FY 2020] for DLR 2.5.1 [DLR 2.4.1 - DLR 2.3.1] + offering sexual and (Baseline: 0%) undisbursed amount from reproductive health usurd mt services previous targets met nri and DLR#2.3.2: The Recipient 2.4.2: No scalability (information a has completed a gaps contraceptive identification of current 2.4.3: No scalability methods). . Training Materials [FY 12020] FY2022 - 2.5.1: FY Allocated Amount DLR#2.3.3: The Recipient x [Actual Achievement up to has finalized the DLR 2.5.1 - DLR 2.4.1] / harmonization of M&E [DLR 2.5.1 - DLR 2.4.1] + Tools undisbursed amount from [FY 2020] previous targets met. 2.5.2: No scalability DLR#2.4. 1: The Recipient has increased the percentage of Secondary and Technical Schools offering sexual and reproductive health services to 40% [FY 2021] DLR#2.4.2: The Recipient has approved updated Training Materials [FY 2021] DLR#2.4.3: The Recipient has approved updated Adolescent and Youth- Friendly Services (SAAJ) Guidelines [FY 2021] DLR#2.5. 1: The Recipient has increased the percentage of Secondary and Technical Schools offering sexual and reproductive health services to 50% [FY 2022] DLR#2.5.2: The Recipient has completed training for health providers and focal -4- points on improved M&E tools [FY 2022] (3) DLI#3: The The Recipient has met the USD 1,000,000 is FY2018 - No scalability Recipient has following targets for Couple allocated for FY2022 FY2019 - FY Allocated increased Couple Years of Protection. Amount x [Actual Years of Achievement up to DLR 3.2 - Protection. DLR#3.1: 2,135,012 [FY DLR 3.1] / [DLR 3.2 - DLR f2018] (Baseline: 1,722,692) 3.1] + undisbursed amount from previous targets met DLR#3.2: 2,3 36,463 [FY FY2020 - FY Allocated 2019] Amount x [Actual Achievement up to DLR 3.3 - DLR 3.2] / [DLR 3.3 - DLR DLR#3.3: 3,190,000 3.2] + undisbursed amount [FY 2020] from previous targets met FY2021 - FY Allocated DLR#3.4: 3,360,000 [FY Amount x [Actual 2021] Achievement up to DLR 3.4 - DLR 3.3] / [DLR 3.4 - DLR 3.3] + undisbursed amount DLR#3.5: 3,540,000 [FY from previous targets met 2022] FY2022 - FY Allocated Amount x [Actual Achievement up to DLR 3.5 - DLR 3.4] / [DLR 3.5 - DLR 3.4] + undisbursed amount from previous targets met. (4) DLI#4: The DLR#4. 1.1: The Recipient FY2018 - No scalability. Recipient has has trained at least 6 FY2020 - FY Allocated increased the trainers, 100% of district Amount x [Actual percentage of nutrition representatives, Achievement up to DLR 4.3 - children between and 30% of Community Baseline] / [DLR 4.3 - 0-24 months of age Health Workers, and Baseline] + undisbursed receiving the identified 30% of amount from previous targets Nutrition volunteers, in 6 of the 8 met Intervention targeted provinces on the Package (NIP) in NIP [FY 2018] the eight provinces FY2021 - (Cabo Delgado, DLR#4.1.2: The Recipient FY Allocated Amount x Inhambane, has finalized the Monitoring [Actual Achievement up to Manica, Nampula, as DLR 4.4 - DLR 4.3] / [DLR Niassa, Sofala, 2018] 4.4 - DLR 4.3] + undisbursed Tete and amount from previous targets Zambezia) with a met prevalence of DLR#4.3: The Recipient has stunting above 35 ensured that 15% of children FY2022 - FY Allocated percent. are benefiting from the Modified NIP [FY 2020] Amount x [Actual (Baseie: 0) [FYAchievement up to DLR 4.5 - (Baseline: 0) DLR 4.] / [DLR 4.5 - DLR 4.] + undisbursed amount IDLR#4.4: The Recipient has from previous targets met ensured that 30% of children -5- are benefitting from the Modified NIP [FY 2021] DLR#4.5: The Recipient has ensured that 40% of children are benefitting from the NIP [FY 2022] (5) DLI#5: The DLR#5.1: Actual Domestic FY2018 - No scalability Recipient has Health Expenditure as a FY2019 - FY Allocated increased the percentage of total Domestic Amount x [Actual Domestic Health Government Expenditure at Achievement up to DLR 5.2 - Expenditures as a least 8.5% [FY 2018] DLR 5.1] / [DLR 5.2 - DLR percentage of total (Baseline: 7.9%) 5.1] + undisbursed amount Domestic from previous targets met Government DLR#5.2: Actual Domestic FY2020 - FY Allocated Expenditures. Health Expenditure as a Amount x [Actual percentage of total Domestic Achievement up to DLR 5.3 - Government Expenditure at DLR 5.2] / [DLR 5.3 - DLR least 8.5% [FY 2019] 5.2] + undisbursed amount from previous targets met DLR#5.3: Actual Domestic FY2021 - FY Allocated Health Expenditure as a Amount x [Actual percentage of total Domestic Achievement up to DLR 5.4 - Government Expenditure at 'DLR 5.3] / [DLR 5.4 - DLR least 9% [FY 2020] 5.3] + undisbursed amount from previous targets met DLR#5.4: Actual Domestic Health Expenditure as a percentage of total Domestic Government Expenditure at least 9.5% [FY 2021] (6) DLI#6: The DLR#6.3.1: Actual FY2020 - Recipient has provincial expenditures in 6.3.1: Allocated Amount x increased health the Underserved Provinces [Actual achievement up to expenditures from from the Sub-Account DLR 6.3.1 - Baseline] / [DLR the Sub-Account Resources increased to USD 6.3.1 - Baseline] Resources in 9 million [FY2020] 6.3.2: Allocated Amount x Underserved (Baseline: 0) [Actual achievement up to Areas.[Ataacivmnupo DLR 6.3.2 - Baseline] / [DLR DLR#6.3.2: Actual district 6.3.2 - Baseline] expenditures in the 6.3.3: Allocated Amount x Underserved Districts from [Actual achievement up to the Sub-Account Resources DLR 6.3.3- Baseline] / [DLR increased to USD 4 million 6.3.3 - Baseline] [FY2020] (Baseline: 0) FY2021 - DLR#6.3.3: Domestic Health Expenditures for the acatemnt x t Actual Underserved Areas achievement up to DLR 6.4 - maintained as a share of -6- provincial and district Baseline] / [DLR 6.4 - Domestic Health Baseline] Expenditures [FY2020] (Baseline: 32% for Underserved Provinces andi 6% in Underserved Allocated Amount x [Actual Districts in 2019) achievement up to DLR 6.5 - Baseline] / [DLR 6.5 - Baseline] + undisbursed DLR#6.4: The Recipient has amount from previous targets signed Results Agreements met with eleven provinces (Baseline: 0) [FY 2021] DLR#6.5: The Recipient has disbursed grants to 90% of primary health care facilities with internment in the three Underserved Provinces (Baseline: 0) [FY 2022] (7) DLI#7: The The Recipient has met the USD 2,000,000 is FY2018 - No scalability Recipient has following percentages of allocated in FY2020 FY2019 - increased the Technical Health Personnel (USD 500,000 for number of assigned to the primary DLR#7.3.1 and USD 7.2.1: FY Allocated Amount Technical Health health care network: 1,500,000; and for x [Actual Achievement up to Personnel assigned DLR#7.3.2). DLR 7.2.1 - DLR 7.1]/ to the primary DL 7[DLR 7.2.1 - 7.1] + hath ary DLR#7.1: 12,205 [FY 2018] undisbursed amount from network. (Baseline: 11,970) previous targets met 7.2.2: FY Allocated Amount DLR#7.2.1: 15,431 [FY x [Actual Achievement up to 2019] DLR 7.2.21 - Baseline]! [DLR 7.2.21 - Baseline] DLR#7.2.2: The Recipient has increased the number of FY2020 - health facilities in the 7.3.1: FY Allocated Amount primary care network that x [Actual Achievement up to have at least two active DLR 7.3.1 - DLR 7.2.1] / maternal child health [DLR 7.3.1 - DLR 7.2.1] + (MCH) nurses to 688 [FY undisbursed amount from 2019] previous targets met 7.3.2: FY Allocated Amount DLR#7.3.1: 15,566 [FY x [Actual Achievement up to 2020] DLR 7.3.2 - DLR 7.2.2] / [DLR 7.3.2 - DLR 7.2.2] + undisbursed amount from |DLR#7.3.2: The Recipient has increased the number of previous targets met health facilities in the primary care network that FY2021 - |have at least two active -7- MCH nurses to 704 [FY 7.4.1: FY Allocated Amount 2020] x [Actual Achievement up to DLR 7.4.1 - DLR 7.3.l] / DLR#7.4.1: 16,182 [FY [DLR 7.4.1 - DLR 7.3.1] + 2021] undisbursed amount from previous targets met 7.4.2: FY Allocated Amount DLR#7.4.2: The Recipient x [Actual Achievement up to has increased the number of DLR 7.4.2 - DLR 7.3.2] / health facilities in the [DLR 7.4.2 - DLR 7.3.2] + primary care network that undisbursed amount from have at least two active previous targets met MCH nurses to 728 [FY 2021] FY2022 - DLR#7.5.1: 17,153 [FY 7.5.1: FY Allocated Amount 2022] x [Actual Achievement up to DLR 7.5.1 - DLR 7.4.1] / [DLR 7.5.1 - DLR 7.4.1] + DLR#7.5.2: The Recipient undisbursed amount from has increased the number of previous targets met health facilities in the 7.5.2: FY Allocated Amount primary care network that x [Actual Achievement up to have at least two active DLR 7.5.2 - DLR 7.4.2] / MCH nurses to 768 [FY [DLR 7.5.2 - DLR 7.4.2] + 2022] undisbursed amount from previous targets met (8) DLI#8: The DLR#8.1: The Recipient has USD 1,000,000 is FY2018 - No scalability Recipient has designed and piloted allocated in FY 2020. FY2019 - FY Allocated increased the hospital scorecards in 6 Amount x [Actual number of district district and rural hospitals, Achievement up to DLR 8.2 - and rural hospitals which receive performance- DLR 8.1] / [DLR 8.2 - DLR receiving based allocations according 8.1] + undisbursed amount performance-based to their performance [FY from previous targets met allocations in 2018] (Baseline: 0) FY2020 - FY Allocated accordance with a Amount x [Actual minimum of one DLR#8.2: The Recipient has Achievement up to DLR 8.3 - scorecard demonstrated that 30% of DLR 8.2] / [DLR 8.3 - DLR assessment in the district and rural hospitals 8.2] + undisbursed amount previous Fiscal received performance-based from previous targets met allocations in accordance IFY2021 - FY Allocated with a minimum of two Amount x [Actual scorecard assessments in the Achievement up to DLR 8.4 - previous Fiscal Year [FY DLR 8.3] / [DLR 8.4 - DLR 2019] 8.3] + undisbursed amount from previous targets met DLR#8.3: The Recipient has FY2022 - FY Allocated demonstrated that 15 district Amount x [Actual and rural hospitals receive Achievement up to DLR 8.5 - allocations based on DLR 8.4] / [DLR 8.5 - DLR prioritized action plans that 8.4] + undisbursed amount respond to scorecard from previous targets met -8- evaluations [FY 2020] 1 (Baseline: 0) DLR#8.4: The Recipient has demonstrated that 31 district and rural hospitals received performance-based allocations in accordance with a minimum of one scorecard assessment in the previous Fiscal Year [FY 2021] DLR#8.5: The Recipient has demonstrated that 44 district and rural hospitals received performance-based allocations in accordance with a minimum of one scorecard assessment in the previous Fiscal Year [FY 2022] (9) DLI#9: The DLR#9. 1: The Recipient has USD 2,000,000 is FY2018 - No scalability Recipient has designed and piloted health allocated in FY 2022 FY2019 - FY Allocated increased the center scorecards with Amount x [Actual number of health community consultations in Achievement up to DLR 9.2 - centers in Priority at least 64 Rural Health DLR 9.1] / [DLR 9.2 - DLR Districts receiving Centers in Priority Districts, 9.1] + undisbursed amount performance-based receiving financial from previous targets met allocations allocations according to FY2020 - FY Allocated according to at their performance [FY 2018] Amount x [Actual least one scorecard (Baseline: 0) Achievement up to DLR 9.3 - assessment with DLR 9.2] / [DLR 9.3 - DLR community DLR#9.2: The Recipient has 9.2] + undisbursed amount consultations in the demonstrated that 130 Rural from previous targets met previous fiscal Health Centers in Priority FY2021 - FY Allocated year (FY). Districts receive Amount x [Actual performance-based Achievement up to DLR 9.4 - allocations according to at DLR 9.3] / [DLR 9.4 - DLR least two scorecard 9.3] + undisbursed amount assessments with froni previous targets met community consultations in FY2022 - FY Allocated the last Fiscal Year [FY Amount x [Actual 2019] Achievement up to DLR 9.5 - DLR 9.4] / [DLR 9.5 - DLR DLR#9.3: The Recipient has 9.4] + undisbursed amount demonstrated that 186 from previous targets met. health centers in priority districts receive financial allocations based on prioritized action plans that !respond to scorecards -9- evaluations [FY 2020] (Baseline: 0) DLR#9.4: The Recipient has demonstrated that 261 health centers in priority districts receive performance-based allocations according to at least one scorecard assessment with community consultations in the last Fiscal Year [FY 2021] DLR#9.5: The Recipient has demonstrated that 391 health centers in priority districts receive performance-based allocations according to at least one scorecard assessment with community consultations in the last Fiscal Year [FY 2022] (10) DLI#10: The The Recipient has achieved USD 2,500,000 is FY2018 - No scalability Recipient has the following targets: allocated in FY 2021. FY2019 - FY Allocated increased the Aount x [Actual number of active DLR#10.1: 4,723 CHWs Achievement up to DLR 10.2 community health trained and active [FY 2018] - Baseline] / [DLR 10.2 - workers (CHWs). (Baseline: 3,380) Baseline] + undisbursed amount from previous targets met DLR#10.2: 6,523 CHWs FY2020 - trained and active [FY FY Allocated Amount x 2019] [Actual Achievement up to DLR 10.3 - DLR 10.2] / DLR#10.3: 6,690 active [DLR 10.3 - DLR 10.2] + CHWs [FY 2020] undisbursed amount from previous targets met FY2021 - DLR#10.4: 7,748 active FY Allocated Amount x CTHWs [FY 2021] [Actual Achievement up to DLR 10.4 - DLR 10.3] / DLR#10.5.1: 8,800 active [DLR 10.4 - DLR 10.3] + CHWs [FY 2022] undisbursed amount from previous targets met DLR#10.5.2: 50% of CHWs FY2 - 10.5.1: FY Allocated Amount deliver services according to |x [t Achievement ut quality standards [FY 2022] LR 10.5.1 - DLR 10.4]! (Baseline: 28%) [DLR 10.5.1 - DLR 10.4] + undisbursed amount from previous targets met '10.5.2: FY Allocated Amount ,x [Actual Achievement up to -10- DLR 10.5.2 -Baseline] / [DLR 10.5.2 - Baseline] (11) DLI# 11: The The Recipient has achieved FY2018 - No scalability Recipient has the following targets: FY2019 - FY Allocated increased the Amount x [Actual percentage of DLR#11.1: 100% of Achievement up to DLR 11.2 deaths in eligible hospitals and 50% of health - DLR 11.1] / [DLR 11.2 - health facilities centers use MGDH to 11.1] + undisbursed amount certified by a generate information on from previous targets met qualified a causes of death FY2020 - qualified climician with the cause of (Baseline: 70% of hospitals 11.3.1: FY Allocated Amount death coded using and 0% of health centers use x [Actual Achievement up to ICD10 or ICD1 1, MGDH to generate DLR 11.3.1 - Baseline] / and the death information on the cause of [DLR 11.3.1 - Baseline] + record captured in death) [FY 2018] undisbursed amount from SISMA Hospital previous targets met Data Management DLR#1 1.2: 70% of the 11.3.2: FY Allocated Amount Module (Modulo health centers use MGDH to x [Actual Achievement up to de Gestio de generate information on the DLR 11.3.2- Baseline] / Dados cause of death [FY 2019] [DLR 11.3.2 - Baseline] + Hospitalares- undisbursed amount from AGDH) and DLR#1 1.3.1: 50% of deaths previous targets met the Recipient has in eligible health facilities increased the certified by a doctor or FY2021 - percentage of qualified clinician with the 11.4.1: FY Allocated Amount deaths registered, cause of death coded using x [Actual Achievement up to certified, and ICD10, and the death record DLR 11.4.1 -DLR 11.3.1] / captured in the captured in the SISMA [DLR 11.4.1 - DLR 11.3.1] + civil registration MGDH [FY 2020] undisbursed amount from system (SiRCEV) (Baseline: 0) previous targets met within one year of peiu agt e thin ocne a of d11.4.2: FY Allocated Amount their occurrence DLR#11.3.2: 15% of deaths x [Actual Achievement up to registered, certified, and DLR 11.4.2 - DLR 11.3.2] / captured in the civil [DLR 11.4.2 - DLR 11.3.2] + registration system undisbursed amount from (SiRCEV) within one year previous targets met of their occurrence [FY 2020] (Baseline: 0) FY2022 - DLR#1 1.4.1: 60% of deaths 11.5.1: FY Allocated Amount in eligible health facilities x [Actual Achievement up to DLR 11.5.1 - DLR 11.4.1] / certified by a doctor or DLR 11.5.1 - DLR 11.1] / qualified clinician with the uDiR amount fRom cause of death coded using upeious aet et ICD10 or ICD 11, and the death record captured in the 111.5.2: FY Allocated Amount SISMA MGDH [FY 2021] x [Actual Achievement up to DLR 11.5.2 - DLR 11.4.2] / [DLR 11.5.2 - DLR 11.4.2] + DLR#1 1.4.2: 20% of deaths 'undisbursed amount from registered, certified and previous targets met captured in the civil registration system -11- (SiRCEV) within one year of their occurrence [FY 2021] DLR#11.5.1: 70% of deaths in eligible health facilities certified by a doctor or qualified clinician with the cause of death coded using ICD10 or ICD 11, and the death record captured in the SISMA MGDH [FY 2022] DLR#11.5.2: 25% of deaths registered, certified, and captured in the civil registration system (SiRCEV) within one year of their occurrence [FY 2022] (12) DLR#12: The The Recipient has achieved FY2021 - No scalability Recipient has the following targets: FY2022 - No scalability introduced reforms DLR#12.4: Expansion of the to increase the Sistema de Informacdo, availability of Gestdo, e Logistica das essential maternal Unhidades Sanitdrias and reproductive (SIGLUS) to 85% of health health medicines at facilities [FY 2021] primary health care facilities. DLR#12.5.1: Approval by the Cabinet of a decree granting the Central de Aledicamentos e Artigos A dicos (CMAM) autonomy to enable an optimized single command structure [FY 2022] DLR#12.5.2:Implementation of outsourcing of last mile transportation and distribution of medicines [FY 2022] TOTAL 10,000,000 AMOUNT